Post on 07-Aug-2018
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Dr.Basavaraju.G.VDr.Keshava murthy.M.LDr.Pushpa
DR KIRANKUMARDr.Divyashree.
Dr.NaushadDr,Anusha
Dr.Shivprakash
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PICU 1 PICU 2 PICU 3
Total cases 148 213 115 476
Directadmission 120 199 74 393
Transfer Incases
28 14 41 83
DAMA cases 10 12 21 43
Deaths 25 3 5 33
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may june july
Total no. Of cases 476
No. of deaths 33
No. of DAMA cases 43
No. of ventilatedcases
36
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Total no of referred 8Total no admission refusedby attender
10
Total no of referred due tonon availability of ventilator
6
Total no of reffered due tonon availability of PICU bed
0
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5yr TOTAL
Febrileconvulsion
7 4 0 11
Seizuredisorder
4 20 19 43
Meningoenc
ephalitis
2 8 12 22
GBS 0 5 0 5
GDD 3 7 5 15
TBM 0 0 4 4
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5yr Total
ALRI 62 18 4 84
WALRI 1 3 0 4
ALTB 1 6 0 7
BRONCHIOLI
TIS
5 0 0 5
CLD 0 0 2 2
ASTHMA 0 0 3 3
BRONCHO
PNEUMONIA
6 0 0 6
EMPYEMA 1 0 0 1
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5yr TOTAL
CCHD 3 0 0 3
ACHD 5 6 1 12
PPHN 2 1 0 3
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< 1 yr 1
5 yr > 5 yr TOTAL
Acute GE 23 3 1 27
Chronicliver disease
0 1 3 4
Hepatitis 0 1 2 3
Wilsonsdisease
0 1 2 3
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5 YRS TOTAL
HTN 1 2 3
ARF
AGN 1 2 3NEPHROTICSYNDROME
1 4 5
CRF 2 2
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total no of dengue cases=115
dengue cat a =71
dengue cat b=35
dengue cat c=9
ns1 antigen positive at our hospital=18
IgM antibodies positive=52 at our hospital
IgM antibodies positive OUTSIDE AT NIV=10
dengue kit were not available at our hospital for aperiod of 11 days
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OP 1
KEROSENE 1
GOOD NIGHT 1
MULTIPLE TABLETS 1DROWNING 2
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BLUNT TRAUMA ABDOMEN 1
HEAD INJURY 8
SUBGLOTTIC GRANULOMA 1
SNAKE BITE 2PROTEIN LOSING ENTEROPATHY 1
CONG HYDROCEPHALUS 1
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NUTRITIONAL ANEMIA 11
THALLESEMIA 1
SICKLE CELL ANEMIA 1
APLASTIC ANEMIA 2LEUKEMIA 1
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Bugs in ICU
Total no of blood culture sent-362No of culture grown- 201)NFGNB-6(sensitive to meropenem,cip, oflox, netilmycin,mrp,piptaz,amikacin)2)CONS-3(sensitive ceftriaxone,cefotaxim, mrp,, cipro,oflox, gentamycin,amikacin)3)Streptococci 1 ( vancomycin)4)Staph aureus-2 (vancomycin, linezolid)5)Klebsiella-5(pipta, meropenem, oflox )6) E Coli 1 ( meropenem,oflox, piptaz )7) S typhi- 2( cip,oflox, amikacin,mrp,piptaz)
BAL- 35No of culture grown- 22NFGNB-6(cipro,oflox,meropenem, piptaz)
Klebsiella-5(oflox,meropenam, piptaz)MRSA-2( VANCO, LINEZOLID)Pseudomonas-7( mrp,piptaz)Enterobacter-2 (mrp,oflox,amikacin)
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Bugs in ICUCSF- 28
No growth
ascitic fluid-1
Pseudomonas ( piptaz, oflox, meropenem)
Urine- citrobacter-2( piptaz)
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Name - SUNANDAAge - 11yrs
Sex - female
Ip no 103719
AddressGujana halli, kunegal tumkur, karnataka
D.O.A 06/07/14
D.O.D 07/07/14 @ 3 am
Duration1 day
Diagnosis ? Tetanus with autonomic disturbances.
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11 yrs old female child sunanda admitted withcomplaints of
Difficulty in opening the mouth 1 day
Abnormal movements of both upper limbs and
lower limbs, multiple episodes x 1 day,
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p/h 15 days back
pt had fever , nausea, vomiting , generalised weaknessfor 4 days
mild jaundice noticed on day 4 of fever
Shown to a local doctor treated with IM injection
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At admission- PR-110/ min, RR-32/min, BP-98/60 mm of Hg
spo2-95% in RA,, Grbs 98,
Pallor and icterus absent
Locked jaw
GCS-13/15, consciouss ,there was hypertonia involvingall the 4 limbs with exageratted reflexes, with
abnormal arching of the bodyb/l pupils reactive, normal size
P/A liver 2 cm BRCM span of 7 cm
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Provisionally diagnosed as a case of tetanus
In view of tetanus pt was started on C Penicillin, tetanusimmunoglobulins, diazepam
Chlorpromazine was planned but not started( nonavailability of drug)
Subsequently pt had fluctuations in the heart rate, bloodpressure, excussive sweating
Autonomic disturbance was suspected in view of that ptwas started on midazolam infusion and magnesiumsulphate , subsequently pt had arrythmias andsuccumbed secondary to autonomic disturbance
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Hb-14.2 TLC-16,800, P73 PCV-41 Platelets-5.14 lacs Urea-30 Cr-0.7
TB-3 DB-1.2 PROTEIN-8.3 ALBUMIN-4.2 OT-88 PT-168 S Na+ 150 S K+ 5.5 CL - 114
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Learning points
Anticipate complications when there is autonomic
disturbance. ?Availabilty of the drug
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NameAtiya taj
Age 9yrs
Sex female
Ip no
104093Address Gammana halli gubbi taluk, tumkur,
karnataka
D.O.A 19/7/14
D.O.D19/7/14
Diagnosis AGN with ARF with ventriculararrythmias
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9 yrs old Child admitted with
c/o fever x 8 day
c/o cough and cold x 8 days
Throat pain x 8 days
Decrease urine output and difficulty in breathing since 2 days
Shown to a local doctor , treated with fluid boluses and referredhere
At admission HR 102/min, pulse not palpable, RR 36/min, BPnot recordable, CFT > 5secs, peripheries cold. spo2 75% RA. GCS12/15
R/Sthere was tachypnoea, SCR/ICR + , with b/L crepts
P/A -no organomegaly
CVS - S1 and s2 + murmur not appreciated
Oral cavity ulcers + , tonsils enlarged , pharynxs congested
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Out side reportsHb-11.2 gm/dl
TLC-16,400 ,P 84, L 13,
Platelets 4.6 lacs
Urea -325
Creatinine-9
In our hospital , fluid bolus was started , subsequently anECG was taken which shown ventricular arrythmias,
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Suspected as a case AGN with electrolyte disturbances with ? ARF
NS 3 Boluses 20ml/kg were given.subsequently calcium gluconatewas started and ceftriaxone was given
Pt was started on ionotropes( noradrenaline and adrenaline added)after fluid boluses .
For arrythmias lignocaine was startedBut pt was succembed secondary to ventricular arrythmias
Hb-11.5
TLC-9000
P72,L23
Platelets-5.45 lacsp/s NNBP with neutrophilia with reactive thrombocytosis
CRP-35
C3- 71 mg/dl(89-135)
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Learning points
Early referral & transportation & intervation
Communication
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Name
gowthamAge 8yr
Sex male
Ip no 103652
Address 6 th main 16 th cross vijayanagar bangalore.
D.O.A 03/7/14
D.O.D 6/7/14
Diagnosisdiptheria
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Child admitted withc/o fever x 4 days
c/o throat pain x 4days
c/o neck swelling x 2 days ,
Difficulty in swallowing x 2 days Difficulty in breathing x 1 day
Altered sensorium x 1 day
With the above complains pt shown in rajarajeshwarimedical college there pt had cardiac arrest ,cpr was doneand pt was intubated and reffered here,
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At rajarajeshwari hospital , while intubating resident noticed thatthere was a whitish yellow membrane in the pharyngotonsillararea.
Pt was received in our hospital with ET tube insitu with PR-100/min, R/R-26/ min, BP-89/49 mm of Hg
GCS-10/15 R/S - air entry decreased on left side Chest expansion decreased on left side X with bag and tube ventilation CVS NORMAL P/A
NORMAL
CNS-GCS-10/15 Rest of the system WNL
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Suspected a case diphtheria, crystalline penicillin started,adrenaline infusion is started After 7 hrs of admission pt had tachycardia(HR 180/min) So myocarditis was suspected , inv showed Trop I 0.5( 12 hrs, urea and creatinine started increasing ( U 194,CR -3.9)
pt had features of sepsis with bleeding from RT Tube, and oralcavity. Started fluid according to ARF regime,Whole blood
transfusion was given, inj piptaz was added. aPTT (56)wasderanged FFP was given . subsequent electrolyes showed hyperkalemia, inj calcium, K bind ,
asthaline neb was started. Pt collapsed on day 3 of admission dueDIC
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3/7/14 4/7/14 5/7/14Hb 11.8 10.9 8.5
TLC 15.500 20,800 47,700
DC P80L15 P82
PC 59,000 27,000 29,000
PCV 34 30 23
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3/7/14 4/7/14 5/7/14
Na+ 135 130 130K+ 5.4 5.3 6.3
CL- 101 105 100
Urea 117 176 194
cr 1.1 2.8 3.9
crp 163
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We were not able to give ADS because of non availability
Not able to do Peritoneal dialysis because ofthrombocytopenia
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Namekaveri
Age 15 yrs
Sex female
Ip no
103618Address madugeri v mallube tq kolar karnataka .
D.O.A 02/7/14
D.O.D 9/7/14
Diagnosis? SLE
? LEPTOSPIROSIS.
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Kaveri 15 yrs old child admitted with complains of
Fever x 15 days Rashes over body x 15 days Headache x 15 days Pain abdomen x 15 days Nasal and gum bleeding x 10 days
Black coloured stools x 3 days Facial puffiness and tiredness x 3 days O/E PR-94/min, RR-28/min, BP-96/54 mm of Hg , SPO2- 98%, CRT->3 sec Pallor +++ , edema +, compensated shock + , periorbital edema +
,bleeding gums + P/A liver palpable 4 cm BRCM , span of 8 cms, smooth surface, firm in
consistency. Rest of the system WNL
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Pt shown in jalappa hospital kolar there they havenoticed anemia (2.2) Hb and thrombocytopeniatreated with a PRBC and platelet transfusions andreferred here.
Outside reports Hb-2.2, TLC- 8100 (P60, L30), PC-5000
P/S Dimorphic anemia with thrombocytopenia
Reticulocyte count-5.6%
Bone marrow-dry tap
Na+ 131, k+ 3.5, ca+ 8.9, urea-16, cr-0.46, ESR-40
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Pt was treated with fluid boluses RL, treated withCEFTRIAXONE, doxycycline, pantoprazole, PRBCwas given in view of pallor and 2 points of platelettransfusions were given in view ofthrombocytoopenia
On day 2 again blood transfusion and on day 4 c-pen was added in view of leptospirosis
On 6/7/14 again platelet transfusion was given
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2/7/1
4
3/7 5/7 6/7 7/7 8/7
Hb 6.5 6.3 8.5 7 6.1 5.4
TLC 15,800
14 100 12 100 11000
11600
11700
DC P75 P82 P76 P69 P68 P74
PCV 19.8 18.7 25.1 19.2 16.2
PC 2000 13,000
34,000
15000
13000
4000
PT 18.6(1
5)
15(15)
APTT
38(30)
30(30)
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2/7 5/7 7/7 9/7
Na 135 132 135 136
K 2.9 3.1 3.9 3.8
CL 110 103 107 106
UREA 23 22 26
CR 0.7 0.5 0.5
CRP 44.9
TP 4.6 6.4
AB 2.5 3.1
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2/7/14 P/S- occ fragmented cells, polchromatophillic cells markedincreased, occ nucleated RBC, NEUTROPHILIC
LEUCOCYTOSIS,sever thrombocytopenia
4/7/14 Rare Nucleated RBCS, no definative anticoagulants seen, neutrophilcleucocytosis, severe thrombocytopenia, minimal toxic changes
6/7/14 Fragmented RBCS, OCC N RBC, relative neutrophilia, severethrombocytopenia
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Weil felix-neg
Ns1 Ag-neg HIV- neg
Blood culture neg
Urine for leptospira- neg
BM=Normocellular marrow with erythoid predominance Ds DNA- neg
Antinuclear Ab- neg
C3 -78 (83-177)
ESR-40
USG ABD and CHEST= mild ascities, b/L pleural effusion,mild pericardial effusion with posterior segmentconsolidation
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There was gradual improvement in nasal and gumbleeding
Nephrology opinion- ? SLE
Dr. anand sir opinion -? SLE
In view of SLE METHYLPREDNISOLNE was started on8/7/14.
On 8thnight ,Pt again had bleeding from gums and nose
which was associated with headache and altered sensoriunand pallor
PRBC , Platelets ,FFP transfusions were given
pt succumbed secondary to ?intracerebral bleed.
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Learning points
? CAUSE ? Methyprednisolone might have started earlier
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Name bharath
Age 3yrs, 5 mths
Sex male
Ip no 103631
Addressvinayaka nagar kabadahalli v tumkur,Karnataka
D.O.A 03/7/14
D.O.D 09/7/14
Diagnosis?rickettesial encephalitis
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Child admitted withc/o fever x 8 days
rashes all over the body involving palms and soles x 7 days
multiple episodes of convulsions GTCS type involving palms and solesx 1 day
At admission HR-114/min, RR-28/ min, CRT- < 3 Sec, BP-96/60 mm of Hg,spo2 98 %
Pt was in altered sensorium with GCS of 10/15 with no signs of meningealirritation
No neurological deficits, cranial nerves were normalP/A- hepatomegaly 5-6 cm BRCM span of 10 cmNo splenomegalyR/S and CVS were NPROVISIONALLY DIAGNOSED as a case of rickettesial encephalitis
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In view of that pt was treated with doxycycline and azithromycin .andeptoin for convulsions
After admission pt had multiple episodes of convulsion treated withphenobarb and 3 % Nacl for raised ICT
ON DAY OF ADMISSION pt was intubated for multiple episodes ofconvulsions and poor GCS Leveteracetam was added for convulsions blood transfusion was given
for anemia On day 4 pt had hypernatremia Na 150 , 3% nacl stopped On day 5 pt was extubated but trial of extubation was failed
on day 6 there was thick yellowish secretion from ET tube, pt had highgrade of fever with features of sepsis ? VAP was suspected Antibiotics was changed to PIPTAZ, fluconazole was added
subsequently inotropes were added for shock On day 7 pt collapsed secondary to refractory septic shock
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3/7 4/7 5/7 8/7
Hb 8.7 7.9 11 11
TLC 21000 17600 20,100 14 700
DC P71, L20 P71,L26 P74,L23 P78PC 96000 68000 1.1 lac 1.95 lac
CRP >100 81 >100
Ns1AG NEG
WEIL
FELIX
NEG
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3/7 4/7 5/7 6/7 7/7 8/7Na 135 136 150 153 148 139
K 3.1 2.8 3 2.7 4.4 4.6
CL 106 103 115 115 113 82
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REPEAT weil felix neg
IgM DENGUEneg
blood culture-neg
tracheal aspirate- neg
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Learning points
VAP BUNDLES