Pediatric intensive care power point presentation

Pediatric intensive care

1. CASE PRESENTATION DR. SUNDAR C INGALESHWAR Paediatric intensivist, Department of Pediatrics DR. MEGHANA SELVARAJ Pediatric Registrar Manipal Hospital, Yeshwanthpur Bengaluru

2. History of presenting complains: 15 year/ female presented to ER with.. H/o Fever- 5 days, intermittent, high grade H/o Loose stools- 1 day, 3 episodes, watery, not mixed with blood H/o Abdomen pain- 2 days H/o Headache, myalgia- 2 days H/o Reduced oral intake- 2 days H/o Reduced urine output- 2 days No H/o rash, cough, cold, breathing difficulty, burning micturition No other significant history No h/o travel

3. On examination: On arrival in ER.. Appeared flushed, dull,dehydrated, drowsy but arousable HR- 150/ min RR- 32/min Bp- 80/48 mmhg peripheries- cold and clammy central pulses- low volume, peripheral pulses- feeble

4. SYSTEMIC EXAMINATION RS- Nasal flare+, mild tachypnea+, nvbs heard, air entry decreased in b/l infra-axillary area and infrascapular area, spo2- 82% in room air P/A- Soft, mild distension+,epigastric tenderness+, tender hepatomegaly+, BS+ CVS- S1 S2 heard, no murmur CNS- Drowsy, arousable, no focal deficits

5. Initial assessment: Hypovolemic shock VBG- metabolic acidosis with elevated lactate Difficult cannulation: EJV secured, samples collected started on O2 inhalation and NS bolus given. after 40ml/kg NS bolus, child shifted to PICU IV FLUIDS- Bolus NS given over 1 hour, maintenance started with DNS and KABILYTE Inotropic support initiated as child had signs of polyserositis and hypotension was persistant Other supportive medications.

6. Immediate concerns: Fluid Refractory shock- requiring inotrope.. started on inj adrenaline and noradrenaline infusion Albumin infusion started in view of hypoalbuminemia, hemoconcentration and polyserositis 6 hours in hospital stay: STATUS- Chest x ray revealed- pleural effusion bilaterally INITIAL INVESTIGATIONS- severe thrombocytopenia-35000/ cumm Hemoconcentration: PCV-47% Total counts- 3100/ cumm Hyponatremia SGOT/SGPT- 486/182 INR- 1.08

7. Treatment and course: On DAY 2 Of hospital stay (day 6 of illness): Shock was corrected Child found in respiratory distress: repeat chest x ray massive pleural effusion-rt sided> lt side Intubated and started on MECHANICAL VENTILATOR: AC/PRVC mode with fio2 50% ICD placed- right lung fluid drained Repeat investigations: Falling platelet counts: 19000 / cumm , total counts-15,800/ cumm , INR-1.35, procal - 4.79 Treatment: Central line secured, SDP transfusion done, electrolytes stabilised , Vitamin K added and antibiotics hiked. NAC infusion started as liver enzymes had worsened

8. Treatment and course: On DAY 3 – day 5 Of hospital stay (day 8 of illness): Chil had new onset of fever spikes, with increase in o2 requirement and copious ET SECRETIONS. Child on mechanical ventilator, ET bleed+, Ng bleed+, perfusion stable Oliguria+ lab work up: acute kidney injury Repeat investigations: Fluctuating platelet counts: 19000 to 22 to 18 / cumm , Transaminitis- Sgot - 4890 to 8723, SGPT-1760 to 2669 Hyperbilirubinemia Hyperferritinemia:2535 to 52,785 Coagulopathy- INR-2.07 Ammonia- 145 Treatment: Second SDP transfusion done, FFP transfused, electrolytes stabilised and antibiotics hiked. Lasix infusion started. NAC continued Secondary HLH documented: Methylprednisolone started- Pulse dose

9. Treatment and course: Day 6 of hospital stay onwards…. Signs of stability and improvement documented. Child extubated Off inotropes Repeat investigations normalising trends- platelet- 64k- 70k- 93k SGOT- 2935- 1108- 513 SGPT- 1482- 803 – 538 Serum ferritin- 7945 INR – stabilized Electrolytes- normal Blood culture, urine culture and ET culture- NO GROWTH (STERILE)

10. FINALLY.. Silver lining Response to treatment….. Chest physiotherapy Protein rich diet NO vocal issues NO neurologic defecits / hypoxic injuries Steroid- tapering dose Child discharged on day 10 of hospital stay

11. Concerns addressed: ACUTE LIVER FAILURE: NAC infusion (Ind: transaminitis) 2. SECONDARY HEMOPHAGOCYTIC HISTIOCYTOSIS Inj. Methylprednisolone (Ind: hyperferritinemia ) 3. PNEUMONIA ( VAP) and EFFUSION Antibiotic coverage was sequentially upgraded ( ceftriaxone-piptaz and finally meropenem and vancomycin) ICD placed at the appropriate time Ind: Increased ventilatory support needs, Chest Xray- haziness, pleural effusion

12. Concerns addressed continued: 4. RESPIRATORY FAILURE Elective intubation done on day 2 of hospital stay. Indication: Dull, desaturation, PCO2- retention, respiratory distress 5. ELECTROLYTE DISTURBANCES: Corrected accordingly- hypokalemia 6. MODS: AKI+ALI+Coagulopathy+Respiratory support

13. DIAGNOSIS SEVERE DENGUE- Dengue shock syndrome SECONDARY HEMOPHAGOCYTIC HISTIOCYTOSIS ( HLH) COAGULOPATHY MULTIPLE ORGAN DYSFUNCTION SYNDROME PNEUMONIA-VAP ACUTE LIVER FAILURE ACUTE KIDNEY INJURY

14. This case is unique in several aspects:   1. T he diagnosis of HLH is difficult in dengue due to the overlap of the clinical features (3,7).       2. This patient's age at the time of diagnosis is relatively older than most reported cases, where HLH has been more commonly observed in children under the age of 10 (5). 3. At the same time, the patient had a successful response to intravenous METHYPREDNISOLONE therapy for 5 DAYS followed by ORAL steroids tapering regimen. This treatment approach differs from some of the other cases reported in the literature, where different immunosuppressive agents and/or hemopoietic stem cell transplants were used [ 6 ]. Therefore, this case highlights the effectiveness of METHYLPREDNISOLONE in managing HLH associated with dengue infection and adds to the existing knowledge on the management of this rare and potentially fatal complication of dengue fever. 

15. Most patients die of bacterial or fungal infections due to prolonged neutropenia, bleeding, hypotension, multiorgan failure, or cerebral dysfunction. The clinical course of HLH may be very aggressive.  Therefore, early identification, prompt treatment initiation is essential for patients' survival. TAKE HOME MESSAGE

16. REFERENCES: Pradeep, C., Karunathilake , P., Abeyagunawardena , S.  et al.  Hemophagocytic lymphohistiocytosis as a rare complication of dengue haemorrhagic fever: a case report.  J Med Case Reports   17 , 224 (2023). https://doi.org/10.1186/s13256-023-03967-1 Umakanth, Maheswaran, and Navaneethakrishnan Suganthan . "Unusual manifestations of dengue fever: a review on expanded dengue syndrome."  Cureus  12.9 (2020).  Wiwanitkit V. Haemophagocytic lymphohistiocytosis and dengue. Acta Clin Belg. 2015;70:72.  Henter JI, Horne AC, Aricó M, Egeler RM, Filipovich AH, Imashuku S,  et al . HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis . Pediatr Blood Cancer. 2007;48:124–31.  Munshi A, Alsuraihi A, Balubaid M, Althobaiti M, Althaqafi A. Dengue-induced hemophagocytic lymphohistiocytosis : a case report and literature review. Cureus . 2021.  https://doi.org/10.7759/cureus.20172 .  Janka G. Hemophagocytic lymphohistiocytosis : when the immune system runs amok. Klin Padiatr . 2009;221:278–85.  Kapdi M, Shah I. Dengue and haemophagocytic lymphohistiocytosis . Scand J Infect Dis. 2012;44(9):708–9.

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