Mortality Risk Prediction by Application of Pediatric Risk of Mortality Scoring System in Pediatric Intensive Care Unit

Objective

The Pediatric Risk of Mortality (PRISM) score is one of the scores used by many pediatricians for prediction of the mortality risk in the pediatric intensive care unit (PICU). Herein, we intend to evaluate the efficacy of PRISM score in prediction of mortality rate in PICU.

Methods

In this cohort study, 221 children admitted during an 18-month period to PICU, were enrolled. PRISM score and mortality risk were calculated. Follow up was noted as death or discharge. Results were analyzed by Kaplan-Meier curve, ROC curve, Log Rank (Mantel-Cox), Logistic regression model using SPSS 15.

Findings

Totally, 57% of the patients were males. Forty seven patients died during the study period. The PRISM score was 0-10 in 71%, 11-20 in 20.4% and 21-30 in 8.6%. PRISM score showed an increase of mortality from 10.2% in 0-10 score patients to 73.8% in 21-30 score ones. The survival time significantly decreased as PRISM score increased (P≤0.001). A 7.2 fold mortality risk was present in patients with score 21-30 compared with score 0-10. ROC curve analysis for mortality according to PRISM score showed an under curve area of 80.3%.

Conclusion

PRISM score is a good predictor for evaluation of mortality risk in PICU.     

Risk factors associated with pediatric intensive care unit admission and mortality after pediatric stem cell transplant: possible role of renal involvement

Background

Hematopoietic stem-cell transplant (HSCT) is associated with many risk factors for life-threatening complications. Post-transplant critical illness often requires admission to the pediatric intensive care unit (PICU).

Methods

A retrospective analysis was made on the risk factors associated with PICU admission and mortality of all HSCT patients at Helen DeVos Children’s Hospital from October 1998 to November 2008.

Results

One hundred and twenty-four patients underwent HSCT, with 19 (15.3%) requiring 29 PICU admissions. Fifty patients received autologous, 38 matched sibling, and 36 matched un-related donor HSCT, with 10%, 13% and 25% of these patients requiring PICU admission, respectively (P=0.01). Among the HSCT patients, those who were admitted to the PICU were more likely to have renal involvement by either malignancy requiring nephrectomy or a post transplant complication increasing the likelihood of decreased renal function (21.1% vs. 4.8%, P=0.03). PICU admissions were also more likely to receive pre-transplant total body irradiation (52.6% vs. 27.6%, P=0.03). Among 29 patients with PICU admission, 3 died on day 1 after admission, and 5 within 30 days (a mortality rate of 17%). Thirty days after PICU admission, non-survivors had a higher incidence of respiratory failure and septic shock on admission compared with survivors (80% vs. 16.7%, P=0.01 and 80% vs. 4.2%, respectively, P=0.001). Two survivors with chronic renal failure underwent renal transplantation successfully.

Conclusions

Total body irradiation and renal involvement are associated with higher risk for PICU admissions after HSCT in pediatric patients, while septic shock upon admission and post-admission respiratory failure are associated with mortality.     

Epidemiology and Outcome of Sepsis in a Tertiary Care PICU of Pakistan

Objective

To determine the epidemiology and outcome of sepsis in children admitted in pediatric intensive care unit (PICU) of a tertiary care hospital.

Methods

Retrospective review of children 1?mo to 14?y old, admitted to the PICU with severe sepsis or septic shock from January 2007 through December 2008 was done. Demographic, clinical and laboratory features of subjects were reviewed. The primary outcome was mortality at the time of discharge from PICU. The independent predictors of mortality were modeled using multiple logistic regression.

Results

In 2?years, 17.3% (133/767) children admitted to the PICU had sepsis. Median age was 18?mo (IQR 6–93?mo), with male: female ratio of 1.6:1. Mean PRISM III score was 9 (±7.8). One third had culture proven infection, majority (20%) having bloodstream infection. The frequency of multi-organ dysfunction syndrome (MODS) was 81% (108/133). The case specific mortality rate of sepsis was 24% (32/133). Multi-organ dysfunction (Adjusted OR 18.0, 95% CI 2.2–144), prism score of >10 (Adjusted OR 1.5, 95% CI 0.6–4.0) and the need for?>?2 inotropes (Adjusted OR 3.5, 95% CI 1.3–9.2) were independently associated with mortality due to sepsis.

Conclusions

The presence of septic shock and MODS is associated with high mortality in the PICU of developing countries.     

Outcome Prediction Value of Red Cell Distribution Width in Critically-ill Children

Objective

To study the association between red cell distribution width (RDW) and mortality in critically-ill children admitted in a Pediatric intensive care unit (PICU).

Methods

101 participants were recruited consecutively over 3 months. Data collected included demographics, vital parameters, laboratory values, severity and organ failure scores, RDW for the first 5 days of admission, duration of PICU stay and survival outcome.

Results

11 patients died during study period. High RDW at admission (RDW D1) correlated significantly with mortality (P=0.007). The odds of death increased by 15 to 23 times with rise in RDW D1 from 18% to >21%. The optimal RDW D1 cut-off value for mortality was 18.6%, which yielded sensitivity 90.9%, specificity 70.8%, positive predictive value 27.8%, negative predictive value 98.4%, and area under curve (AUC) 0.83 (95%CI 0.737, 0.925). 29 out of 60 (48.3%) patients with RDW D4 >18% had PICU stay of ≥7 days.

Conclusion

High (≥18.6%) RDW at admission and its persistent high levels are associated with high mortality and prolonged stay in PICU, respectively.

     

Platelet Distribution Width to Platelet Count Ratio as an Index of Severity of Illness

Objective

To prospectively validate association between the ratio of platelet distribution width (PDW)/platelet count (PCT) and pediatric intensive care unit (PICU) mortality.

Methods

The study was done in the pediatric intensive care unit (PICU). Platelet indices in the first sample taken after admission were used. In this case control analysis, cases were the patients who died in PICU and the survivors served as controls. Consecutive 209 eligible patients over a period of 15 mo from January 2014 through March 2015 were included. Exposure was PDW/PC above 0.07. Of them 174 survived and 35 died.

Results

The mean PDW for survivors was 16.77 (±0.92) and for those who died it was 17.33 (±1.03) (p 0.0015). Mean platelet count (PC) for survivors was 3,46,000 (±1,64,700) and for those who died it was 1,75,800 (±1,61,500) (p < 0.001). PDW/PC for survivors was 0.12 (±0.46) and for those who died it was 0.336 (±0.53) (p 0.0014). Using the cut-off of 0.07 for PDW/PC described by Golwala et al., 77.14% above the cut-off died, compared to 22.85% below that cut-off. The odds ratio (OR) for death was 10.6 (95% CI: 4.48 to 25.12). The area under the receiver operating curve (ROC) curve for PDW/PC ratio was 0.81.

Conclusions

The ratio of PDW/PC, higher than 0.07 in the first sample after admission can be considered as an independent predictor of mortality with sensitivity and specificity of 77.1% and 77.5%, respectively. It may be a useful component for inclusion in composite scores for predicting mortality.

     

Trauma related admissions to the PICU at Chris Hani Baragwanath Academic Hospital,Johannesburg

Background

Paediatric trauma is a major cause of morbidity and mortality in low and middle income countries. Data from these regions are scant. We aimed to describe the demographic and injury profile, treatment modality and outcome of trauma admissions to the paediatric intensive care unit at Chris Hani Baragwanath Academic Hospital (CHBAH).

Methods

A retrospective record review of trauma cases admitted to the PICU at CHBAH from 2011 to 2013 was performed.

Results

One-fifth of admissions were due to trauma. 58% of admissions were male. Weekends accounted for 49% of admissions. Road traffic injuries (RTI) (66%) and toxin ingestion (TI) (17%) contributed the majority of admissions. Children aged 0–4 years accounted for 45%, 5–9 years 39%, and 10–15 years 16% of admissions. The mortality rate was 9.0% with RTI accounting for 64%. 64% of mortalities occurred in the 0–4 year cohort. Mean age of survivors (5.8 years) was significantly higher than non-survivors (3.4 years) (p < 0.05). 89% of all children required invasive ventilation on PICU admission. Mean length of ventilation in non-survivors (10.2 days) was significantly longer than survivors (4.5 days) (p < 0.05).

Conclusions

RTI accounted for the majority of trauma admissions to our PICU. RTI, female gender and age less than 4 years were all associated with an increased risk for mortality in our study.

     

Association of Fluid Overload with Mortality in Critically-ill Mechanically Ventilated Children

Objectives

To study the association of fluid overload with mortality and morbidity in critically-ill mechanically ventilated children.

Design

Prospective observational study.

Setting

Pediatric Intensive Care Unit (PICU) of a tertiary care hospital, New Delhi, India.

Participants

118 children (age 1 mo - 15 y) requiring mechanical ventilation.

Outcome measures

Primary: Association of fluid overload with mortality. Secondary: Association of fluid overload with oxygenation, organ dysfunction, duration of mechanical ventilation and PICU stay.

Results

Cumulative fluid overload of ≥15% was observed in 74 (62.7%) children. About 50% of these children reached cumulative fluid overload of ≥15% within the first 5 days of PICU stay. The mortality was 40.5% in those with ≥15% cumulative fluid compared to 34% in the rest [OR (95% CI): 1.02 (0.97, 1.07)]. On multivariate analysis, after adjusting for confounders, cumulative fluid overload ≥15% was associated with higher maximum PELOD (pediatric logistic organ dysfunction) score (Median: 21 vs. 12; P = 0.03), longer median duration of mechanical ventilation (10 vs. 4 d; P <0.0001) and PICU stay (13.5 vs. 6 d; P <0.0001). There was no significant association of fluid overload with oxygenation index (P=0.32).

Conclusion

There is no association of fluid overload with mortality. However, it is associated with poor organ function, longer duration of mechanical ventilation and PICU stay in critically-ill, mechanically ventilated children.

     

Laktat und Trainingssteuerung bei Kindern und Jugendlichen

Background

Lactate is the product of anaerobic glycolysis, a metabolic carbon intermediate with high energy content and a substrate of cellular respiration and gluconeogenesis. Additionally, lactate modulates glycolytic energy production and oxidative combustion of lactate in mitochondria.

Blood lactate concentration and intensity zones

The blood lactate concentration (BLC) increases with increasing exercise intensity which is termed the lactate power curve (LPC). The LPC discriminates between subjects with different performance capacities and distinct testing protocols. During prolonged constant power exertion the BLC can remain close to the resting level (intensity zone I), show a steady state above resting BLC (intensity zone II) or increase continuously until termination of physical exertion (intensity zone III). The maximal lactate steady state (MLSS) depicts the transition from intensity zone II to III. Lactate thresholds detect LPC points which indicate the transition from intensity zone I to II or II to III.

Intensity zones in the training process

Intensity zone I serves for training sessions lasting up to 6 h. Intensity zone II is utilized for extensive and intensive endurance training sessions sustainable for between 30 min and 90 min. Interval and tempo training sessions are performed at intensity zone III.

Blood lactate concentration measurement for training control

Measurement of BLC not only detects performance changes under laboratory and field conditions but can also be used to assess the metabolic stress of selected training sessions. If adolescents perform training volumes which require a training intensity distribution comparable to adult high performance athletes then BLC monitoring of selected training sessions is advised. Corresponding training BLC measurements are not required in performance-oriented training of prepuberty and early puberty children.     

Ventilator-associated pneumonia in an Italian pediatric intensive care unit: a prospective study

Background

This study was undertaken to determine the prevalence, risk factors and outcomes associated with ventilator-associated pneumonia (VAP) in a European pediatric intensive care unit (PICU).

Methods

A total of 451 children who had been mechanically ventilated in the PICU for ≥48 hours during a 3-year period were enrolled in this prospective study.

Results

In comparison with children without VAP, 30 children (6.6%) who developed VAP had a longer PICU stay (P=0.0001) and hospital stay (P=0.0001), and a higher mortality rate (P=0.04). Logistic regression analysis showed that the need for re-intubation (P=0.0001), the presence of tracheostomy (P=0.04), and enteral feeding (P=0.02) were independent risk factors for VAP.

Conclusions

A relevant proportion of intubated children develop VAP, which is closely related to invasive procedures. As VAP is associated with increased medical costs and death, multicenter studies are urgently needed to improve the therapeutic approach to VAP and VAP prevention.     

The Value of Serum Uric Acid as a Mortality Prediction in Critically Ill Children

Objective

The role of initial serum uric acid on admission in critically ill patients is controversial; we presumed that uric acid level can predict the mortality of the admitted patients to intensive care unit as a simple test.

Methods

Totally, 220 consecutively admitted children (96 girls, 124 boys) with mean age 3.5 years, who were at least 24 hours in pediatric intensive care unit (PICU), were enrolled in a prospective cohort study during January 2006 to December 2007. The subsequent PICU admission in the same hospitalization, those who were discharged from the hospital and then re-admitted to the PICU during the observation period, and the patients with chronic renal failure were excluded. Serum uric acid level was measured during the first day of PICU admission. Death or transfer from PICU was considered as final outcome. The statistical analysis was done by using linear regression analysis, ROC curve, Student t-test, and Chi- square. P value less than 0.05 was considered significant.

Findings

From 44 patients who had serum uric acid level more than 8 mg/dl, 17 cases died showing with a higher relative risk of 1.88, higher mortality (P<0.05). The relative risk of death in patients who had serum uric acid >8 mg/dl and needed vasopressor was 1.04, and in those under mechanical ventilation 1.33. In patients who scored pediatric risk of mortality of >38 it was 1.4, and in septic cases 4 (P<0.05). Stepwise linear regression analysis showed that mainly the need for mechanical ventilation (P=0.001) and vasopressor had statistically significant correlation with the poor outcome (P=0.001).

Conclusion

Uric acid level during the first day of intensive critical care admission is not an independent risk of mortality in PICU. Need for mechanical ventilation or inotropic agents was associated with poor outcome and only higher uric acid level in sepsis played an additive risk factor role.     

Intranasal Clonidine vs. Midazolam as Premedication in Children: A Randomized Controlled Trial

Objectives

To compare anxiolysis produced by intranasal clonidine with intranasal midazolam as premedication in children undergoing surgery.

Design

Double-blind randomized controlled study.

Setting

Tertiary-care hospital, July 2009 to June 2010.

Patients

60 American Society of Anesthesiologists physical status I–II surgical patients aged 1–10 yr.

Intervention

Participants randomly allocated to receive either intranasal clonidine 4 mcg/kg (Group I) with atropine or intranasal midazolam 0.3 mg/kg (Group II).

Outcome Measures

Primary: satisfactory anxiolysis at 30 min after drug administration. Secondary: satisfactory mask acceptance, times of onset of sedation and anxiolysis, drug acceptance, level of sedation, wake-up score and side effects.

Results

All children achieved satisfactory anxiolysis at 30 min. Group I fared significantly better than Group-II on mask acceptance (100% in Group I vs. 80% in Group II; P=0.024), drug acceptance (93% vs. 13%; P<0.001) and proportion of patients with satisfactory wake-up scores (100% vs. 53%; P<0.001). Group II patients had significantly faster onset of sedation (median 10 min vs. 15 min; P<0.05) but not that of anxiolysis compared to Group-I (median 10 min for both groups; P>0.05). Side effects were significantly more frequent in Group II.

Conclusions

Though intranasal midazolam produced faster sedation, both the drugs produced satisfactory anxiolysis at 30 min.     

Risk factors for mortality in community-acquired pneumonia among children aged 1–59 months admitted in a referral hospital

Objective

To determine the case fatality rate and factors for death in community acquired pneumonia among children aged 1 month to 59 months admitted in a referral Hospital.

Design

Hospital based retrospective study.

Setting

Institute of Child Health and Hospital for Children, Chennai.

Patients

Case records of children aged 1 month to 59 months of age with pneumonia (clinically diagnosed pneumonia, radiologically diagnosed pneumonia, and clinically and radiologically diagnosed pneumonia), from January 2006 to December 2008.

Outcome measures

Case fatality rate (CFR) was calculated. Risk factors for mortality analyzed were young age of 1 to 6 months old, female sex, wheeze, respiratory rate ??70/min, chest indrawing, altered level of consciousness, convulsions, shock, associated heart disease, recent measles, weight for age <?2 Z score and need for assisted ventilation. The association of risk factors to mortality was arrived at for all three categories of pneumonia cases separately.

Results

Case fatality rate was 8.2% (95% CI: 7.37?C8.99%). There was no significant difference in the CFR among the three study groups. Need for assisted ventilation alone was found to be an independent risk factor for mortality in children with pneumonia among all the study groups. Other risk factors like young age, weight for age <-2 Z score, altered level of consciousness, and congenital heart disease were also observed among these groups.

Conclusion

Among 1 month to 59 months old hospitalized children with pneumonia, CFR was 8.2%. Need for assisted ventilation was a significant risk factor associated with mortality.     

Predictors of Stress Among Parents in Pediatric Intensive Care Unit: A Prospective Observational Study

Objective

To determine the sociodemographic and clinical factors leading to stress among parents whose children are admitted in pediatric intensive care unit (PICU).

Methods

A prospective observational study was conducted in PICU of a tertiary care hospital of north India. Parents of children admitted to PICU for at least 48 h duration were eligible for participation. At the end of 48 h, parental stress was assessed using parental stress scale (PSS:PICU) questionnaire which was administered to the parents. Baseline demographic and clinical parameters of children admitted to PICU were recorded. The parental stress was compared with demographic and clinical characteristics of children using appropriate statistical methods.

Results

A total of 49 parents were finally eligible for participation. Mean (SD) parental stress scores was highest in domains of procedures [1.52 (0.66)] and behavior and emotional [1.32 (0.42)] subscales. Mean (SD) total parental stress score among intubated children [1.31 (0.25)] was significantly more than among non intubated children [0.97 (0.26)] (p?p?=?0.15) and socioeconomic status (p?=?0.32). On subscale analysis, it was found that professional communication is a significant stressor in age groups 0–12 mo [0.61(0.41)] (p?=?0.02). It was observed that parents of intubated children were significantly stressed by the physical appearance of their children (p?p?=?0.008) and impairment in parental role (p?=?0.002). Total parental stress score had a positive correlation with PRISM score (r?=?0.308).

Conclusions

Indian parents are stressed maximally with environment of PICU. Factor leading to parental stress was intubation status of the child and was not affected by gender or socio demographic profile of the parents.     

Hypophosphatemia in Critically Ill Children: Risk Factors,Outcome and Mechanism

Objectives

To determine the prevalence of hypophosphatemia in critically ill children and its association with clinical outcomes; to determine risk factors and mechanism of hypophosphatemia.

Methods

Levels of serum phosphate, phosphate intake, renal phosphate handling indices and blood gases were measured on days 1, 3, 7 and 10 of pediatric intensive care unit (PICU) stay. Hypophosphatemia was defined as any serum phosphorus <3.8 mg/dl for children younger than 2 y and <3.5 mg/dl for children 2 y or older. Renal phosphate loss was assessed using the ratio of tubular maximum reabsorption of phosphate (TmP) to glomerular filtration rate (GFR) [TmP/GFR].

Results

Prevalence of hypophosphatemia was 71.6 % (95 % CI: 64.6–78.6). On adjusted analysis, hypophosphatemia was associated with prolonged PICU length of stay (PICU LOS > 6 d) (adjusted OR: 3.0 [95 % CI: 1.4–6.7; p = 0.005]) but not associated with increased mortality. Renal phosphate threshold was significantly lower on all the days in hypophosphatemic group compared to that of non-hypophosphatemic group. No statistically significant difference in the amount of phosphate intake was seen in both the groups.

Conclusions

Hypophosphatemia is highly prevalent in critically ill children and is associated with prolonged PICU LOS. Increased phosphate loss in urine is one of the mechanism responsible for hypophosphatemia in critically ill children.

     

Validation of Pediatric Index of Mortality-2 Scoring System in a Single Pediatric Intensive Care Unit in Iran

Objective

A study to validate and calibrate Pediatric Index of Mortality-2 (PIM2) in children admitted to our pediatric intensive care unit (PICU).

Methods

This is a prospective cohort study performed in Bahrami Children''s Hospital affiliated to Tehran University of Medical Sciences. We studied the patients admitted to PICU from May 2007 to November 2008. Clinical measures were identified upon arrival in PICU. We used PIM2 score and logistic regression analysis to compare expected mortality risk with observed mortality rate. Receiver operating characteristics (ROC) curve analysis was done and standardized mortality ratio was calculated. PIM2 Index assessment was performed by use of Hosmer and Lemeshow goodness-of-fit test.

Findings

240 patients were included in this study. The model fit was achieved adequately (P value=0.741). The area under the ROC curve was 0.795 (0.715-0.875 for 95% confidence interval) and standardized mortality ratio was 1.8 (1.28-2.465 for 95% confidence interval) High-risk group diagnosis with adjusted odds ratio (AOR)=14.75, pupil reaction to light (AOR=0.13) and duration of stay in PICU (AOR=1.03) had significant statistical association to pediatric mortality.

Conclusion

PIM2 is a good index for prediction of mortality in our pediatric intensive care unit. This study revealed that there is significant statistical association between the children mortality and the length of hspita;ization, pupillary light reflex and the risk level category on admission.     

The efficacy of measurement of the serum beta-d glucan in the patients with biliary atresia

Background

The pediatric end-stage liver disease (PELD) score is not a direct index that reflects the degree of hepatocellular injury. Beta-d glucan (BDG) in the portal vein blood is processed by the hepatic reticuloendothelial system. It is possible that the hepatic clearance of BDG may be used as a biological index to assess the liver function. In this study, the relationship between PELD score and hepatic clearance of BDG was made clear in order to study the efficacy of measurement of the serum BDG.

Methods

This study including 21 patients with biliary atresia (BA) who underwent liver transplantation (LT) was performed. The BDG was measured in the preoperative peripheral vein blood and the portal vein blood at the time of LT.

Results

The portal vein blood showed a significantly high level of BDG than the peripheral vein blood (p?<?0.01). There was a significant negative correlation between the PELD score and the hepatic clearance of BDG in the 10 patients who were indicated for LT due to liver failure (p?<?0.01).

Conclusion

The serum BDG can be used as a biological index in place of liver metabolism and should be measured in BA patients as a non-invasive indicator of the degree of progression of liver failure.     

Healthcare-associated infections in a neonatal intensive care unit in Turkey

Objective

To determine the incidence, risk factors, mortality rate, antibiotic susceptibility and causative agents of healthcare-associated infections (HAIs) in the Neonatal Intensive Care Unit.

Design

Prospective, cohort.

Setting

A 38-bed, teaching, referral, neonatal intensive-care unit.

Participants

All patients in the neonatal intensive care unit who did not have any sign of infection at admission and remained hospitalized for at least 48 hours.

Methods

The study was conducted between January 2009 and January 2011. Healthcare-associated infection was diagnosed according to the criteria of CDC. Risk factors for HAI were analyzed with univariate and multivariate regression analysis.

Results

The incidence of HAI was found to be 16.2%. Blood stream infection was observed as the most common form of HAI (73.2%). The mortality rate was 17.3%. Antenatal steroid use, cesarean section, male gender, low birth weight, parenteral nutrition, percutaneous and umbilical catheter insertion, mechanical ventilation and low Apgar scores were found to be related with HAI (P<0.05). A 10% reduction in infection rate as a consequence of the application of a new total parenteral nutrition guideline was observed. Coagulase negative staphylococci (44. 4%) and Klebsiella pneumoniae (25.9%) were the most common etiologic agents isolated from cultures. Methicillin resistance of coagulase-negative staphylococci and ESBL resistance of Klebsiella pneumoniae were 72% and 44%, respectively.

Conclusions

Antenatal steroid was found to be associated with HAI. Newly applied total parenteral nutrition guidelines reduced the attack rate of infection. Efforts should be focused on developing more effective prevention strategies to achieve better outcomes.     

The impact of hydration on renal measurements and on cortical echogenicity in children

Background

Kidney ultrasonography is frequently performed in children; to date there are no specific guidelines regarding hydration before the examination.

Objective

Because certain renal measurements can be indicative of pathology, we used sequential US images to investigate the effect of standardised hydration in children relative to renal size, echogenicity and pelvic expansion.

Materials and methods

Thirty-one children (7 years to 14 years old) underwent US examinations before hydration (T0) and at 30 min (T30) and 60 min (T60) after ingesting water. We measured bladder volume, inter-polar kidney size, renal volume and anterior-posterior diameter of the pelvis. Cortical echogenicity was compared to that of the liver and spleen.

Results

On the right side the increase in average inter-polar renal size was 2.5% at T30 and 2.6% at T60 (P?<?0.05) compared to T0. On the left the increase was 3.8% at T30 and 4.3% at T60 (P?<?0.05). Volume expansion for the right kidney was 16.8% at T30 and 14.0% at T60 (P?<?0.05). On the left it was 12.9% at T30 and 10.2% at T60 (P?<?0.05). Cortical echogenicity progressed from hypoechogenicity to isoechogenicity (P?<?0.05). The percentage of expanded pelves increased with hydration (T0: 3.2%, T30: 9.7%, T60: 22.6%).

Conclusion

Oral hydration influences renal length, volume and echogenicity in children. Hydration results in expansion of the pelvis. We recommend standardisation of hydration before US examination.     

Predictors of Mortality in Hospitalized Children with Pandemic H1N1 Influenza 2009 in Pune, India

Objective

To analyse the factors associated with increased mortality among Indian Children with H1N1.

Methods

Data were abstracted from available hospital records of children less than 12?y of age, who were admitted to Sassoon General Hospital in Pune, India, with confirmed pandemic 2009 H1N1 influenza infection from August 2009 through January 2010. Logistic regression analysis was used to identify clinical characteristics associated with mortality.

Results

Of 775 pediatric cases admitted with Influenza Like Illness (ILI), 92 (11.8%) had confirmed H1N1 influenza infection. The median age of HIN1 cases was 2.5?y; 13 (14%) had an associated co-morbid condition. Median duration of symptoms was 4?d (interquartile range (IQR), 3?C7?d). All 92 H1N1 cases received oseltamivir and empiric antimicrobials on admission. Intensive care unit (ICU) admission was required for 88 (96%) children, and 20 (23%) required mechanical ventilation.Fifteen children (16%) died; mortality was associated with presence of diffuse alveolar infiltrate on admission chest radiography (odds ratio (OR) 45, 95%CI :5.4?C370; p?p?=?0.001), SpO₂ <80% on admission (OR 32.8, 95% CI: 5.8?C185.5; p?p?n?=?4 each, 27%) with gram positive organisms consistent with severe viral and bacterial co-infection.

Conclusions

Hypoxia, ARDS and use of corticosteroids in children with ARDS who were mechanically ventilated were the factors associated with increased odds of mortality. Necropsy also suggested bacterial co-infection as a risk factor.     

Incidence and Etiology of Acute Kidney Injury in Southern India

Objectives

To determine the incidence, etiology, short term outcome and predictors of mortality in hospitalized children aged 1 mo to 13 y with Acute Kidney Injury (AKI).

Methods

This prospective observational study was conducted in the pediatric wards and the pediatric intensive care unit (PICU) of a tertiary hospital in southern India, to study the clinico-etiological profile of AKI (defined according to the Acute Kidney Injury Network criteria). From June 2010 through March 2011, 2376 children were included in the study.

Results

The incidence of AKI was 5.2 % in the pediatric wards and 25.1 % in the PICU. AKI occurred in association with infections (55.4 %), acute glomerulonephritis (16.9 %), cardiac disease (4.8 %), envenomations (4.2 %) and hemolytic uremic syndrome (3.6 %). Pneumonia constituted 26.1 % of the infections. Tropical febrile illnesses (dengue, scrub typhus, enteric fever, cholera, tuberculosis, malaria and leptospirosis) constituted 15.6 % of children with AKI. Dialysis was required in 14.5 % of patients; mortality was 17.5 %. A significant proportion of children (17.5 % of survivors) had partial renal recovery at discharge. On multivariate logistic regression, dysnatremia and meningoencephalitis were independent predictors of mortality in AKI.

Conclusions

The incidence of AKI is high in the patient population, including the non-critically ill children. AKI continues to be associated with adverse outcomes. Presence of dysnatremia and meningoencephalitis are poor predictors of outcome in AKI.