Septic shock in children is the prototype combination of hypovolemia,cardiogenic and distributive shock. Recently published American college of critical care medinie(ACCM )recommendations for hemodynamic support of neonatal and pediatric patients with sepsis,Surviving sepsis campaign and its pediatric considerations and subsequent revision of definitions for pediatric sepsis has led to compilation of this review article. Practical application of this information in Indian set up in a child with septic shock will be discussed based on available evidence.Though guidelines mainly apply to pediatric age group,however a reference has been made to neonatal age group wherever applicable.

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Acute organic insecticide poisoning is a major health problem all over the world, particularly in the developing countries, where organophosphates (OPs) are the most common suicidal poisons with high morbidity and mortality and account for a large proportion of patients admitted to intensive care units. Other insecticides less commonly used are organocarbamates, organochlorides, and pyrethroids, which are less toxic and are associated with less morbidity and mortality. Patients with poisoning present with a wide spectrum of gastrointestinal, neurological, and cardiac manifestations. A strong clinical suspicion is necessary to make an early diagnosis and to start appropriate therapy. Treatment is primarily supportive and includes decontamination, anticholinergics, protection of the airway, and cardiac and respiratory support. The use of oximes has been controversial and may be associated with higher mortality owing to a higher incidence of type-II paralysis. They may have other toxic side effects. This paper reviews the literature on OP poisoning.

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Aim: To study the various modes of presentation of acute myocardial infarction (AMI). Methods: A total number of 60 patients of AMI admitted in various teaching hospitals of Kasturba Medical College, Mangalore, were studied. The following factors were evaluated: onset of symptoms, mode of presentation, site of infarction, and hospital outcome. Results: Out of 60 patients, 12 (20%) presented with atypical symptoms. The maximum incidence AMI with atypical symptoms was in the age group of 65-74 yr (30.7 %), followed by the age group of 55-64 yr (25%). No patient presented with atypical symptoms below 30 yr. Patients experiencing MI without chest pain tended to be older (mean age 61 vs 58 yr) and were women (35% vs 12.5%); 80% of patients presented with chest pain followed by dyspnea (28.3%) and vomiting (13.3%). The in-hospital mortality of MI patients who presented with typical and atypical symptoms were 16.6% and 33.3%, respectively. In this study, anteroseptal infarction was most common (31.6%). Fifty percent of inferior-wall MI patients presented with atypical symptoms. Conclusion: In this study, there was no significant association between onset of MI and circadian pattern.

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Background: Nosocomial infection rate are often higher for intensive care unit (ICU) than other units of hospitals, and hands of health-care workers (HCWs) play a major role in the transmission of the infections. Aim: To compare the efficacy of conventional hand wash with the hand rub in reducing the transient bacterial flora on the hands of nurses in ICU. Subject and Methods: The 34 nurses posted in our ICU during January-March 2003 were included. A total of 204 samples were collected for the residual bacterial flora on fingers using impression method on MacConkey agar plates. The subjects then used alcoholic hand rub or conventional hand wash and the residual bacterial flora rechecked by testing impression of fingers on MacConkey agar. Results: Escherichia coli, Klebsiella spp., nonlactose fermenting Gram-negative bacilli, staphylococci, and streptococci formed the transient bacterial flora on the hands. Moderate to heavy bacterial density was seen in more than 92.2% of the hands before washing or hand rub application. Conventional hand wash resulted in drastic reduction in the transient bacterial flora on hands in 50% cases whereas alcoholic hand rub achieved the effect in 95% of the samples. Conclusion: Compared with conventional hand wash, alcoholic hand rub is far more efficient in reducing transient bacterial flora on the hands of HCWs and it is more convenient and time saving. It is recommended as a hand hygiene practice in critical areas such as ICU.

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Aim: To present a fatal case of serotonin syndrome accompanied by moclobemide and paroxetine overdose. Case presentation: A 34-year-old married woman was presented following intentional ingestion of 3.5 g moclobemide and 2.6 g paroxetine. She was drowsy, agitated, and having rigor. In 1 h she developed myoclonus and diffuse muscle rigidity prominent in lower extremities. All laboratory tests were unremarkable except hyperglycemia (160 mg/dl), sinus tachycardia (103/min), and metabolic acidosis (7.051 pH, 52 mmHg pO2, 74.7 mmHg pCO2, 15% HCO3, 77% SaO2). Despite oxygen supplementation, her respiratory acidosis got worse and the SaO2 concentration decreased to 72%. Endotracheal intubation and paralysis were decided to control muscle hyperactivity followed by hyperthermia (max. 42.3ºC) unresponsive to benzodiazepine. Even aggressive supportive treatment (mechanical ventilation, buffer replacement, cyproheptadine, and dantrolene) were applied, the patient could not recover and suffered cardiopulmonary arrest 20 h after presentation. Conclusion: Physicians working in the emergency departments and intensive care units, managing patients presenting with acute ingestion of selective serotonin reuptake inhibitors combined with monoamine oxidase inhibitors, should be aware of recognizing and treating serotonin stndrome. This is because many of these patients may require intensive care monitoring as well as tracheal intubation and ventilatory support.

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Background: Cardiopulmonary bypass (CPB) affects almost every body system by hypoperfusion either subclinically or clinically and produces a systemic inflammatory response owing to contact of blood with mechanical surfaces. There has been no documentation regarding pyruvate in predicting postoperative mortality and morbidity. Aim: This study was carried out to evaluate lactate levels, pyruvate levels, and lactate-pyruvate ratio in pediatric patients undergoing CPB (for correction of congenital cardiac anomaly) and their correlation to perioperative outcomes. Method: 50 consecutive patients (less than 14 years of age) of various congenital heart diseases undergoing CPB were studied. Patients were classified into three categories according to their surgical complexity. Arterial blood samples were collected at different stages of CPB to estimate blood lactate and pyruvate levels by using documented spectrophotometric method. Results: The observed mean baseline lactate levels were 2.24 + 0.79 mmol/l (normal range of 0.9-1.7 mmol/l). The mean circulating lactate levels, at 15 and 45 min after institution of CPB, increased to 4.49 + 1.2 and 5.24 + 1.02 mmol/l, respectively. A progressive decline in the mean lactate levels was noted during rewarming (at 35°C) and immediately off-bypass which continued steadily even 24 and 48 h postoperatively. The mean baseline lactate-pyruvate ratio was 24.73, which increased at 15 and 45 min after institution of CPB, rewarming (at 35°C), and immediately off-bypass. As far as the duration of CPB is concerned, we found that lactate levels were elevated significantly (P < 0.05) and the lactate-pyruvate ratio was significantly high (P < 0.001) during rewarming, off-bypass, and 24- and 48-h post-CPB in patients requiring CPB for more than 1 h. The average duration of postoperative mechanical ventilation, inotropic support, and lactate-pyruvate ratio were significantly higher (P < 0.001) in category III of patients in comparisons with categories I and II. Conclusion: In patients undergoing CPB for congenital heart operation, elevations in lactate-pyruvate ratio can predict the postoperative outcome significantly better in comparison with lactate levels.

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Background: Fibrinolytic therapy has reduced mortality following acute myocardial infarction (AMI) with the major effect coming from early achievement of infarct-related artery patency. Aim: To evaluate the door-to-needle time for fibrinolytic administration for AMI and to identify factors associated with a prolonged door-to-needle time. Materials and Methods: Our study was a prospective audit of patients who were thrombolyzed for AMI at our hospital from July 1, 2004 to March 15, 2005. All patients admitted with AMI, who were candidates for fibrinolysis, were included. We recorded the door-to-needle time. Whenever possible, we tried to find out the reason for prolonged door-to-needle time. Results: A door-to-needle time of <30 min could be achieved in 19 of our 35 patients (54.28%). Mean door-to-needle time was 45.25 min. Discussion: Although most guidelines recommend a door-to-needle time of less than 30 min, most hospitals fail to achieve this in most patients. A study conducted by Zed et al. at the Vancouver General Hospital showed that a door-to-needle time of less than 30 min was achieved in only 24.3%. The door-to-needle time achieved at our center was shorter. In most of our patients who were thrombolyzed late, a delay in taking or interpreting an electrocardiogram was responsible. Transfer to the intensive care unit for thrombolysis also resulted in considerable delay. Conclusions: A door-to-needle time of less than 30 mins could be achieved in 19 of our 35 patients (54.28%). A significant number of AMI patients thrombolyzed did not meet the guideline for door-to-needle time of less than 30 min.

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Background: Acute respiratory distress syndrome (ARDS) owing to leptospirosis is associated with a high mortality. This is in spite of mechanical ventilation in a critical care setting. ARDS by its very nature, associated with economic constraints in our patients has made treating these patients a challenge. Objective: To study if combination of methylprednisolone and noninvasive ventilation is life-saving in ARDS owing to leptospirosis. Design: Interventional pilot study. Setting: Medical intensive care unit of a rural medical college hospital. Participants: Eight patients diagnosed to have ARDS owing to leptospirosis. Main outcome indicator: Survival. Results: Seven out of eight patients who were treated with methylprednisolone and noninvasive ventilation recovered fully to resume normal life. Conclusion: Methylprednisolone with noninvasive ventilation is life-saving in ARDS owing to leptospirosis.

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Background and Aim: Infection is a common problem in intensive care medicine and many patients are treated aggressively and empirically with broad-spectrum antibiotics. Meningitis may be missed in intensive care unit (ICU) because some of these patients have fever and altered mental status from another illness and may be treated with impression of sepsis. In order to identify undiagnosed meningitis in ICU admitted patients, postmortem CSF analysis was performed immediately after death. Subjects and Methods: During 1 year, 43 patients underwent lumbar puncture after death. Samples were collected and analysis for cells, sugar and protein concentrations were obtained. Demographic characteristics and diagnosis of the patients were recorded and data analysis was performed by SPSS version 11.5. Results: CSF was completely normal in 62.8% of the patients and it was compatible with meningitis in two of them. Both of them had admitted with impression of sepsis and had another source of infection. Considering a subgroup of the patients who admitted to ICU with impression of sepsis, they were statistically significant. There was no significant difference between surgical and nonsurgical patients. Conclusions: Our findings suggest that meningitis may be missed in ICUs, and more liberal use of CSF analysis should be considered in critically ill patients, especially those who referred with impression of sepsis.

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