Cerebrovascular complications are being frequently recognized in the pediatric intensive care unit in the recent few years. The epidemiology and risk factors for pediatric stroke are different from that of the adults. The incidence of ischemic stroke is almost slightly more than that of hemorrhagic stroke. The list of diagnostic causes is increasing with the availability of newer imaging modalities and laboratory tests. The diagnostic work up depends on the age of the child and the rapidity of presentation. Magnetic resonance imaging, computerized tomography and arteriography and venography are the mainstay of diagnosis and to differentiate between ischemic and hemorrhagic events. Very sophisticated molecular diagnostic tests are required in a very few patients. There are very few pediatric studies on the management of stroke. General supportive management is as important as the specific treatment. Most of the treatment guidelines and suggestions are extrapolated from the adult studies. Few guidelines are available for the use of anticoagulants and thrombolytic agents in pediatric patients. So, our objective was to review the available literature on the childhood stroke and to provide an insight into the subject for the pediatricians and critical care providers.

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Background: Acute kidney injury (AKI) is an uncommon but serious complication after trauma. The objective of this study was to evaluate the prevalence, clinical characteristics and outcome of AKI after trauma. Patients and Methods: This was a retrospective study performed from January 2006 to January 2008 in an emergency specialized hospital in Fortaleza city, northeast of Brazil. All patients with AKI admitted in the study period were included. Prevalence of AKI, clinical characteristics and outcome were investigated. Results: Of the 129 patients admitted to the intensive care unit (ICU), 52 had AKI. The mean age was 30.1 ± 19.2 years, and 79.8% were males. The main causes of AKI were sepsis in 27 cases (52%) and hypotension in 18 (34%). Oliguria was observed in 33 cases (63%). Dialysis was required for 19 patients (36.5%). Independent risk factors associated with AKI were abdominal trauma [odds ratio (OR) = 3.66, P = 0.027] and use of furosemide (OR = 4.10, P = 0.026). Patients were classified according to RIFLE criteria as Risk in 12 cases (23%), Injury in 13 (25%), Failure in 24 (46%), Loss in 1 (2%) and End-stage in 2 (4%). Overall in-hospital mortality was 95.3%. The main cause of death was sepsis (24%). Mortality was 100% among patients with AKI. Conclusions: AKI is a fatal complication after trauma, which presented with a high mortality in the studied population. A better comprehension of factors associated with death in trauma-associated AKI is important, and more effective measures of prevention and treatment of AKI in this population are urgently needed.

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Background: India reported its first case of 2009 pandemic influenza A (H1N1) virus infection in May 2009 and in Saurashtra region in August 2009. We describe the epidemiology and factors associated with severe and non-severe cases of 2009 influenza A (H1N1) infection reported in Saurashtra region. Materials and Methods: From September 2009 to February 2010, we observed 274 patients who were infected with 2009 influenza A (H1N1) virus and admitted in different hospitals in Rajkot city. Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) testing was used to confirm infection. Factors associated with severe disease were determined by comparing with non-severe cases. Results: Out of 274 patients, 87 had severe disease (requiring intensive care or died) and 187 had non-severe diseases (admitted in wards and survived). The median age of severe disease patients was 30 years; the median time was 5 days from the onset of illness to diagnosis, and 4 days median time was reported for hospital stay. More than half of the patients (56.3%) were females, and 58.6% patients were residing in urban area (OR = 1.65, CI = 0.97-2.8), among severe disease patients. Significant association (P < 0.01) was reported among severe disease patients for delayed referral from general practitioner/physician after initial treatment. All patients received antiviral drug, but only 19.5% received the same within 2 days of illness. Presence of coexisting condition [odds ratio (OR) = 0.53, confidence interval (CI) = 0.31-0.90], mainly pregnancy (OR = 0.22, CI = 0.06-0.76), was strongly associated with severe disease. Conclusion: Delayed referral from general practitioner/physician, duration of antiviral treatment, and presence of coexisting condition (especially pregnancy) were responsible for intensive care or mortality in patients of severe influenza A (H1N1) illness.

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In this report, we describe a patient in whom we used a functional residual capacity (FRC) tool available on a critical care ventilator to identify the loss of lung volume associated with pulmonary complications and increase in FRC with the application of a recruitment maneuver. The case report underlines the utility of the FRC tool in rapid visualization of the lung volume changes and the effects of application of corrective strategies in patients receiving mechanical ventilation.

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Toxic shock syndrome (TSS) is a serious, potentially life-threatening condition resulting from an overwhelming immunological response to an exotoxin released by Staphylococcus aureus and group A streptococci. High index of suspicion, early diagnosis and aggressive therapeutic measures must be instituted in view of high mortality of the TSS. In recent years, new agents have been tested to reduce morbidity and mortality in patients with severe sepsis, in addition to standard supportive measures. Among them, recombinant human activated protein C (rhAPC) has been reported to significantly reduce mortality and morbidity in patients with severe sepsis and two or more acute organ failures. We describe our experience with this drug in the early reversal of septic shock from TSS.

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Background: Sulfur mustard (SM) is an alkylating chemical warfare agent that was widely used during Iran-Iraq war between 1983 and 1988. SM exposure leads to various late complications. The aim of this study was to determine the late cardiovascular effects of SM in war-disabled Iranian victims. Materials and Methods: This was a retrospective cohort case control study on 50 patients with symptoms of SM exposure and 50 cases who had been in Iran-Iraq war, without chemical injury. We performed exercise stress test and echocardiography for all of patients. Results: The study group comprised 100 males of mean age 45.6 ± 6.2 years. In chemical war injury group, two patients (4%) had positive exercise stress test. On coronary angiography, they were found to have coronary artery disease. One patient had severe mitral regurgitation and normal coronary angiography; he was referred for mitral valve replacement. Left ventricular (LV) diastolic abnormality was detected in 23% of these subjects. In another group, 5% had LV diastolic abnormality (P = 0.02) and all of them had normal stress test. Conclusions: Cardiovascular abnormalities are another late complication in chemical war disabled Iranian victims. Diastolic dysfunction was the most common abnormality in both groups of patients.

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False passage and loss of airway during tracheostomy are not uncommon, especially in patients with short and thick necks. Distorted neck anatomy following either repeated insertion attempts or due to underlying malignancy may make it very difficult to locate the trachea even while attempting open/surgical tracheostomy, despite good exposure of the neck in such situations. The lightwand is not an ideal device for tracheal intubation in such patients. However, it can be useful in these patients while performing open tracheostomy. Passing the lightwand through the orotracheal tube can aid in rapid identification of the trachea in such situations and may help reduce the occurrence of complications subsequent to repeated false passage. We report a series of four such cases where use of lightwand aided in rapidly locating the trachea during tracheostomy complicated by distorted anatomy.

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Esophageal obstruction due to solidified enteral feeds is a rare but distressful complication in intensive care unit (ICU) patients. It has been suggested that gastroesophageal reflux, very low gastric pH, decreased pepsin and pancreatic enzyme secretions may be responsible for the solidification of casein containing enteral formulas. Recognition and avoidance of these factors will prevent such complication.

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This case series details our experience with seven patients with pandemic (H1N1) 2009 influenza from an intensive care unit in India. All the patients had respiratory failure requiring ventilation except one; two patients developed pneumothorax. Of the seven patients, two died (28.5%) and five recovered. Four patients had co-morbid conditions and one was morbidly obese; all the five patients were discharged alive.

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