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Maya M, Rameshkumar R, Selvan T, Delhikumar CG. High-Flow Nasal Cannula Versus Nasal Prong Bubble Continuous Positive Airway Pressure in Children With Moderate to Severe Acute Bronchiolitis: A Randomized Controlled Trial. Pediatr Crit Care Med 2024:00130478-990000000-00336. [PMID: 38639564 DOI: 10.1097/pcc.0000000000003521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
OBJECTIVES To compare high-flow nasal cannula (HFNC) versus nasal prong bubble continuous positive airway pressure (b-CPAP) in children with moderate to severe acute bronchiolitis. DESIGN A randomized controlled trial was carried out from August 2019 to February 2022. (Clinical Trials Registry of India number CTRI/2019/07/020402). SETTING Pediatric emergency ward and ICU within a tertiary care center in India. PATIENTS Children 1-23 months old with moderate to severe acute bronchiolitis. INTERVENTION Comparison of HFNC with b-CPAP, using a primary outcome of treatment failure within 24 hours of randomization, as defined by any of: 1) a 1-point increase in modified Wood's clinical asthma score (m-WCAS) above baseline, 2) a rise in respiratory rate (RR) greater than 10 per minute from baseline, and 3) escalation in respiratory support. The secondary outcomes were success rate after crossover, if any, need for mechanical ventilation (invasive/noninvasive), local skin lesions, length of hospital stay, and complications. RESULTS In 118 children analyzed by intention-to-treat, HFNC (n = 59) versus b-CPAP (n = 59) was associated with a lower failure rate (23.7% vs. 42.4%; relative risk [95% CI], RR 0.56 [95% CI, 0.32-0.97], p = 0.031). The Cox proportion model confirmed a lower hazard of treatment failure in the HFNC group (adjusted hazard ratio 0.48 [95% CI, 0.25-0.94], p = 0.032). No crossover was noted. A lower proportion escalated to noninvasive ventilation in the HFNC group (15.3%) versus the b-CPAP group (15.3% vs. 39% [RR 0.39 (95% CI, 0.20-0.77)], p = 0.004). The HFNC group had a longer median (interquartile range) duration of oxygen therapy (4 [3-6] vs. 3 [3-5] d; p = 0.012) and hospital stay (6 [5-8.5] vs. 5 [4-7] d, p = 0.021). No significant difference was noted in other secondary outcomes. CONCLUSION In children aged one to 23 months with moderate to severe acute bronchiolitis, the use of HFNC therapy as opposed to b-CPAP for early respiratory support is associated with a lower failure rate and, secondarily, a lower risk of escalation to mechanical ventilation.
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Affiliation(s)
- Malini Maya
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
- Pediatric Intensive Care Unit, Department of Pediatrics, Mediclinic City Hospital, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Tamil Selvan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Chinnaiah Govindhareddy Delhikumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Kandasamy S, Rameshkumar R, Sangaralingam T, Krishnamoorthy N, Shankar NCG, Vijayakumar V, Sridharan B. High-flow nasal oxygen in infants and children for early respiratory management of pneumonia-induced acute hypoxemic respiratory failure: the CENTURI randomized clinical trial. Intensive Care Med Paediatr Neonatal 2024; 2:15. [PMID: 38567201 PMCID: PMC10982089 DOI: 10.1007/s44253-024-00031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/01/2024] [Indexed: 04/04/2024]
Abstract
Objective To compare the effectiveness of early high-flow nasal cannula (HFNC) and low-flow oxygen support (LFOS) in children under 5 years with acute hypoxemic respiratory failure (AHRF) due to severe community-acquired pneumonia in low-middle-income countries. Methods An open-label randomized clinical trial enrolled children aged 2-59 months with AHRF due to severe community-acquired pneumonia and randomized into HFNC and LFOS. In the LFOS group, the patient received cold wall oxygen humidified by bubbling through sterile water administered through simple nasal prongs at a fixed flow rate of 2 L/min. In the HFNC group, the patient received humidified, heated (37 °C), high-flow oxygen at a flow rate assigned based on weight range, with a titratable oxygen fraction. The primary outcome was treatment failure in 72 h (escalating the respiratory support method using any modality other than primary intervention). Results Data was analyzed intention-to-treat (HFNC = 124; LFOS = 120). Median (IQR) age was 12 (6-20) and 11 (6-27) months, respectively. Treatment failure occurred in a significantly lower proportion in the HFNC group (7.3%, n = 9/124) as compared to the LFOS group (20%, n = 24/120) (relative risk = 0.36, 95% CI 0.18 to 0.75; p = 0.004; adjusted hazard ratio 0.34, 95% CI 0.16 to 0.73; p = 0.006). The intubation rate was significantly lower in the HFNC group (7.3%, n = 9/124 vs. 16.7%, n = 20/120; relative risk = 0.44, 95% CI 0.21 to 0.92, p = 0.023). There were no significant differences noted in other secondary outcomes. No mortality occurred. Conclusion High-flow nasal cannula oxygen therapy used as early respiratory support in children under 5 years with acute hypoxemic respiratory failure due to severe community-acquired pneumonia was associated with significantly lower treatment failure compared with standard low-flow oxygen support. Trial registration CTRI/2016/04/006788. Registered 01 April 2016, https://ctri.nic.in/Clinicaltrials/advsearch.php. Supplementary Information The online version contains supplementary material available at 10.1007/s44253-024-00031-8.
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Affiliation(s)
- Sasidaran Kandasamy
- Advanced Pediatric Critical Care Centre, Pediatric Acute Care Education & Research (PACER) Unit, Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006 India
- Present Address: Pediatric Critical Care, Mediclinic City Hospital, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates
| | | | | | - N. C. Gowri Shankar
- Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Vimalraj Vijayakumar
- Advanced Pediatric Critical Care Centre, Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Balaji Sridharan
- Pediatric Acute Care Education and Research (PACER) Unit, Department of Pediatrics, Mehta Multi-Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
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Sankar J, Muralidharan J, Lalitha AV, Rameshkumar R, Pathak M, Das RR, Nadkarni VM, Ismail J, Subramanian M, Nallasamy K, Dev N, Kumar UV, Kumar K, Sharma T, Jaravta K, Thakur N, Aggarwal P, Jat KR, Kabra SK, Lodha R. Multiple Electrolytes Solution Versus Saline as Bolus Fluid for Resuscitation in Pediatric Septic Shock: A Multicenter Randomized Clinical Trial. Crit Care Med 2023; 51:1449-1460. [PMID: 37294145 DOI: 10.1097/ccm.0000000000005952] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine if initial fluid resuscitation with balanced crystalloid (e.g., multiple electrolytes solution [MES]) or 0.9% saline adversely affects kidney function in children with septic shock. DESIGN Parallel-group, blinded multicenter trial. SETTING PICUs of four tertiary care centers in India from 2017 to 2020. PATIENTS Children up to 15 years of age with septic shock. METHODS Children were randomized to receive fluid boluses of either MES (PlasmaLyte A) or 0.9% saline at the time of identification of shock. All children were managed as per standard protocols and monitored until discharge/death. The primary outcome was new and/or progressive acute kidney injury (AKI), at any time within the first 7 days of fluid resuscitation. Key secondary outcomes included hyperchloremia, any adverse event (AE), at 24, 48, and 72 hours, and all-cause ICU mortality. INTERVENTIONS MES solution ( n = 351) versus 0.9% saline ( n = 357) for bolus fluid resuscitation during the first 7 days. MEASUREMENTS AND MAIN RESULTS The median age was 5 years (interquartile range, 1.3-9); 302 (43%) were girls. The relative risk (RR) for meeting the criteria for new and/or progressive AKI was 0.62 (95% CI, 0.49-0.80; p < 0.001), favoring the MES (21%) versus the saline (33%) group. The proportions of children with hyperchloremia were lower in the MES versus the saline group at 24, 48, and 72 hours. There was no difference in the ICU mortality (33% in the MES vs 34% in the saline group). There was no difference with regard to infusion-related AEs such as fever, thrombophlebitis, or fluid overload between the groups. CONCLUSIONS Among children presenting with septic shock, fluid resuscitation with MES (balanced crystalloid) as compared with 0.9% saline resulted in a significantly lower incidence of new and/or progressive AKI during the first 7 days of hospitalization.
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Affiliation(s)
- Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jayashree Muralidharan
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - A V Lalitha
- Department of Pediatrics Intensive Care, St Johns' Medical College Bengaluru, India
| | | | - Mona Pathak
- Research and Development Department, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | | | - Vinay M Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Javed Ismail
- Pediatric Intensive Care Unit, NMC Royal Hospital Khalifa City, Abu Dhabi, United Arab Emirates
| | - Mahadevan Subramanian
- Division of Pediatric Critical Care, Department of Pediatrics, JIPMER, Puducherry, India
| | - Karthi Nallasamy
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | - Nishanth Dev
- Department of Medicine, VMMC and Safdarjung Hospital, New Delhi, India
| | - U Vijay Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kiran Kumar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Taniya Sharma
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kanika Jaravta
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Thakur
- Division of Pediatric Critical Care, Department of Pediatrics, PGIMER, Chandigarh, India
| | | | - Kana Ram Jat
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - S K Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Subramani S, Parameswaran N, Ananthkrishnan R, Abraham S, Chidambaram M, Rameshkumar R, Subramanian M. Assessment of the Endotracheal Tube Tip Position by Bedside Ultrasound in a Pediatric Intensive Care Unit: A Cross-sectional Study. Indian J Crit Care Med 2022; 26:1218-1224. [PMID: 36873587 PMCID: PMC9983650 DOI: 10.5005/jp-journals-10071-24355] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction The chest X-ray (CXR) is the standard of practice to assess the tip of the endotracheal tube (ETT) in ventilated children. In many hospitals, it takes hours to get a bedside CXR, and it has radiation exposure. The objective of this study was to find the utility of bedside ultrasound (USG), in assessing the ETT tip position in a Pediatric Intensive Care Unit (PICU). Methods It was a prospective study conducted in the PICU of a tertiary care center involving 135 children aged from 1 month to 60 months, requiring endotracheal intubation. In this study, the authors compared the position of the ETT tip by the CXR (gold standard) and USG. The CXR was taken in children to assess the correct position of the tip of ETT. The USG was used to measure the distance between the tip of ETT and the arch of the aorta, thrice in the same patient. The mean of the three USG readings was compared with the distance between the tip of the ETT and carina in CXR. Results The reliability of three USG readings was tested by absolute agreement coefficient in intraclass correlation (ICC), 0.986 (95% CI: 0.981-0.989). The sensitivity and specificity of the USG in identifying the correct position of the ETT tip in children when compared to CXR were 98.10% (95% CI: 93.297-99.71%) and 50.0% (95% CI: 31.30-68.70%), respectively. Conclusion In ventilated children <60 months of age, identifying the tip of ETTs by bedside the USG has good sensitivity (98.10%) but poor specificity (50.0%). How to cite this article Subramani S, Parameswaran N, Ananthkrishnan R, Abraham S, Chidambaram M, Rameshkumar R, et al. Assessment of the Endotracheal Tube Tip Position by Bedside Ultrasound in a Pediatric Intensive Care Unit: A Cross-sectional Study. Indian J Crit Care Med 2022;26(11):1218-1224.
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Affiliation(s)
- Seenivasan Subramani
- Department of Pediatric Intensive Care, Madras Medical College, Chennai, Tamil Nadu, India
| | - Narayanan Parameswaran
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Ramesh Ananthkrishnan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Shilpa Abraham
- Department of Pediatrics, Believers Church Medical College, Thiruvalla, Kerala, India
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Ramachandran Rameshkumar
- Department of Paediatrics, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Mahadevan Subramanian
- Director, Sri Venkateshwaraa Medical College Hospital & Research Centre, Ariyur, Puducherry, India
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Jain P, Rameshkumar R, Satheesh P, Mahadevan S. Erratum to: Early goal-directed therapy with and without intermittent superior vena cava oxygen saturation monitoring in pediatric septic shock: A randomized controlled trial. Indian Pediatr 2022. [PMCID: PMC9065229 DOI: 10.1007/s13312-022-2507-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Puneet Jain
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006 India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006 India
| | - Ponnarmeni Satheesh
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006 India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006 India
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Rameshkumar R, Jain P. Authors’ Reply. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2511-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kallekkattu D, Rameshkumar R, Chidambaram M, Krishnamurthy K, Selvan T, Mahadevan S. Threshold of Inotropic Score and Vasoactive-Inotropic Score for Predicting Mortality in Pediatric Septic Shock. Indian J Pediatr 2022; 89:432-437. [PMID: 34318405 PMCID: PMC8315255 DOI: 10.1007/s12098-021-03846-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/07/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the threshold of the inotropic score (IS) and vasoactive-inotropic score (VIS) for predicting mortality in pediatric septic shock. METHOD This retrospective cohort study included children aged 1 mo to 13 y with septic shock, requiring vasoactive medication. The area under curve receiver operating characteristic (AUROC) was calculated using mean IS and mean VIS to predict PICU mortality, and Youden index cut points were generated. Sensitivity, specificity, and binary regression analysis were performed. RESULTS A total of 176 patients were enrolled (survivor, n = 72, 41% and nonsurvivor, n = 104, 59%). For predicting the PICU mortality, AUROC (95% CI) of IS was 0.80 (0.74-0.86) [sensitivity of 88.5 (80.7-94) and specificity of 58.3 (46.1-69.8)] and AUROC of VIS was 0.88 (0.82-0.92) [sensitivity of 83.7 (75.1-90.2) and specificity of 80.6 (69.5-89)]. The respective cutoff scores of IS and VIS were 28 and 42.5. On regression analysis (adjusted odds ratio, 95% CI), illness severity (PRISM-III) (1.12, 1.05-1.12), worst lactate value (1.31, 1.08-1.58), IS (> 28) (3.98, 1.24-12.80), and VIS (> 42.5) (4.66, 1.57-13.87) independently predicted the PICU mortality (r2 = 0.625). CONCLUSION Threshold of inotropic score (> 28) and vasoactive-inotropic score (> 42.5) were independently associated with PICU mortality. In addition to IS and VIS, severity and worst lactate value independently predicted septic shock mortality in PICU.
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Affiliation(s)
- Dipu Kallekkattu
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | | | - Tamil Selvan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
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Rameshkumar R. Trial of Furosemide to Prevent Acute Kidney Injury in Critically Ill Children: A Double-Blind, Randomized, Controlled Trial: Author's Reply. Indian J Pediatr 2022; 89:527. [PMID: 35320502 DOI: 10.1007/s12098-022-04100-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/18/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India.
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Rameshkumar R, Jain P. Early Goal-Directed Therapy and Superior Vena Cava Oxygen Saturation Monitoring in Pediatric Septic Shock: Few Concerns: Authors' Reply. Indian Pediatr 2022; 59:347. [PMID: 35410979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- R Rameshkumar
- Department of Pediatrics, JIPMER, Puducherry 605 006.
| | - P Jain
- Department of Pediatrics, JIPMER, Puducherry 605 006
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Bhowmick R, Rameshkumar R, Ponnusamy M, Rajaraman V, Chidambaram M, Sheriff A, Mahadevan S. Modified Schwartz formula and 99mTc-DTPA plasma clearance methods to calculate glomerular filtration rate in critically ill children. Pediatr Nephrol 2022; 37:899-906. [PMID: 34546418 DOI: 10.1007/s00467-021-05197-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Studies comparing the modified Schwartz formula with measured GFR (m-GFR) are lacking in critically ill children. METHODS This prospective cohort study enrolled children aged 1 month to 12 years, within 24 h of admission. m-GFR measured by technetium-99m-labeled diethylenetriaminepentaacetic acid (99mTc-DTPA) and calculated by Russell's two-sample slope-intercept method. Serum creatinine was estimated by modified Jaffe method and estimated GFR (e-GFR) calculated by modified Schwartz formula. The primary outcome was to find agreement between the two methods. Bias, precision, and accuracy were calculated. Secondary outcomes were the incidence of AKI (by p-RIFLE criteria) and the difference between the two methods to diagnose AKI. RESULTS A total of 208 pairs were analyzed. e-GFR showed good agreement with m-GFR with a mean bias of -4.37 ml/min/1.73 m2 and precision (SD of bias) of 33.07, 95% limit of agreement -69.18 to 60.45, and intraclass correlation of 74% (95%CI 66-80%, P < 0.001). e-GFR underestimated m-GFR by 19.8% (95% CI 7.9-31.7%). Accuracy of e-GFR values within 10%, 20%, and 30% of m-GFR were 68.3%, 72.6%, and 78.8%, respectively. Incidence of AKI within 24 h was 60.1% by e-GFR and 54.3% by m-GFR (kappa 0.569, P < 0.001; sensitivity of 85.8%, 95%CI (78-91.7%). CONCLUSIONS The modified Schwartz formula shows good agreement with 99mTc-labeled DTPA double plasma sample clearance method for calculating GFR in critically ill children aged 1 month to 12 years. The underestimation of GFR should be kept in mind while applying the formula at the bedside in PICU. TRIAL REGISTRATION Protocol accessible at Clinical Trial Registry of India (CTRI) www.ctri.nic.in . (Trial Registered Prospectively and Registration No. CTRI/2017/10/010014) ([Registered on: 06/10/2017] Trial Registered Prospectively.) (Title "Measured glomerular filtration rate using Diethylenetriaminepentaacetic acid (DTPA) renal scan versus estimated glomerular filtration rate using modified Schwartz formula in critically ill children: A prospective observational, analytical study."). A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Rohit Bhowmick
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India.
| | - Madhusudhanan Ponnusamy
- Department of Nuclear Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Vishnukumar Rajaraman
- Department of Nuclear Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India.,Department of Pediatrics, Saveetha Medical College, Chennai, Tamil Nadu, 600004, India
| | - Abraar Sheriff
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
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Rameshkumar R, Chidambaram M, Bhanudeep S, Krishnamurthy K, Sheriff A, Selvan T, Mahadevan S. Prospective Cohort Study on Cumulative Fluid Balance and Outcome in Critically Ill Children Using a Restrictive Fluid Protocol. Indian J Pediatr 2022; 89:226-232. [PMID: 34106444 DOI: 10.1007/s12098-021-03788-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To study the association of cumulative fluid balance and clinical outcomes in a pediatric intensive care unit (PICU) practicing restrictive fluid protocol. METHODS In this prospective cohort study, children aged less than 13 y admitted for more than 48 h were screened. Children with unstable hemodynamics throughout the stay were excluded. Fluid balance was calculated by percentage fluid overload (%FO) for the first 7 d. Patients were divided into positive fluid and negative fluid balance groups. The primary outcome was all-cause 28-d mortality. RESULTS A total of 888 patients (positive fluid balance group = 531, negative fluid balance group = 357) were analyzed. Mean (SD) cumulative %FO was 1.52 (0.67) vs. -1.18 (0.71), p = < 0.001, and minimum and maximum cumulative %FO were -3.0% and 3.1%, respectively. There was no significant difference in all-cause 28-d mortality between the two groups (n = 104/531, 19.6% vs. n = 60/357, 16.8%, RR = 1.17, 95% CI 0.87 to 1.55; p = 0.29). There was no difference in organ dysfunction [mean (SD) sequential organ failure assessment (SOFA) score 3.3 (0.7) vs. 3.3 (0.6)], acute kidney injury (65% vs. 63.6%), need for renal replacement therapy (14% vs. 13%), and duration of ventilation (median, IQR 4, 2-6 vs. 4, 2-6 d). Longer stay in PICU (5, 3-9 vs. 4, 3-7 d; p = 0.014) and in hospital (8, 5-11 vs. 7, 4-10 d; p = 0.007) were noted in the positive fluid balance group. CONCLUSION Cumulative fluid balance within 3% using restrictive fluid protocol was not associated with a significant difference in PICU mortality and morbidity.
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Affiliation(s)
- Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Singanamalla Bhanudeep
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | | | - Abraar Sheriff
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Tamil Selvan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
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Rameshkumar R. Refractory status epilepticus in children: What Indian scenario needs now and future? J Pediatr Crit Care 2022. [DOI: 10.4103/jpcc.jpcc_73_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Jain P, Rameshkumar R, Satheesh P, Mahadevan S. Early Goal-Directed Therapy With and Without Intermittent Superior Vena Cava Oxygen Saturation Monitoring in Pediatric Septic Shock: A Randomized Controlled Trial. Indian Pediatr 2021; 58:1124-1130. [PMID: 34047722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To compare early goal-directed therapy (EGDT) 'with' and 'without' intermittent superior vena cava oxygen saturation (ScvO2) monitoring in pediatric septic shock. DESIGN Open label randomized controlled trial. SETTING Pediatric intensive care unit in a tertiary care center. PARTICIPANTS Children aged 1 month to 12 year with septic shock. INTERVENTION Patients not responding to fluid resuscitation (up to 40 mL/kg) were randomized to EGDT 'with' (n=59) and 'without' (n=61) ScvO2 groups. Resuscitation was guided by ScvO2 monitoring at 1-hour, 3-hour, and later on six-hourly in the 'with' ScvO2 group, and by clinical variables in the 'without' ScvO2 group. OUTCOME Primary outcome was all-cause 28-day mortality. Secondary outcomes were time to and proportion of patients achieving therapeutic endpoints (at 6 hours and PICU stay), need for organ supports, new organ dysfunction (at 24 hours and PICU stay), and length of PICU and hospital stay. RESULTS The study was stopped after interim analysis due to lower mortality in the intervention group. There was significantly lower all-cause 28-day mortality in EDGT with ScvO2 than without ScvO2 group [37.3% vs. 57.5%, adjusted hazard ratio 0.57, 95%CI 0.33 to 0.97, P=0.04]. Therapeutic endpoints were achieved early in 'with' ScvO2 group [mean (SD) 3.6 (1.6) vs. 4.2 (1.6) h, P=0.03]. Organ dysfunction by sequential organ assessment score during PICU stay was lower in 'with' ScvO2 group [median (IQR) 5 (2,11) vs. 8 (3,13); P=0.03]. There was no significant difference in other secondary outcomes. CONCLUSIONS EGDT with intermittent ScvO2 monitoring was associated with reduced mortality and improved organ dysfunction in pediatric septic shock.
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Affiliation(s)
- Puneet Jain
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry. Correspondence to: Dr Rameshkumar R, Associate Professor, Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605 006.
| | - Ponnarmeni Satheesh
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
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Baranwal AK, Das R, Rameshkumar R, Kumar-M P, Bhatia P, Nair A. Effect of Sepsis on Iron Parameters in a Population with High Prevalence of Malnutrition and Iron Deficiency: A Cross-Sectional Case-Control Pilot Study. Indian J Hematol Blood Transfus 2021; 37:609-615. [PMID: 34744344 DOI: 10.1007/s12288-020-01393-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/05/2020] [Indexed: 11/29/2022] Open
Abstract
There is lack of data on iron metabolism in critically ill sepsis children from population with high prevalence of iron deficiency (ID). The study was designed to study impact of sepsis on iron parameters in children with ID. Sepsis patients (age 6-59 months) and their apparently healthy sibling/cousin as controls were enrolled in this case-control pilot study. Serum iron, TIBC, transferrin saturation, ferritin and sTfR were measured in the two groups. sTfR-Ferritin index was calculated. Patients (n = 134) were significantly underweight compared to controls (n = 54) (WAZ score < - 2; 58% vs. 28%; p < 0.001). Serum iron and sTfR (mg/L) were lower [71.5 (51.0, 115.0) vs. 87.0 (64.5, 130.5), p = 0.068; 3.1 (2.1, 4.5) vs. 3.5 (2.8, 4.8), p = 0.026 respectively] while serum ferritin was higher [229 (94, 484.5) vs. 22 (9.2, 51); p < 0.001] in patients compared to controls. sTfR-Ferritin index was lower in patients [1.3 (0.8, 2.3) vs. 2.5 (1.8, 4.5); p < 0.001]. ROC AUC (patients vs. controls) were 0.89 (95% CI 0.83-0.95) and 0.76 (95% CI 0.68-0.85) for ferritin and sTfR-ferritin index respectively. Survivors and non-survivors were similar in terms of iron parameters. Sepsis-induced alterations in iron parameters among ID children are complex. Qualitatively it is similar (with quantitative differences) to non-ID adult population. Lack of correlation of iron parameters with mortality may be due to ID-associated immune dysfunction.
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Affiliation(s)
- Arun K Baranwal
- Division of Pediatric Critical Care, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Reena Das
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
| | - Praveen Kumar-M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prateek Bhatia
- Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwini Nair
- Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Gupta A, Rameshkumar R, Chidambaram M, Selvan T, Mahadevan S. A Prospective Cohort Study on Serum Sodium and Clinical Outcome in Pediatric Nontraumatic Coma. Indian J Pediatr 2021; 88:1092-1098. [PMID: 34018137 DOI: 10.1007/s12098-021-03726-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/02/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To study the serum sodium level and clinical outcome in pediatric nontraumatic coma. METHODS A prospective cohort study was conducted in a tertiary care pediatric intensive care unit (PICU) from September 2015 to June 2016. Children aged < 13 y with nontraumatic coma [modified-Glasgow Coma Scale (m-GCS) score ≤ 8 or fall of ≥ 3 from baseline within 24 h of admission] were included. Children who received intravenous fluids for > 24 h, those with developmental delay, or died within 24 h of admission were excluded. The serum sodium profile (mEq/L) in the first 72 h and clinical outcome [mortality, length of stay in mechanical ventilation, PICU, and hospital] were studied. RESULTS Eighty patients [Died n = 26 and Survived n = 54] were enrolled. Median [interquartile range (IQR)] age and m-GCS were 21 (4-78) mo and 9 (7-11), respectively. The mean [standard deviation (SD)] Pediatric Risk of Mortality-III (PRISM-III) was 17.7 (4). The most common etiology was acute central nervous system (CNS) infections (30%, n = 24) followed by an intracranial bleed (11.3%, n = 9). Mean (Standard error, SE) sodium levels and fluctuation of serum sodium from baseline up to 72 h were similar between nonsurvivors and survivors [140.8 (1.3) vs. 139.6 (0.8), p = 0.421] and [1.2 (0.3) vs. 0.8 (0.2), p = 0.307], respectively. On multivariate analysis, the need for vasoactive therapy was an independent predictor of mortality [adjusted odds ratio = 20.78, 95% CI 4.24-101.85, p = < 0.001, R2 = 0.62]. CONCLUSION Mean serum sodium within normal range and fluctuation of serum sodium of 0.8 to 1.2 mEq/L over 72 h was not associated with poor outcomes in pediatric nontraumatic coma. Vasoactive therapy was an independent predictor of mortality.
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Affiliation(s)
- Akanksha Gupta
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India.
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Tamil Selvan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
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Bhanudeep S, Rameshkumar R, Chidambaram M, Selvan T, Mahadevan S. Prospective Inverse Probability of Treatment-Weighting Analysis of the Clinical Outcome of Red Blood Cell Transfusion Practice in Critically Ill Children. Indian J Pediatr 2021; 88:985-990. [PMID: 33864604 DOI: 10.1007/s12098-021-03740-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To study the clinical outcomes of red blood cell (RBC) transfusion practices in critically ill children. METHOD This prospective cohort study was conducted in a tertiary care pediatric intensive care unit (PICU) from March-2015 to January-2018. Inverse probability of treatment weighting (IPTW) using propensity score analysis was used. Children aged 1 mo to 12 y admitted to the PICU were screened. Patients were classified into 'transfused' and 'nontransfused', based on whether they received a transfusion or not. Patients with hematological malignancies, or immunosuppressant drugs, or those who received repeated transfusions, or received transfusion before admission, or died within 24 h were excluded. The primary outcome was all-cause 28 d mortality. Secondary outcomes were new-onset organ dysfunction, mechanical ventilation duration, and length of PICU and hospital stay. RESULTS A total of 1014 patients [transfused = 277; nontransfused = 737) were included. In IPTW analysis, the risk of all-cause 28 d mortality was 53% higher in transfused than nontransfused patients [hazard ratio = 1.53, 95% CI: 1.18-1.98, p = 0.001 by Log-rank test]. Organ dysfunction was higher in transfused than nontransfused patients [3.8% vs. 1.3%, hazard ratio = 3.0, 95% CI: 1.40-6.48, p = 0.005]. The risk of staying in the mechanical ventilation was similar in both groups [hazard ratio = 1.03, 95% CI: 0.86-1.23, p = 0.756]. The risk of extended stay in the PICU and hospital was 16% and 21% higher in transfused than nontransfused patients [hazard ratio = 1.16, 95% CI: 1.03-1.30; p = 0.005; and 1.21, 95% CI: 1.08-1.36; p = 0.001], respectively. CONCLUSION Red blood cell transfusion was independently associated with higher all-cause 28 d mortality and morbidities in critically ill children.
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Affiliation(s)
- Singanamalla Bhanudeep
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India.
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
| | - Tamil Selvan
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India
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Sheriff A, Rameshkumar R, Chidambaram M, Maulik K, Kumar RS, Jamal A, Bhowmick R, Biswal N, Mahadevan S. Epinephrine Plus Vasopressin vs Epinephrine Plus Placebo in Pediatric Intensive Care Unit Cardiopulmonary Resuscitation: A Randomized Double Blind Controlled Clinical Trial. Indian Pediatr 2021; 58:624-630. [PMID: 33612485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To compare the efficacy of epinephrine plus vasopressin vs epinephrine plus placebo in the pediatric intensive care unit (PICU) cardiopulmonary resuscitation (CPR). DESIGN Randomized, double-blind controlled clinical trial. SETTING PICU in a tertiary care institute from February, 2019 to May, 2020. PARTICIPANTS Children aged one month to 13 years who required CPR during PICU stay. Patients in whom vascular access was not available or return of spontaneous circulation (ROSC) was achieved by defibrillation without epinephrine were excluded. INTERVENTION Patients were randomized to receive vasopressin 0.1 mL per kg (=0.8 unit per kg) or placebo (0.1 mL per kg normal saline) in addition to epinephrine (1:10000) 0.1 mL per kg. The drugs were given as bolus doses every three minutes until the ROSC or up to a maximum of five doses, whichever was earlier. OUTCOME MEASURE The primary outcome was the proportion of patients who achieved ROSC. The secondary outcomes were survival rate and functional status (at 24-hour, PICU, hospital, and 90-day post-discharge), need for organ supports, length of stay (PICU and hospital), and adverse effect(s) of the study drugs. RESULTS 90 patients (epinephrine plus vasopressin group, n=45 and epinephrine plus placebo group, n=45) were analyzed on intention-to-treat basis. There was no significant difference in the primary outcome between epinephrine plus vasopressin (n=25, 55.5%) and epinephrine plus placebo groups (n=24, 53.3%) (Relative risk 1.04, 95% CI 0.71 to 1.52). There was no significant difference in survival rate at 24-hour (n=7, 15.6% vs. n=8, 17.8%), at PICU, hospital, and 90-day post-discharge (n=1, 2.2% vs n=1, 2.2%). There was no difference in other secondary outcomes. No trial drug-related serious adverse events were observed. CONCLUSIONS A combination of epinephrine plus vasopressin did not improve the rate of return of spontaneous circulation in the pediatric intensive care unit cardiopulmonary resuscitation as compared with epinephrine plus placebo.
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Affiliation(s)
- Abraar Sheriff
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry. Correspondence to: Dr Rameshkumar R, Associate Professor, Division of Pediatric Critical care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605 006.
| | - Muthu Chidambaram
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Kaushik Maulik
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Routhu Santhosh Kumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Atahar Jamal
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Rohit Bhowmick
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Niranjan Biswal
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry
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Rameshkumar R, Satheesh P, Jain P, Anbazhagan J, Abraham S, Subramani S, Parameswaran N, Mahadevan S. Low-Dose (0.05 Unit/kg/hour) vs Standard-Dose (0.1 Unit/kg/hour) Insulin in the Management of Pediatric Diabetic Ketoacidosis: A Randomized Double-Blind Controlled Trial. Indian Pediatr 2021; 58:617-623. [PMID: 33612484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To compare the efficacy of insulin infusion of 0.05 Unit/kg/hour vs 0.1 Unit/kg/hour in the management of pediatric diabetic ketoacidosis (DKA). DESIGN Randomized, double-blind controlled clinical trial. SUBJECT Pediatric critical care division of a tertiary care hospital from October, 2014 to July, 2018. PARTICIPANTS Children aged 12 years or younger with a diagnosis of DKA. Children with septic shock and those who had received insulin before enrollment were excluded. INTERVENTION Low-dose (0.05 Unit/kg/hour) vs. Standard-dose (0.1 Unit/kg/hour) insulin infusion. OUTCOME MEASURES The primary endpoint was time for resolution of DKA (pH ≥7.3, bicarbonate ≥15 mEq/L, beta-hydroxybutyrate <1 mmol/L). Secondary outcomes were the rate of fall in blood glucose until 250 mg/dL or less and the rate of complications (hypokalemia, hypoglycemia, and cerebral edema). RESULTS Sixty patients were analyzed on an intention-to-treat basis (Low-dose group: n=30; Standard-dose group: n=30). Mean (SD) time taken for the resolution of ketoacidosis was similar in both groups [22 (12) vs 23 (18.5) hours; P=0.92]. The adjusted hazard ratio (95% CI) of the resolution of ketoacidosis was lower in the low-dose group [0.40 (0.19 to 0.85); P=0.017]. Mean (SD) rate of blood glucose decrease until 250 mg/dL or less reached [56 (41) vs 64 (65) mg/dL/hour; P=0.41] and time to achieve the target [4.2 (3.1) vs 4.8 (3.3) hours; P=0.44] were similar in both groups. Hypokalemia [30% vs 43.3%; P=0.28] and hypoglycemia [3.3% vs 13.3%; P=0.35] were lower in low-dose group. No child had cerebral edema, and no mortality occurred. CONCLUSIONS Time for resolution of ketoacidosis was similar in the low-dose and standard-dose insulin with a lower rate of therapy-related complications in the low-dose group. Hence, low-dose insulin infusion can be a safer approach in the management of pediatric DKA.
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Affiliation(s)
- Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry. Correspondence to: Dr R Rameshkumar, Associate Professor, Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605 006.
| | - Ponnarmeni Satheesh
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
| | - Puneet Jain
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
| | - Jagadeesh Anbazhagan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
| | - Shilpa Abraham
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
| | - Seenivasan Subramani
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
| | - Narayanan Parameswaran
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
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Rameshkumar R, Satheesh P, Jain P, Anbazhagan J, Abraham S, Subramani S, Parameswaran N, Mahadevan S. Low-Dose (0.05 Unit/kg/hour) vs Standard-Dose (0.1 Unit/kg/hour) Insulin in the Management of Pediatric Diabetic Ketoacidosis: A Randomized Double-Blind Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2255-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Sankar J, Lalitha AV, Rameshkumar R, Mahadevan S, Kabra SK, Lodha R. Use of Honey Versus Standard Care for Hospital-Acquired Pressure Injury in Critically Ill Children: A Multicenter Randomized Controlled Trial. Pediatr Crit Care Med 2021; 22:e349-e362. [PMID: 33181730 DOI: 10.1097/pcc.0000000000002611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine if the use of honey (medicated) for dressing is superior to standard care in terms of time to complete wound healing in stages 1-3 of pressure injuries in children admitted to the PICU. DESIGN Multicenter, open-label, parallel-group, randomized trial. SETTING Tertiary-care PICU from August 2017 to January 2019. PATIENTS Critically ill children, 2 months to 17 years old, who developed pressure injury (stages 1-3) were included; those on more than two inotropes or with signs of acute wound infection or wounds with greater than 5 cm diameter or known allergy to honey were excluded. INTERVENTIONS Children were randomized to receive either medicated honey dressing or standard (routine) wound care for the management of their pressure injury. MEASUREMENTS AND MAIN RESULTS The primary outcome was the time to complete wound healing. Manuka or active Leptospermum honey dressing/gel was used in the intervention group. Enrolled children were followed up until death or discharge from the hospital. A total of 99 children were enrolled: 51 in the intervention group and 48 in the standard care group. Baseline characteristics, including the nutritional status, were comparable between the groups. The most common sites of injury were bony prominences at face mask contact points. The median time to complete healing was 7 days (95% CI, 6-7 d) versus 9 days (7-10 d) in the intervention and standard care groups, respectively (p = 0.002; log-rank test). At any random time, children in the intervention group were about 1.9-fold more likely to have their pressure injury completely healed than those in the standard care group (hazard ratio 1.86; 95% CI, 1.21-2.87). There were no allergic reactions or secondary wound infections in the intervention group. CONCLUSIONS The use of medicated honey dressings decreased the time to wound healing in critically ill children with pressure injuries. There were no allergic reactions or secondary bacterial infections in any of these children.
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Affiliation(s)
- Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - A V Lalitha
- Division of Pediatric Critical Care, Department of Pediatrics, St. Johns Medical College, Bengaluru, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Sushil K Kabra
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Jain P, Rameshkumar R, Satheesh P, Mahadevan S. Early Goal-Directed Therapy With and Without Intermittent Superior Vena Cava Oxygen Saturation Monitoring in Pediatric Septic Shock: A Randomized Controlled Trial. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2392-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
BACKGROUND AND OBJECTIVES Among Southeast Asian countries, India has reported the highest mortality due to snakebite envenomation. To identify the risk factors of poor outcome (mortality/mechanical ventilation/renal replacement therapy-RRT) in pediatric snakebite envenomation. METHOD Case records of children aged less than 13 years with snakebite envenomation admitted between June 2009 and July 2015 were reviewed retrospectively. Medical records of the patient died within 6 h, those required RRT before administration of antisnake venom (ASV), and those with unknown bites were excluded. RESULTS A total of 308 patients were included. One hundred eighty (58.4%) had hemotoxic, and 128 (41.6%) had neuroparalytic envenomation. Median (interquartile range) bite to ASV time was 3 (2-6) h. Seventy-five (24.4%) patients received ASV within 6 h of bite. Poor outcomes occurred in 128 (41.6%), and 36 (11.7%) patients died. On binary logistic analysis (adjusted odds ratio, 95% confidence interval), age ≤5 years (2.97, 1.28-6.90), walking (6.15, 2.88-13.17), playing (3.36, 1.64-6.88), no tourniquet (2.39, 1.25-4.57), time to ASV more than 6 h (2.71, 1.45-5.06), fang marks (2.22, 1.21-4.07), neurotoxic envenomation (3.01, 1.11-8.13) and additional ASV dose (8.41, 2.99-23.60) were independently predicted the poor outcome (Hosmer and Lemeshow goodness of fit model p = 0.135; overall percentage of the model is 72.2% and R-square = 0.28). CONCLUSION Age below 5 years, activity at/after the bite (playing/walking), no tourniquet, a longer bite to ASV time, presence of fang marks, neurotoxic envenomation and need for additional ASV dose were independent predictors of poor outcome in pediatric snakebite envenomation.
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Affiliation(s)
- Ganapathi Suryanarayana
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605 006, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605 006, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605 006, India
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Rameshkumar R, Chidambaram M. Infusion of vasoactive drug through peripheral line: A myth or fact? J Pediatr Crit Care 2021. [DOI: 10.4103/jpcc.jpcc_9_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rameshkumar R, Bhowmick R. Dengue fever in children-identify the devils hidden. J Pediatr Crit Care 2021. [DOI: 10.4103/jpcc.jpcc_76_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Latha AV, Rameshkumar R, Bhowmick R, Rehman T. Kinetic Estimated Glomerular Filtration Rate and Severity of Acute Kidney Injury in Critically Ill Children. Indian J Pediatr 2020; 87:995-1000. [PMID: 32436154 DOI: 10.1007/s12098-020-03314-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study the Kinetic estimated Glomerular Filtration Rate (KeGFR) using serum creatinine (SCr) for the identification of acute kidney injury (AKI), stages of AKI, and extent of agreement with Kidney Disease Improving Global Outcomes (KDIGO) classification in critically ill children. METHODS A prospective observational study was conducted in a pediatric intensive care unit (PICU) in a tertiary care institute of South India from July through August 2018. Sixty children were enrolled. The patients with known End-Stage Renal Disease (ESRD), with previous renal transplantation, admission SCr more than 4 mg per dL, expired within 24 h of admission and patients who underwent Renal Replacement Therapy (RRT) before PICU admission were excluded. KeGFR was calculated for the first seven days, and the worst achieved value was determined. AKI staging by KDIGO was compared with AKI by KeGFR value. The requirement of RRT, multi-organ dysfunction syndrome (MODS), mechanical ventilation, cumulative fluid balance, PICU stay, and hospital mortality was recorded. RESULTS AKI detection by KeGFR method showed a sensitivity of 93% (95% CI 80% - 98.2%) and specificity of 76% (95% CI 49.8% - 92.2%) compared to KDIGO criteria. The good agreement between KDIGO and KeGFR values for AKI was noted (Kappa = 0.71, p < 0.001). It was observed that 81.3% (n = 13) of Group-I, 56% (n = 14) of Group-II, 77.8% (n = 7) of Group-III and 90% (n = 9) of Group-IV by KeGFR were graded as Stage-0, Stage-1, Stage-2 and Stage-3 of AKI by KDIGO criteria respectively (p < 0.001). There was no significant difference noted in secondary outcomes. The survival of children with AKI and those without AKI (by both KDIGO staging and KeGFR) showed no significant difference. CONCLUSIONS KeGFR is highly sensitive, and there is a good agreement with KDIGO criteria in the identification of AKI in critically ill children. Further research is required to validate these study results.
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Affiliation(s)
- Akarsh Vijayakumar Latha
- Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Ramachandran Rameshkumar
- Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India.
| | - Rohit Bhowmick
- Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
| | - Tanveer Rehman
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006, India
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Vignesh V, Rameshkumar R, Mahadevan S. Comparison of Phenytoin, Valproate and Levetiracetam in Pediatric Convulsive Status Epilepticus: A Randomized Double-blind Controlled Clinical Trial. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1755-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Vignesh V, Rameshkumar R, Mahadevan S. Comparison of Phenytoin, Valproate and Levetiracetam in Pediatric Convulsive Status Epilepticus: A Randomized Double-blind Controlled Clinical Trial. Indian Pediatr 2020; 57:222-227. [PMID: 32198861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To compare the efficacy of phenytoin, valproate, and levetiracetam in the management of pediatric convulsive status epilepticus. DESIGN Randomized double-blind controlled clinical trial. SETTING Pediatric critical care division in a tertiary care institute from June, 2016 to December, 2018. PARTICIPANTS 110 children aged three month to 12 year with convulsive status epilepticus. INTERVENTION Patients not responding to 0.1 mg/kg intravenous lorazepam were randomly assigned (1:1:1) to receive 20 mg/kg of phenytoin (n=35) or valproate (n=35) or levetiracetam (n=32) over 20 minutes. Patients with nonconvulsive status epilepticus, recent hemorrhage, platelet count less than 50,000 or International normalized ratio (INR) more than 2, head injury or neurosurgery in the past one-month, liver or kidney disease, suspected or known neurometabolic or mitochondrial disorders or structural malformations, and allergy to study drugs; and those who were already on any one of the study drugs for more than one month or had received one of the study drugs for current episode, were excluded. OUTCOME MEASURE The primary outcome was the proportion of patients that achieved control of convulsive status epilepticus at the end of 15 minutes after completion of the study drug infusion. Secondary outcomes were time to control of seizure, rate of adverse events, and the requirement of additional drugs to control seizure, length of ventilation, hospital stay, and functional status after three months (Glasgow Outcome Scale). RESULTS The study was stopped after the planned mid-interim analysis for futility. Intention to treat analysis was done. There was no difference in primary outcome in phenytoin (31/35, 89%), valproate (29/35, 83%), and levetiracetam (30/32, 94%) (P=0.38) groups. There were no differences between the groups for secondary outcomes. One patient in the phenytoin group had a fluid-responsive shock, and one patient in the valproate group died due to encephalopathy and refractory shock. CONCLUSIONS Phenytoin, valproate, and levetiracetam were equally effective in controlling pediatric convulsive status epilepticus.
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Affiliation(s)
- Vinayagamoorthy Vignesh
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. Correspondence to: Dr Rameshkumar Ramachandran, Associate Professor, Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Amberpet R, Sistla S, Parija SC, Rameshkumar R. Risk factors for intestinal colonization with vancomycin resistant enterococci' A prospective study in a level III pediatric intensive care unit. J Lab Physicians 2020; 10:89-94. [PMID: 29403213 PMCID: PMC5784302 DOI: 10.4103/jlp.jlp_32_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE: Vancomycin-resistant enterococci (VRE) emerged as one of the major nosocomial pathogens across the globe. Gut colonization rate with VRE is higher in patients admitted to intensive care units (ICUs) due to the higher antibiotic pressure. VRE colonization increases the risk of developing infection up to 5–10 folds. The aim of this study was to determine the rates of VRE colonization among the patients admitted to pediatric ICU (PICU) and risk factors associated with it. MATERIALS AND METHODS: Rectal swabs were collected after 48 h of admission to PICU from 198 patients. The samples were inoculated onto bile esculin sodium azide agar with 6 mg/ml of vancomycin. Growth on this medium was identified by the standard biochemical test, and minimum inhibitory concentration of vancomycin and teicoplanin was detected by agar dilution method. Resistance genes for vancomycin were detected by polymerase chain reaction. Risk factors were assessed by logistic regression analysis. RESULTS: The rates of VRE colonization in patients admitted to PICU was 18.6%. The majority of the isolates were Enterococcus faecium (75.6%) followed by Enterococcus faecalis (24.4%). One patient acquired a VRE bloodstream infection (2.6%) among colonized patients, and none of the noncolonized patients acquired the infection. Consumption of vancomycin was found to be the only risk factor significantly associated with VRE colonization. CONCLUSION: Routine surveillance and isolation of patients found to be VRE colonized may not be possible in tertiary care hospitals; however, educating health-care workers, promoting handwashing with antiseptic soaps or solutions, and antibiotic Stewardship policy may help in the reduction of vancomycin resistance and VRE colonization.
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Affiliation(s)
- Rajesh Amberpet
- Department of Microbiology, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sujatha Sistla
- Department of Microbiology, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Subhash Chandra Parija
- Department of Microbiology, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramachandran Rameshkumar
- Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Rameshkumar R, Jain P, Satheesh P, Mahadevan S. Acyclovir crystalluria: The utility of bedside urine routine microscopic examination. J Pediatr Crit Care 2020. [DOI: 10.4103/jpcc.jpcc_90_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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30
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Rameshkumar R, Balkisanji L, Satheesh P, Jain P, Jayaseelan V, Mahadevan S. A prospective cohort study on closed-circuit television monitoring and direct observation for hand hygiene compliance in a pediatric intensive care unit. Int J Adv Med Health Res 2020. [DOI: 10.4103/ijamr.ijamr_21_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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31
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Rameshkumar R, Jain P, Satheesh P, Pavani C. Giant asymmetrically peaked T-waves in a child with raised intracranial pressure due to acute central nervous system infection: A case report and review of the literature. J Pediatr Crit Care 2020. [DOI: 10.4103/jpcc.jpcc_91_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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32
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Rameshkumar R, Ravikumar N, Satheesh P, Mahadevan S. Retrospective study on 48-h fluid balance and outcome in mechanically ventilated critically ill children. J Pediatr Crit Care 2020. [DOI: 10.4103/jpcc.jpcc_83_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rameshkumar R, Kurup PM. Capillary b-hydroxybutyrate in Diabetic Ketoacidosis: Authors' Reply. Indian Pediatr 2019; 56:513. [PMID: 31278242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
| | - Praveen M Kurup
- Division of Pediatric Critical Care, Department of Pediatrics,JIPMER, Puducherry, India
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Dayal D, Yadav J, Kumar P, Goyal JP, Vasudevan J, Verma A, Kaushik JS, Vashishtha VM, Pemde HK, Balasubramanian S, Goyal A, Rameshkumar R, Kurup PM, Paul Y, Adhisivam B, Sindhu S, Virmani A, Sharma S, Gupta S. Correspondence. Indian Pediatr 2019. [DOI: 10.1007/s13312-019-1580-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kurup PM, Rameshkumar R, Soundravally R, Satheesh P. Capillary versus Serum b-hydroxybutyrate in Pediatric Diabetic Ketoacidosis. Indian Pediatr 2019; 56:126-129. [PMID: 30819992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To find the strength of agreement between point-of-care and serum b-hydroxybutyrate. METHODS 236 paired samples (capillary b-hydroxybutyrate by a point of care device and serum b-hydroxybutyrate by colorimetric enzymatic estimation) samples were collected from 26 children aged <13 years admitted with diabetic ketoacidosis. Inborn errors of metabolism and septic shock were excluded. RESULTS Capillary b-hydroxybutyrate showed excellent agreement with serum â-hydroxybutyrate with mean (SD) bias of 0.027 (0.78); 95% limit of agreement -1.51, 1.56 and intraclass correlation 96.1% (95%CI 95%-97%, P<0.001). An increase in the bias noted for value above 5 mmol/L (P<0.001) (serum measurements were higher than capillary point-of-care measure-ments). Capillary â-hydroxybutyrate correlated significantly with blood pH, anion gap,bicarbonate and carbon dioxide levels on blood gas analysis (P<0.05). CONCLUSIONS Capillary b-hydroxybutyrate estimation is a valid method for monitoring of ketonemia in pediatric diabetic ketoacidosis.
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Affiliation(s)
- Praveen M Kurup
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ramachandran Rameshkumar
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India. Correspondence to: Dr Rameshkumar R, Associate Professor, Division of Pediatric Critical care, Department of Pediatrics, (JIPMER), Puducherry 605 006, India.
| | - Rajendran Soundravally
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ponnarmeni Satheesh
- Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Abimannane A, Rameshkumar R, Satheesh P, Mahadevan S. Second Dose of Scorpion Antivenom in Children with Indian Red Scorpion (Mesobuthus tamulus) Sting Envenomation. Indian Pediatr 2018; 55:315-318. [PMID: 29428915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To study the effect of the second dose of scorpion antivenom in children with non-resolving or worsening scorpion sting envenomation. METHODS 72 children aged ≤12 years with scorpion sting envenomation grade 2 and above were enrolled. 61 received the first dose of three vials of antivenom at admission (group A). Children with persistent/worsening envenomation at 6 hours received the second dose (group B). The time required for resolution of autonomic symptoms, myocardial dysfunction, predictors of the second dose and side effects were studied. RESULTS The mean time taken for resolution of autonomic symptoms were similar in GroupA and B (4.1 vs. 5.3 hours, P=0.452), and of myocardial dysfunction was shorter in Group A (10.8 vs. 37.6 hours, P=0.019). On regression analysis, abnormal echocardiography at admission was found to be a significant predictor of the second dose (OR=27.6, 95% CI, 4.7-162.5; P=<0.001). CONCLUSION Children with severe scorpion sting envenomation with abnormal echocardiography may require a higher dose of scorpion antivenom.
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Affiliation(s)
- Anitha Abimannane
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India. Correspondence to: Dr Ramachandran Rameshkumar Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry- 605 006, India.
| | - Ponnarmeni Satheesh
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Subramanian Mahadevan
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Rameshkumar R, Jain P, Satheesh P, Kaur H. Reply to Al-Mendalawi. Int J Adv Med Health Res 2017. [DOI: 10.4103/ijamr.ijamr_42_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rameshkumar R, Jain P, Satheesh P, Kaur H. Cerebral venous thrombosis in an infant with pneumococcal meningitis: A case report and review of literature. Int J Adv Med Health Res 2017. [DOI: 10.4103/ijamr.ijamr_78_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sharma S, Rameshkumar R, Mahadevan S. N-acetylcysteine in Cleistanthus collinus Poisoning: A Report of Two Cases in Children. J Trop Pediatr 2016; 62:487-489. [PMID: 27240665 DOI: 10.1093/tropej/fmw030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Cleistanthus collinus, also known as Oduvanthalai in Tamil, is the most commonly encountered plant poison in southern India. The leaves are used for poisoning humans (suicide or homicide) and animals (cattle and fish) and as an abortifacient, especially in rural south India. Although this poisoning is commonly reported in adults, data regarding the use of N-acetylcysteine in pediatric poisoning is lacking. We report two previously healthy male siblings of pediatric age group who ingested the liquid extracted from crushed leaves of this plant given to them by their mother as a means of deliberate harm. Both patients developed distal renal tubular acidosis, with hypokalemia. The younger sibling also developed myocardial toxicity. Other significant findings noted include hypocalcemia, hypomagnesemia and elevated liver enzymes. Both patients received supportive care along with N-acetylcysteine infusion, and showed complete recovery within 10 days.
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Affiliation(s)
- Shreya Sharma
- Department of Pediatrics, JIPMER, Puducherry, India - 605 006
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Mahadevan S, Rameshkumar R. Systemic manifestations in children with scorpion sting envenomation: how to manage? Indian J Pediatr 2015; 82:497-8. [PMID: 25689958 DOI: 10.1007/s12098-015-1705-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 01/15/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Subramanian Mahadevan
- Pediatric Critical Care Unit, Department of Pediatrics, JIPMER Women and Children's Hospital, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006, India,
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Hegde HV, Yaliwal VG, Annigeri RV, Sunilkumar K, Rameshkumar R, Rao PR. Efficacy of orally disintegrating film of ondansetron versus intravenous ondansetron in prophylaxis of postoperative nausea and vomiting in patients undergoing elective gynaecological laparoscopic procedures: A prospective randomised, double-blind placebo-controlled study. Indian J Anaesth 2014; 58:423-9. [PMID: 25197110 PMCID: PMC4155287 DOI: 10.4103/0019-5049.138977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Aims: Ondansetron is one of the most widely used drugs for postoperative nausea and vomiting (PONV) prophylaxis. Orally disintegrating film (ODF) formulations are relatively recent innovations. We evaluated the efficacy of ODF of ondansetron for the prophylaxis of PONV. Methods: One hundred and eighty American Society of Anaesthesiologists-I or II women, in the age group 18-65 years, scheduled for elective gynaecological laparoscopic procedures were studied in a prospective randomised, double-blind, placebo-controlled trial. The patients were randomised into four groups: Placebo, intravenous (IV) ondansetron 4 mg, ODF of ondansetron 4 mg (ODF4) and 8 mg (ODF8) groups. PONV was assessed in two epochs of 0-6 and 7-24 h. Primary outcome measure was the incidence of PONV and secondary outcome measures were severity of nausea, need for rescue anti-emetic, analgesic consumption, time to oral intake, overall patient satisfaction and side effects such as headache and dizziness. PONV was compared using analysis of variance or Mann–Whitney U-test as applicable. Results: Data of 173 patients were analysed. The incidence of postoperative nausea was significantly lower (P = 0.04) only during the 0-6 h in the ODF8 group when compared with the placebo group. During the 0-6 h interval postoperatively, the ODF8 group had a significantly lower incidence of vomiting when compared with the placebo (P = 0.002) and the IV group (P = 0.044). During the 0-24 h interval postoperatively, ODF4 (P = 0.01) and ODF8 (P = 0.002) groups had a significantly lower incidence of vomiting compared to the placebo group. Conclusions: Orally disintegrating film of ondansetron is an efficacious, novel, convenient and may be a cost-effective option for the prophylaxis of PONV.
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Affiliation(s)
- Harihar V Hegde
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Vijay G Yaliwal
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Rashmi V Annigeri
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Ks Sunilkumar
- Department of Obstetrics and Gynaecology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - R Rameshkumar
- Department of Obstetrics and Gynaecology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - P Raghavendra Rao
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
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Rameshkumar R, Mahadevan S, Ganesh RN, Narayanan P, Bhat V. Histopathological changes in septic acute kidney injury in critically ill children: an observational analytical study of postmortem renal biopsies. Crit Care 2014. [PMCID: PMC4273878 DOI: 10.1186/cc14051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
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Rameshkumar R, Jagadeesh A, Kedarnath M, Mahadevan S, Narayanan P, Harikrishnan KN, Sistla S. Impact before and after introduction of a multifaceted quality improvement intervention on device-related infections in a pediatric ICU in India: a single-centre experience. Crit Care 2014. [PMCID: PMC4273879 DOI: 10.1186/cc14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sharan D, Ajeesh PS, Rameshkumar R, Manjula M. Musculoskeletal disorders in caregivers of children with cerebral palsy following a multilevel surgery. ACTA ACUST UNITED AC 2014; 41 Suppl 1:1891-5. [PMID: 22316991 DOI: 10.3233/wor-2012-0403-1891] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The patients of cerebral palsy need assistance for their self activities which expose the caregivers to different risk factors of musculoskeletal disorders. But there is a scarcity of studies revealing the prevalence and the risk factors present among the caregivers of the cerebral palsy children. This lead to formulate a study to identify prevalence and risk factors among the caregivers of cerebral palsy children. Result revealed that most of the caregivers among both the groups were female (63.4% and 69.3%). The common age group of the children who underwent multilevel surgery was at the age group of 6 - 10 years. It has been observed that among the study group 56.5% were totally cooperative children. The Caregiver Strain Index value showed there is no significant difference among both the groups. Regional body pain of shoulder, elbow, upper back, lower back and ankle revealed a higher prevalence among the study group. Clinical diagnosis revealed prevalence of MPS, FMS and TOS among the study group were 27.6%, 24.5% and 23.0% respectively. Study further revealed that cooperativeness of the child was significantly associated with lower back pain, MPS, FMS and TOS among the study group.
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Affiliation(s)
- Deepak Sharan
- RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
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Rameshkumar R, Mayilsamy K. Prediction of tar and particulate in biomass gasification using adaptive neuro fuzzy inference system. Journal of Intelligent & Fuzzy Systems 2014. [DOI: 10.3233/ifs-131004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- R. Rameshkumar
- Department of Automobile Engineering, K.S.R College of Engineering, Tiruchengode, TN, India
| | - K. Mayilsamy
- Department of Mechanical Engineering, Institute of Road and Transport Technology, Erode, TN, India
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Sharan D, Ajeesh P, Rameshkumar R, Mathankumar M, Paulina RJ, Manjula M. Virtual reality based therapy for post operative rehabilitation of children with cerebral palsy. ACTA ACUST UNITED AC 2012; 41 Suppl 1:3612-5. [DOI: 10.3233/wor-2012-0667-3612] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Deepak Sharan
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
| | - P.S. Ajeesh
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
| | - R Rameshkumar
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
| | - M Mathankumar
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
| | - R Jospin Paulina
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
| | - M Manjula
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
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Sharan D, Ajeesh PS, Rameshkumar R, Jose J. Risk factors, clinical features and outcome of treatment of work related musculoskeletal disorders in on-site clinics among IT companies in India. ACTA ACUST UNITED AC 2012; 41 Suppl 1:5702-4. [DOI: 10.3233/wor-2012-0924-5702] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Deepak Sharan
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
| | - PS Ajeesh
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
| | - R Rameshkumar
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
| | - Jeena Jose
- Address for correspondence: RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India
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Hegde HV, Patil PB, Rameshkumar R, Sunita TH, Bhat MT, Desai RM, Rao PR. A rare case of antepartum posterior reversible encephalopathy syndrome. Anaesth Intensive Care 2011; 39:499-502. [PMID: 21675075 DOI: 10.1177/0310057x1103900326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pre-eclampsia and eclampsia are well-known causative factors of posterior reversible encephalopathy syndrome (PRES). There are only a few reported cases of antepartum PRES. We report a 25-year-old primigravid woman who presented with eight months of amenorrhoea and an abrupt onset of eclampsia associated with a history of a fall. A computed tomography scan ruled out intracranial haemorrhage and PRES was diagnosed. She responded well to supportive care, labour was induced and maternal and neonatal outcomes were good. Antepartum PRES poses different challenges to those of PRES in non-obstetric or postpartum patients, because of the additional management aspects required to ensure foetal wellbeing. We were posed with a difficult decision about the disadvantages of caesarean section versus those of vaginal delivery in our patient.
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Affiliation(s)
- H V Hegde
- Department of Anaesthesiology, Shri Dharmasthala Manjunatheshwara College of Medical Sciences and Hospital, Dharwad, Karnataka, India.
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