Outcome of pediatric procedural sedation & analgesia in a tertiary care hospital in Pakistan

Background and Objective: Procedural sedation and analgesia (PSA) is pharmacologically induced state which allows patients to tolerate painful procedures while maintaining protective reflexes. It is the standard of care but there is limited data from Pakistan. Our objective was to assess the safety of the procedural sedation and analgesia in pediatric population at a tertiary care setting.Methods: A retrospective notes and record review was conducted at the Aga Khan University Hospital, Karachi over 4 years from April 2010 to August 2014. Patients were between ages 6 months to 16 years and were in low risk category. The combination of Ketamine and Propofol were used. Data collected on the standardized hospital PSA form. All procedures were performed by two trained persons.Results: A total of 3489 diagnostic and therapeutic procedures were performed. Satisfactory level of sedation was achieved for 3486 (99%) of procedures. Adverse events occurred in 21 (0.6%) patients including: 12 (0.3%) episodes of hypoxia, 07 (0.2%) episodes of apnea, 02 (0.06%) episodes of post sedation hallucination. No major events were noted.Conclusion: Procedural sedation & analgesia for children using Propofol and Ketamine is found safe and effective in our setting

Implementation of ventilator bundle in pediatric intensive care unit of a developing country

The aim of this study was to assess the frequency of VAP(ventilator associated pneumonia) after strict implementation of ventilator bundle in PICU. Medical records of all children (age 1 month - 16 years) were retrospectively reviewed, who were on mechanical ventilation (MV) for more than 48 hours and received all key components of ventilator bundle from January 2012 to December 2014. Out of 1050, 565 (54%) patients were enrolled. The mean age was 4.02 SD 4.29 years and 62 (69%) were male. The indications of MV were respiratory illness (54%), neurological illness (31%), shock (9%), and postoperative care (6%). The mean duration of MV was 7.05 SD 5.4 days. Only 4 patients (0.7%) developed VAP. The incidence-density of VAP was 1.6 per 1000 ventilator days. The strict implementation of simple, inexpensive interventions (ventilator bundle) in care of mechanically ventilated children can decrease significantly VAP even in resource-limited country

High flow nasal cannula therapy in children with acute respiratory insufficiency in the pediatric intensive care unit of a resource-limited country: A preliminary experience

A retrospective study was performed in children (aged one month - 16 years) receiving HFNC to determine the frequency, efficacy and adverse effects of high flow nasal cannula (HFNC) therapy in the pediatric intensive care unit (PICU), from January to December 2017. Treatment failure was defined as clinical deterioration on HFNC therapy such that mechanical ventilation (MV) was required. Clinical parameters before and after HFNC were assessed using repeated measures analysis of variance. A total of 120 patients received HFNC therapy (21% of total admissions). Primary diagnosis were respiratory disease (50%), central nervous system diseases (14.2%), sepsis (10.8%), and postoperative care (10%). Mean duration of HFNC was 27.5 ±19.7 hours and mean PICU length of stay was 6 ± 6 days. Pneumothorax developed in four patients. MV was required in 28 patients, and subsequently, 15 deaths occurred in that group. HFNC is a frequently used, safe and effective therapy for children requiring respiratory support in PICU. Key Words: Respiratory insufficiency, Non-invasive ventilation, Paediatric intensive care unit

Gastrointestinal complications in critically ill children: Experience from a resource-limited country

Objectives: To determine the frequency and predictors of outcome of gastrointestinal complications (GIC) in critically ill children.Methods: This descriptive study was prospectively conducted in The Pediatric Intensive Care Unit (PICU), The Aga Khan University Hospital (AKUH), Karachi, from September 2015 to January 2017. After obtaining approval from the Ethical Review Committee of AKUH and informed consent from the parents, all children (aged one month to 18 years), of either gender, admitted to the Pediatric Intensive Care Unit (PICU) during the study period were included. The frequency of the defined GIC: vomiting, high gastric residue volume (GRV), diarrhea, constipation, and gastrointestinal bleed were recorded daily for the first week of the PICU stay. The data was collected by the primary investigator on a predesigned data collection form with inclusion of variables and predictors in light of existing literature and local expertise. The questionnaire was shared with the Pediatric Critical Care Medicine faculty and a consensus was sought on the elements to be incorporated.Results: GIC developed within the first 48 hours of admission in 78 (41%) patients. Of the patients who developed GIC, 37 (47.4%) patients developed high GRV: 31 (39.7%) patients developed constipation, 18 (23.1%) patients developed vomiting, 14 (17.9%) patients developed abdominal distension. With regards to prevalence by occurrence, 32/78 (41%) of patients presented with two GI complications, followed by 21 patients (27%) who presented with a single GIC. Only 11 patients (14%) presented with more than three complications. Median length of stay was higher in patients with GIC (8 days) than with those who did not develop GIC (4 days). The frequency of gastrointestinal complications was significantly higher in children receiving mechanical ventilation, on sedatives and relaxants and those with multiorgan dysfunction syndrome (MODS) and inotropes.Conclusion: GI complications are a frequent occurrence in the PICU and are associated with worse clinical outcomes. The use of sedative drugs and the presence of shock with MODS were amongst the important contributing factors

Defining reference area for prediction of aerodynamic coefficients of a biologically inspired hybrid buoyant vehicle

Geometric and volumetric quantities are usually used to define the reference area for the prediction of aerodynamic coefficients of various aquatic mammals, airships and unmanned vehicle. However, reference area does not have a unique definition, especially for a hybrid buoyant aerial vehicle having hybrid lifting hull which resembles a Steller sea lion. The term square cube root of volume is traditionally used as reference area to nondimensionalize the aerodynamic forces for conventional as well as unconventional airships. Published experimental data are usually available for complete configuration at low speed and in nondimensionalized form. So, a generic model of an aircraft's fuselage was first tested in a wind tunnel as a test case to first determine the lift force and then the influence of different choices of reference area on the lift. A hybrid lifting hull was numerically simulated for the prediction of lift as well as drag coefficients and their ratio. It was found that the volumetric term has undefined correlation with aerodynamic forces in both cases. Changes in aerodynamic coefficients are not prominent when using the wetted area as the reference area. Based on the predicted trends of aerodynamic coefficients and a deep literature survey, the projected planform area is proposed as the best option for reference area of a Steller sea lion as well as for hybrid lifting hull of a hybrid buoyant vehicle

Spectrum of Intracerebral Hemorrhage in children: A report from PICU of a resource limited country

Intracerebral hemorrhage (ICH) in children is a rare but disabling disease that accounts for almost half cases of stroke. We report our experience of ICH in children. Retrospective review of medical records of children (1 month-16 years) admitted in Pediatric Intensive Care Unit between January 2007 and December 2014 was done. Data collected included age, gender, presentation, examination findings, neuroimaging done (CT, MRI, and angiography) management (conservative/intervention), and outcome. Results are presented as frequency and percentages. Of the total 50 patients, 58% were male and 26% were \u3c1 year. On presentation 44% had vomiting, 42% had seizures, and GCS \u3c 8 while 40% had altered level of consciousness. Single bleed was present in 88%, 94% had supratentorial bleed, and 32% had intraventricular extension. 72% had bleed volume of \u3c30 mL and 8% had \u3e60 mL. CT scan was done in 98% patients and MRI in 34%, while 6% underwent conventional angiography. 60% patients were managed conservatively, 36% underwent neurosurgical intervention, and 6% underwent radiological vascular intervention. Hematologic causes were identified in 52% patients and vascular malformations in 14% and in 26% no cause could be identified. 26% of patients expired

Hyperlactetemia and its trends In critically Ill Children Admitted In Pediatric Intensive Care Unit Of A Developing Country

Background: There is increasing evidence that in setting of critical ailments clinical signs lag biomarkers like Lactate and hyperlactetemia can be the only marker for this disorder. This study was conducted to describe the incidence of hyperlactatemia in critically ill children and its association with outcome.Methods: Retrospective review of medical records of all children who had their lactic acid (LA) levels measured during their admission in PICU from January 2014 to December 2015 was done. Demographic and clinical variables were recorded along with PICU therapies, outcome (Survived or expired) and development of multi-organ dysfunction. Results are presented as frequency with percentages and mean with standard deviation. Appropriate statistical tests were applied and p-value of \u3c 0.05 was taken as significant.Results: Total 300 patients had their LA measured and 202 were included in the study. Males were 130 (64%) and mean age was 5.7±4.6 years. Hyperlactatemia was found in 68 (33%) patients and another 75 (37%) had a second LA level \u3e 4 mmol/L. Increasing LA trend was found in 79 (39%) patients. Diagnostic categories included cardiovascular diseases (45, 22%), central nervous system diseases (40, 20%), respiratory diseases (31, 15%), sepsis (28, 14%), and gastrointestinal diseases14 (7%). 168 (83%) needed mechanical ventilation. Mean pH was 7.31±0.15 and metabolic acidosis was observed in 91 patients (45%). Mean LA levels in survivors and non survivors were 3.3±3.12 and 5.35±5.47 respectively. Hyperlactatemia was associated with death (p=0.01) and development of MODS (p=0.03) on univariate analysis. On multivariate logistic regression rising lactate and development of MODS were significantly associated with death (p= \u3c 0.05, odds ratio (OR) 9.24 (95% confidence interval 1.55-55.20).CONCLUSIONS: Hyperlactatemia and increasing LA trend in critically ill children are associated with worse outcome in PICU

Red blood cell transfusion in critically-ill children and its association with outcome

Objective: To determine the indications and threshold of haemoglobin levels for packed red blood cell transfusion and its association with outcomes in a paediatric intensive care setting.Methods: The retrospective study was conducted in the paediatric intensive care unit of the Aga Khan University Hospital, Karachi, and comprised medical records of all inpatients with age between 1 month and 16 years who received packed red blood cell transfusions between January and December 2017. Data was retrieved from the hospital database and was analyzed using SPSS 22.Results: Of the 147 subjects with a mean age of 67.89±65.8 months, 76(51.7%) were males. Mean paediatric risk of mortality score was 11.72±7.86. Major admitting diagnosis included sepsis and multiorgan dysfunction 50(34%), respiratory diseases 26(17.7%) and haematology/oncology diseases 22(15%). The indications for transfusion was low haemoglobin in 90(61.2%) patients, shock 29(19.7%) and hypoxia 28(19%). Acute transfusion reaction was observed in 1(0.7%) patient; 120(82%) required mechanical ventilation; and 94(64%) required inotropic support. Of the total, 88(59.9%) patients survived. Paediatric risk of mortality score, need for inotropic support and mechanical ventilation were associated with mortality (p\u3c0.05).Conclusions: Packed red blood cell transfusion, which is frequently prescribed in intensive care settings, was not found to be associated with favourable outcome

Comparison of digital DATCOM and wind tunnel data of a winged hybrid airship’s generic model

Use of low fidelity tools in designing subscale generic wind tunnel models is usually required to get first-hand knowledge about general trends of aerodynamic and stability parameters. Most of such tools are limited to well-defined conventional aircraft configurations. In the present work, aerodynamic and stability characteristics of a winged hybrid airship is explored at low subsonic speed by using Aircraft Digital DATCOM, which is based on semi-empirical methods for preliminary aircraft geometries. Spheroidal ellipsoidal shaped hull of the airship is modeled in DATCOM along with the geometrical details of wing and empennages. The prediction of zero lift drag coefficient, coefficient of lift and pitching moment is the focus of this paper. Except the drag coefficients, trends of analytical results compare well with experimental dat