Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : SC10 - SC14 Full Version

Outcome Analyses of the Admitted Patients in a Paediatric Intensive Care Unit in a Resource Poor Setting: A Prospective Observational Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52568.16476
Chandra Jyoti Bora, Rashmita Bora, Suhani Borbhuyan

1. Associate Professor, Department of Paediatrics, Lakhimpur Medical College, North Lakhimpur, Assam, India. 2. Registrar, Department of Paediatrics, Assam Medical College, Dibrugarh, Assam, India. 3. Paediatric Oncologist, Department of Paediatric Oncology, B Baruah Cancer Institute, Gauhati, Assam, India.

Correspondence Address :
Dr. Suhani Borbhuyan,
Department of Paediatric Oncology, B Baruah Cancer Institute, Gauhati, Assam, India.
E-mail: suhani.barbhuiyan@gmail.com

Abstract

Introduction: Paediatric intensive care is an indispensible part in the management of critically ill children. Facilities for intensive care are sparse in low income countries requiring strict admission criteria. Adequate data generation regarding the profile of patients, outcomes and identification of the risk factor for poor prognosis can help in appropriate utilisation of this specialised care.

Aim: To analyse the outcome of admissions in the Paediatric Intensive Care Unit (PICU) of a tertiary care centre in upper Assam and identification of risk factors for poor prognosis.

Materials and Methods: A prospective observational study was carried out at the PICU of Assam Medical College Hospital, Dibrugarh, Assam, India, from March 2019 to April 2020. Data collected were -demographic details of the admitted children, the outcome and the risk factors affecting the mortality. Statistical methods used were Odds Ratio (OR), simple proportion test, Chi-square test and Relative Risk (RR) estimation with 95% confidence intervals, backward and forward logistic regression.

Results: Total 495 children were enrolled in the study. The three most common disease categories were neurological disease (33.3%), respiratory disease (31.1%), and sepsis (10.7%). The overall mortality was 17.8%. Diseases related to the nervous system were the leading cause of death (38.6%). Highest mortality (43.2%) was in the age group of 1 month to 1 year. Highest disease specific mortality was due to Acute Encephalitis Syndrome (28.4%). Presence of circulatory shock, Poor Glasgow Coma Scale (GCS) (GCS<8), hypoxia, dyselectrolytemia, malnutrition, renal failure, and requirement of ionotropic support, mechanical ventilation were significantly associated with mortality with p value<0.05.

Conclusion: Mortality rate (17.7%) was relatively high. Requirement of mechanical ventilation and Cardiopulmonary Resuscitation (CPR), use of inotropes, GCS ≤8, malnutrition, renal failure, dyselectrolytemia, hypoxia and sepsis were associated with increased mortality. Circulatory shock, requirement of CPR and mechanical ventilation were the independent predictors of mortality.

Keywords

Independent variables, Morbidity pattern, Mortality, Outcome of patients, Risk factors

The United Nations world leaders defined Millennium Development Goal 4 (MDG 4) to reduce under-5-year mortality rates by two-thirds by the year 2015 (1). Unfortunately, only few developed countries could make it a reality. India had a under-5-year mortality rates of 35.73 per 1000 live birth in 2020 and expecting a reduction to 25 per 1000 live birth as Sustainable Developmental Goal (SDG) by 2030 (2). In addition to preventative care and nutritional support, the development of effective paediatric emergency and critical care services in resource-limited countries can substantially reduce global mortality in children <5 years of age (3).

Maximum benefit from the sparse resources in these settings can be expected if the allocation of the same can be done wisely. Identification of the illness profile and the possible outcome from an authentic dataset is utmost necessary for the best allocation of the resources. In the context of intensive care management, a rational and objective way to define and quantify severity of illness is through the prediction of mortality risk by identifying risk factors that can influence the outcome. A variety of scoring system predicting mortality risk are created in the resource rich settings and validated in PICUs of the developed countries. Amongst them some of the standard scoring system like PRISM, PIM1 and PIM2 have been evaluated in resource-limited areas, including some of the tertiary centers of India. The results are conflicting, giving rise to under prediction of mortality, poor sensitivity of the scoring systems, varied calibrating and discriminative ability (4),(5).

Reliable scores that can be used in all resource-limited settings are absent, and hence, the definition of critical illness and estimating its burden is difficult (6). In resource poor settings there can be logistic problems to obtain all the standard laboratory parameters required to use the available scoring systems. So identification of the risk factors with prognostic value may greatly help the treating team to triage and focus on the specific group of children appropriately. Paediatric intensive care is still in an evolving stage in the state of Assam in terms of both resource and manpower. The number of PICU is less in number and functioning only in the teaching institutes. Each unit has a vast catchment area and number of children requiring intensive care is quiet high specially during seasons of epidemic encephalitis. Keeping these points in mind the study was planned to analyse the profile of admitted children in the PICU of Assam Medical College and Hospital and to identify the risk variables that may affect the mortality.

Material and Methods

This was a hospital-based prospective observational study, conducted from March 2019 to April 2020, in the PICU of Assam Medical College and Hospital Dibrugarh, Assam, India.

Inclusion criteria: The inclusions of the study subjects were done after obtaining proper informed consent from the guardian or the care taker. Data on demographic characteristics, diagnosis on admission, nature of intervention and outcome were obtained from the patients admitted into PICU of Department of Pediatrics of Assam Medical College & Hospital, Assam, India.

Exclusion criteria: Children who died within 24 hrs of PICU admission or left against medical advice. Child who required CPR after admission and didn’t survive. Children who get admitted for temporary monitoring like after surgery and for IVIG infusion etc.

The study institution is an eight-bedded PICU established on March 2018 with six-bedded recovery unit with facilities for invasive and non invasive ventilation, portable X-ray, Ultrasonography, critical care monitors, defibrillation, microinfusion and peritonial dialysis. Arterial Blood Gas (ABG) analyses was done in the central ICU inside the institution. The PICU is staffed 24/7 by a team of skilled paediatric intensive care team. The team of this unit per 24 hours is composed of two residents (PICU residents are senior residents who spend at least six months in the general ward familiar with the use of mechanical ventilator and managing critically ill cases), one faculty skilled with paediatric intensive care and three nurses and nurse aids. The patients are either referred from the emergency department or the paediatric ward or from other hospitals.

D
ata collection: Information was collected during the first 24 hours in PICU. On admission, a proforma was filled up for each patient. Data was collected after getting written consent from parents (or guardians). All patients had routine clinical assessments and basic investigations. Details on admission day were plotted separately in the proforma. Clinico-demographic data collected were age, sex, specific diagnosis, vitals at the time of admission, level of consciousness, respiratory distress, circulatory shock, convulsions, and hypoxemia along with relevant findings from systemic examination. Neurological status was represented with the GCS/ modified GCS scoring. GCS score less then 8 was considered as coma. Hypoxia was defined as SpO2 less than 90 in room air, in absence of cyanotic congenital heart disease. Dyselectrolytemia was diagnosed as per standard definition of the specific electrolyte. Associated co-morbidities like presence of anaemia, malnutrition were observed. Requirement of oxygen, mechanical ventilation, vasoactive medication and cardio pulmonary resuscitation was noted. Laboratory parameters were complete blood count, organ function tests, ABG report, electrolyte status/ other metabolic parameters and imaging parameter.

Statistical Analysis

Quantitative variables were clinical profile and outcome pattern. Statistical analysis used was OR, Chi-square and simple proportion test. Means, Standard Deviations (SD), percentages, and ranges were used as appropriate to describe continuous variables. The significance of each factor associated with mortality in children admitted to PICU was first analysed by using univariate analysis. Univariate analysis was performed through Chi-square test and RR estimation with 95% confidence intervals. Thereafter, a multivariate analysis (forward and backward stepwise logistic regression) was applied to determine the contribution of each prognostic factor after ruling out confounding factors. The level of significance was p<0.05. Statistical software used was Medcalc Version 20.026.

Results

Of the total sample of 495 children admitted to PICU, 283 (57.2%) were male and 212 (42.8%) were female. Most of the patients (50%) belonged to the age group of 1 month to 1 year, 77 % admitted children are under five age group (Table/Fig 1). Total 33.3% of the admitted children had diseases related to nervous system, 31.1% had diseases associated with the respiratory system, 10.7% patients admitted with Sepsis (Table/Fig 2)). Single most common specific diagnosis was pneumonia followed by Acute Encephalitis Syndrome (AES) mostly due to Japanese encephalitis (Table/Fig 3).

Eighty eight (17.8%) children died among the sample population (Table/Fig 2). Highest number of mortality (43.1%) was observed 11in the infancy. Most of the non survivors suffered from nervous system disorder (38.6%) followed by sepsis (19.3%), respiratory disorders (12.5%). Nervous system diseases comprised of acute meningoencephalitis, seizure disorders, Tubercular Meningitis (TBM), cerebral palsy with complications. Single most common cause of death was AES followed by systemic sepsis. Pneumonia was the third leading cause of death in the PICU (Table/Fig 3).

On analyses of risk factors, it was noticed that age groups and gender had no significant (p-value =0.58) association with mortality (Table/Fig 4). Presence of shock, poor GCS, hypoxia, dyselectrolytemia, malnutrition, and renal failure was significantly associated with mortality. Moreover, use of ionotropes, requirement of cardiopulmonary resuscitation and ventilations were also significantly associated with mortality. The association of mortality with the different variables and their predictability is shown in (Table/Fig 5),(Table/Fig 6). Out of the above-mentioned variables circulatory shock, use of ventilation and CPR comes with positive significant values on binary logistic regression analyses as independent predictor of mortality (Table/Fig 7).

Discussion

The number of well-equipped PICU in terms of both manpower and facilities are scanty in the developing countries but the demand for a PICU bed is exponentially high due to high prevalence of severe form of common childhood illness (4),(6). Mortality of a sick child depends on multiple factors which act from before reaching hospital. It reflects the overall standard of the healthcare network of a region. This study was done in a dedicated Medical College PICU with a vast catchment area extending around six districts and three bordering States. Total 495 children were enrolled in the study, out of the 644 admitted children (age range from 1 month to 14 years) during this period. Maximum admission (50%) was in the infancy age group and 77% of children were below 5 years. This was similar to the study by Abhulimhen-Iyoha BI et al., from KIMS Hyderabad, India, in their study a total of 341 patients were admitted into PICU during the study period of which 50.7% were infants and 72.4% patients were aged <5 years. The major reason for PICU admission in present study was neurological disease (33.3%) followed by respiratory infection (31.3%) which was similar to observation by Kumar R et al., from Bihar (8). Systemic sepsis (10.7%) was a major cause of PICU admission in present study which was similar to study from Nepal, and another from AIIMS, India. In these studies, the incidence of sepsis as the primary cause of admission was stated as 24% and 14.8%, respectively (9),(10).

The overall mortality observed in this study was 17.8%. Morality rate varies in a wide range in different PICUs. A mortality rate of 6.7% was recorded by Khilnani P et al., from India (11). Bellad R et al., from India recorded a mortality rate of 16.7% (12). Abhulimhen-Iyoha BI et al., from India stated a mortality rate of 2.3% in 2013 (7). Another study from Greece recorded mortality rate of 9.7% in 2011 by Volakli E et al., (13). The high mortality rate in the present study may be due to the multiple factors. The PICU has a vast covering area and sick children need to travel a long distance to reach here with possible deterioration during transport. It is more significant for the sick children coming from the neighbouring hilly states. Due to the small capacity of the unit, in comparison to the population it covers, only the sickest patients are admitted. Prevalence of Japanese encephalitis, co-morbidities like severe malnutrition, anaemia are important contributing factors.

Major reason of death in this study was neurological disease followed by respiratory infection and sepsis. Kapil D and Bagga A reported that septicemia was the most common cause of death followed by congenital heart disease in the AIIMS study in 1993 (10). Shah VB and Mehta K reported that pneumonia was the leading cause of death. In children under 5 years, infection was 58.9% cause of death (14). Khilnani P et al., from India in the 2004 study stated cardiovascular disease, infection especially dengue illness and trauma as major causes of death (11). Neurological disease was the leading reason of death in the present study. This can be explained by the prevalence of epidemic meningoencephalitis in Assam. Regular outbreaks of Japanese encephalitis occur in the post monsoon period specially in the districts of upper Assam. It leads to huge morbidity and mortality in both children and adults in spite of vaccination drive against the disease since 2013. Similar results were observed in a study from Bihar in 2019 by Kumar R et al., (8).

The incidence of sepsis as the primary diagnosis on admission is quite significant (10.7%), and is the second leading cause of death (19.3%), after meningoencephalitis (28.4%). Sakr Y et al., also stated a high incidence of sepsis in the ICU from a worldwide data from the Intensive Care over Nations Audit. There was wide variation of incidence of sepsis, causative microorganism and sepsis related mortality rate around the World (15). The prevalence of sepsis, severe sepsis, and septic shock were 42.6%, 25.9%, and 19.8%, respectively in the study by de Souza DC et al., from North America (16).

In the Pediatric index of Mortality study (PIM study, 1997) there were seven variables which could predict mortality, i.e., elective admission, specified diagnosis, fixed pupil, and use of mechanical ventilation (17). Pudjiadi AH et al., found five variables that could predict the probability of PICU death-age, consciousness level, HR, PaO2/FiO2, and use of mechanical ventilation (18). Analysis of the risk factors in present study revealed nine variables which affects mortality with statistical significance-circulatory shock, poor GCS on admission (GCS<8), hypoxia, dyselectrolytemia, renal failure, septicemia, malnutrition, use of ionotropes and ventilation and requirement of CPR to stabilise as dependent variable. 42.6% admitted children required mechanical ventilation during the course of hospital stay and showed a statistically significant increase in mortality then the non ventilated group (32.2% and 7%). These findings were in accordance with studies conducted by E Volakli E et al., which showed that requirement of mechanical ventilation was a significant risk factor for mortality. 29.8% patients received inotropic support during the course of hospital stay (13). The results were similar to study conducted from Pakistan by Anwar-ul-Haque et al., which reported that 39% patients who received inotropes died during the course of illness (19). Out of the above-mentioned variables circulatory shock, requirement of ventilation and CPR were independent predictors of PICU mortality on multivariate analyses by a binary logistic regression model. de Freitas Aragão et al., found associations between death and age below 2 years old, use of mechanical ventilation and CVP, presence of hospital acquired infection, length of hospital stay of 2 days or less; and class 4 clinical severity according to the Clinical Classification System (CCS), in children admitted to the PICU, in a referral hospital in Brazil (20). Presence of malnutrition though not an independent variable, was an important predictor of mortality in the index study. Bagri NK et al., concluded that ICU outcome is decisively influenced by their nutritional status of the patients if they could be stabilised in the initial critical phase (21). Teshager NW et al., in their study from Ethiopia mentioned the following factors to be significant and independent predictors of mortality at the PICU. Those were admission over weekends, admission from other facility and emergency room, presence of more than one resident at admission, presence of severe acute malnutrition, Multiorgan Dysfunction Syndrome (MODS), mechanical ventilation, and higher PIM2 scores (22).

Limitation(s)

It was a study spanning a short duration. Some of the important variables could not be included, like acid base parameters, invasive monitoring parameters due to logistic issues. Residual morbidities (e.g. persistent neurological deficits, persistent cardiopulmonary insufficiency etc.),which could also reflect the standard of PICU care, were not included for analyses.

Conclusion

Childhood neurological illness, acute respiratory diseases, and systemic infections were the leading causes of admission to a PICU as reflected in the study. The risk factors affecting mortality can be identified with analyses of correctly extracted data. Childhood anaemia, severe acute malnutrition and common childhood infections like pneumonia strongly contributes to PICU mortality. Requirement of mechanical ventilation, cardiovascular collapse and any acute events leading to sudden cardiorespiratory arrest are the independent predictors of mortality at the PICU. Identification of risk factor and proper triaging of PICU admitted children with focused management can be an integral part of care to the sick children and can improve the overall outcome.

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DOI and Others

DOI: 10.7860/JCDR/2022/52568.16476

Date of Submission: Sep 29, 2021
Date of Peer Review: Dec 07, 2021
Date of Acceptance: Mar 04, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 30, 2021
• Manual Googling: Feb 16, 2022
• iThenticate Software: Apr 04, 2022 (7%)

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