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Education of parents and healthcare workers on home safety still remains the mainstay of prevention. How to cite this article Jain MK, Patnaik S, Rup AR, Gaurav A. A Rare Case of Podophyllin Poisoning Early Intervention is Lifesaving. Indian J Crit Care Med 2020;24(6)477-479.Diabetic ketoacidosis (DKA) is the most serious complication of type I diabetes mellitus (DM) in children. Majority of these patients respond to fluid resuscitation, insulin, and supportive measures and rarely require renal replacement therapy. Here, we report the case of a young girl with DKA with severe refractory metabolic acidosis and acute kidney injury (AKI) and was successfully managed with renal replacement therapy. How to cite this article Jain R, Kumar P. Challenging Management of Refractory Metabolic Acidosis and Acute Kidney Injury in a Child with Diabetic Ketoacidosis. Indian J Crit Care Med 2020;24(6)475-476.How to cite this article Choudhary N, Magoon R, Walian A, Kohli JK. Pulmonary Vascular Permeability Indices Fine Prints of Lung Protection? Indian J Crit Care Med 2020;24(6)473-474.

The aim of the study was to investigate the association of urinary albumincreatinine ratio (ACR) with regard to the outcome of sepsis patients and to study the trends of ACR with severity of disease, organ dysfunction, microcirculation status, the use of inotrope, and mechanical ventilation use, and length of pediatric intensive care unit (PICU) stay.

In the prospective observational study, the patients with varying categories of sepsis admitted in the PICU with stay >24 hours were enrolled consecutively. Urine samples were collected at the time of admission (ACR1), 12 hours (ACR2), and 24 hours (ACR3).

One hundred and thirty-eight patients including 56 cases of sepsis, 31 of severe sepsis, 22 of septic shock, and 29 of multiorgan dysfunction syndrome (MODS) cases were analyzed. There were 29 (21%) deaths. ACR (median, IQR) was significantly higher in nonsurvivors [ACR1 198.9 (111.2-329.4) vs 124.5 (59.37-294.5),

0.03], [ACR2 213.8 (112.5-350) vs 117.8 (62.6-211.9)

0.008], [ACR3 231.8 (99.9-441ian J Crit Care Med 2020;24(6)465-472.

Sachdev A, Raheja K, Gupta N, Chugh P. Association of Urinary AlbuminCreatinine Ratio with Outcome of Children with Sepsis. Indian J Crit Care Med 2020;24(6)465-472.

Respiratory distress (RD) in children is a life-threatening condition. Delay in diagnosis has a deleterious effect on morbidity and mortality. The bedside lung ultrasound in emergency (BLUE) is a fast method that aims to accelerate the diagnosis with minimal radiological exposure. We targeted to evaluate the efficacy of BLUE protocol to speed and increase the precision of recognizing the cause of RD compared with chest X-ray (CXR) in the emergency department.

A cross-sectional study on 63 children with RD attended the emergency of a tertiary, university-affiliated, pediatric medical center between January 2017 and January 2018.

Most cases were males 52.4%. We designed to estimate the value of BLUE as a diagnostic tool for RD and comparing it with CXR. Pneumonia with or without pleural effusion was the main etiology of RD detected by BLUE in 47.7% of studied children, pulmonary edema in 22.2%, bronchiolitis and asthma in 17.4%, and pneumothorax in 12.7%. Lung ultrasound (LUS) was superior to CXR in the diagnosis of RD cause, and most cases, 47.7% were diagnosed with pneumonia with a sensitivity of 93.5% and specificity 96.9%.

Bedside lung ultrasound in emergency is an effective tool for identifying the cause of RD which is more sensitive and specific compared with CXR.

Hegazy LM, Rezk AR, Sakr HM, Ahmed AS. Comparison of Efficacy of LUS and CXR in the Diagnosis of Children Presenting with Respiratory Distress to Emergency Department. Indian J Crit Care Med 2020;24(6)459-464.

Hegazy LM, Rezk AR, Sakr HM, Ahmed AS. Comparison of Efficacy of LUS and CXR in the Diagnosis of Children Presenting with Respiratory Distress to Emergency Department. Indian J Crit Care Med 2020;24(6)459-464.

The prolonged use of benzodiazepines and opioids can lead to an increase in the incidence of withdrawal syndrome. Dihydroartemisinin One of the known risk factors is the lack of a sedative-weaning protocol. This study established a sedative-weaning protocol and compared this protocol with the usual care of weaning in high-risk critically ill children.

This was an open-label, randomized controlled trial in a tertiary-care hospital. We recruited children aged 1 month to 18 years who had received intravenous sedative or analgesic drugs for at least 5 days. The exclusion criteria were patients who had already experienced the withdrawal syndrome. We established a weaning protocol. Eligible patients were randomly divided into the protocolized (intervention) and usual care (control) groups. The primary objective was to determine the prevalence of the withdrawal syndrome compared between two groups.

Thirty eligible patients were enrolled (19 in the intervention and 11 in the control group). link2 Baseline characteristics were not signi N, Anantasit N. Protocolized Sedative Weaning vs Usual Care in Pediatric Critically Ill Patients A Pilot Randomized Controlled Trial. Indian J Crit Care Med 2020;24(6)451-458.

Children with scrub typhus may present with one or more organ failures. Identifying the predictors of severe disease and need for pediatric intensive care unit (PICU) admission would help clinicians during outbreak seasons.

This observational study included 160 children admitted to the emergency department (ED) with scrub typhus confirmed by polymerase chain reaction (PCR) between January 2013 and December 2015. Demographic, clinical, and laboratory data were collected and predictors for PICU admission were identified.

There was a seasonal trend with peak presentation in post-monsoon months between August and October. Mean (SD) age at presentation was 6.8 (3.2) years. Fever was present in all with a median (IQR) duration of 9 (6-11) days. Respiratory distress (42%), altered sensorium (24%), hepatomegaly (93%), splenomegaly (57%), and lymphadenopathy (54%) were other features. Rash and eschar were noted in 24% each. Thrombocytopenia (83%), hypoalbuminemia (63%), and hyponatremia (62%) were common laborat of Intensive Care Unit Admission in Pediatric Scrub Typhus A Retrospective Observational Study from North India. Indian J Crit Care Med 2020;24(6)445-450.

Nallasamy K, Gupta S, Bansal A, Biswal M, Jayashree M, Zaman K, et al. Clinical Profile and Predictors of Intensive Care Unit Admission in Pediatric Scrub Typhus A Retrospective Observational Study from North India. Indian J Crit Care Med 2020;24(6)445-450.Coronavirus disease-19 (COVID-19) pandemic is causing a worldwide humanitarian crisis. Old age, comorbid conditions, end-stage organ impairment, and advanced cancer, increase the risk of mortality in serious COVID-19. A subset of serious COVID-19 patients with serious acute respiratory illness may be triaged not to receive aggressive intensive care unit (ICU) treatment and ventilation or may be discontinued from ventilation due to their underlying conditions. Those not eligible for aggressive ICU measures should receive appropriate symptom management. Early warning scores (EWS), oxygen saturation, and respiratory rate, can facilitate categorizing COVID-19 patients as stable, unstable, and end of life. Breathlessness, delirium, respiratory secretions, and pain, are the key symptoms that need to be assessed and palliated. Palliative sedation measures are needed to manage intractable symptoms. link3 Goals of care should be discussed, and advance care plan should be made in patients who are unlikely to benefit from aggressive ICU measures and ventilation. For patients who are already in an ICU, either ventilated or needing ventilation, a futility assessment is made. If there is a consensus on futility, a family meeting is conducted either virtually or face to face depending on the infection risk and infection control protocol. The family should be sensitively communicated about the futility of ICU measures and foregoing life-sustaining treatment. Family meeting outcomes are documented, and consent for foregoing life-sustaining treatment is obtained. Appropriate symptom management enables comfort at the end of life to all serious COVID-19 patients not receiving or not eligible to receive ICU measures and ventilation. How to cite this article Salins N, Mani RK, Gursahani R, Simha S, Bhatnagar S. Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India. Indian J Crit Care Med 2020;24(6)435-444.

Cytokine storm or cytokine release syndrome (CRS) is inevitable in severe and critically ill patients with novel coronavirus disease-2019 (COVID-19). This review aimed to discuss current therapeutic options for the management of CRS in COVID-19.

Cytokine storm is caused by the colossal release of proinflammatory cytokines [e.g., IL (interleukin)-2, IL-6, IL-8 TNF (tumor necrosis factor)-α, etc.] causing dysregulated, hyperimmune response. This immunopathogenesis leads to acute lung injury and acute respiratory distress syndrome (ARDS). Targeting cytokine storm with the therapies that are already available in India with the support of published guidelines and consensus can assist in achieving a better outcome in COVID-19.

We predominantly included published guidelines or consensus recommendations about the management of cytokine storm in COVID-19. From the existing literature evidence, it is observed that among the currently available agents, low-dose corticosteroids and heparin can be beneficial in mana(COVID-19) Expert Management Considerations. Indian J Crit Care Med 2020;24(6)429-434.

Mehta Y, Dixit SB, Zirpe KG, Ansari AS. Cytokine Storm in Novel Coronavirus Disease (COVID-19) Expert Management Considerations. Indian J Crit Care Med 2020;24(6)429-434.

Simulation is to imitate or replicate real-life scenarios in order to improve cognitive, diagnostic and therapeutic skills. An ideal model should be good enough to output realistic clinical scenarios and respond to interventions done by trainees in real time. Use of simulation-based training has been tried in various fields of medicine. The aim of our study was to prospectively evaluate the effectiveness of simulation model "CRITICA"™ (MEDUPLAY systems) in training critical care physicians.

The advanced intensive care unit (ICU) simulator "CRITICA"™ (MEDUPLAY systems) was developed as a joint collaboration between the Indian Institute of Science, Bengaluru and St John's Medical College, Bengaluru. Two-day workshop was conducted. Intensive didactic and case-based scenarios were simulated to formally teach principles of advanced ICU scenarios. The physicians were tested on clinical scenarios in hemodynamic monitoring and mechanical ventilation displayed on the simulator. Assessment of the analytical thinkintilation An Assessment of Physician's Performance. Indian J Crit Care Med 2020;24(6)423-428.

Havaldar AA, Krishna B, Sampath S, Paramasivam SK. Simulation Training in Hemodynamic Monitoring and Mechanical Ventilation An Assessment of Physician's Performance. Indian J Crit Care Med 2020;24(6)423-428.

Multiple scoring systems are designed and prepared nowadays that can be used to determine and predict the severity, morbidity, and mortality rate of patients. Among them, the rapid emergency medicine score (REMS) system has been designed to predict the motility of nonsurgical patients admitted to the emergency department (ED). This study was performed with the aim of evaluating the predictive value of REMS in the mortality rate of nonsurgical patients.

This study was carried out in 2017 among 300 nonsurgical patients referred to the ED. Data were collected using a checklist containing two parts of demographic information and REMS scale.

Based on the results, we found a significant correlation between the duration of hospitalization and other parameters of the study. The results of this study indicated that the REMS of patients increased by 11%, 3%, and 5%, per each unit rise in patient's age, heart rate, and respiratory rate, respectively. On the contrary, 12% and 22% decrements for every unit increase in SPO

and GCS levels were observed, respectively.