Pakistan Journal of Intensive Care Medicine

CLINICAL SPECTRUM AND OUTCOME OF PATIENTS ADMITTED IN PEDIATRIC INTENSIVE CARE UNIT OF A TERTIARY HOSPITAL

A REHMAN — 2024-12-30

Background: Pediatric Intensive Care Units (PICUs) are crucial for managing critically ill children, yet limited data exist regarding the clinical spectrum and outcomes of patients admitted to PICUs in developing countries, particularly in Pakistan. Objective: To assess the clinical spectrum, outcomes, and burden of pediatric patients admitted to the PICU. Study Design: A cross-sectional study. Setting: The study was conducted at the PICU of The Children’s Hospital, Lahore. Duration of Study: January to December 2023. Material and Methods: A total of 884 patients admitted to the PICU during the study period were included. Patient data, including demographics, diagnoses, clinical interventions, and outcomes, were recorded over one year and analyzed using SPSS version 26. Descriptive statistics were employed, and associations were identified using the Chi-square test, with statistical significance set at p < 0.05. Results: The mean age of patients was 6.7 years, with 58.8% being male. The most common diagnoses included pneumonia (22.3%), diabetic ketoacidosis (21.9%), and Guillain-Barré syndrome (15.6%). Mechanical ventilation was required in 54.1% of cases. The overall mortality rate was 14.4%, with pneumonia accounting for 44% of deaths. Significant predictors of mortality included sepsis (p = 0.000) and mechanical ventilation (p = 0.000). Mortality was notably higher among patients under 1 year of age (p = 0.000). Conclusion: This study underscores the significant burden of respiratory illnesses, diabetic ketoacidosis, and sepsis in the PICU, along with high mortality rates. Enhancing early interventions, optimizing resource allocation, and implementing targeted care protocols are essential to improving outcomes in critically ill pediatric populations in resource-limited settings.

NURSES ABILITIES OF CRITICAL THINKING AND CLINICAL DECISION-MAKING CORRELATED WITH QUALITY OF NURSING HANDOVER

S SALEEM — 2024-12-30

Background: Effective nursing handovers are essential for patient safety and continuity of care. Critical thinking and clinical decision-making are vital cognitive skills that ensure structured, accurate, error-free handovers. Despite their importance, research on how these cognitive abilities influence nursing handovers in Pakistan is limited. Objective:This study aims to evaluate the relationship between critical thinking, clinical decision-making, and the quality of nursing handovers among nurses in tertiary care hospitals in Lahore, Pakistan. Study Design:A descriptive cross-sectional study was conducted. Settings: The study was conducted at Services Hospital Lahore and Fatima Memorial Hospital Lahore, both tertiary care hospitals in Lahore, Pakistan. Duration of Study: The study was conducted September 2023 to February 2024. Methods: A total of 171 nurses were recruited using a convenience sampling technique. Data were collected using structured questionnaires, including the California Critical Thinking Disposition Inventory (CCTDI), the Clinical Decision-Making in Nursing Scale (CDMNS), and the Handover Evaluation Scale (HES). Statistical analysis was performed using SPSS version 26, applying descriptive statistics and Pearson’s correlation and regression analysis to assess the associations between the variables. A p-value ≤0.05 was considered statistically significant. Results: The study found that 50.9% of nurses acknowledged the role of critical thinking in nursing handovers, while only 38.6% expressed confidence in their decision-making abilities. A significant positive correlation was observed between critical thinking and clinical decision-making (r = 0.470, p < 0.001) and between decision-making and handover quality (r = 0.528, p < 0.001). Nurses with higher critical thinking scores reported improved handover accuracy and fewer communication errors. However, only 35.1% of nurses had received formal critical thinking training, indicating a significant gap in nursing education. Conclusion: The study confirms that critical thinking and decision-making skills significantly enhance the quality of nursing handovers. The findings highlight the importance of structured training programs and standardised handover protocols in Pakistani hospitals. Integrating evidence-based communication tools like SBAR (Situation, Background, Assessment, Recommendation) into clinical practice is crucial. Future research should focus on interventional studies evaluating the impact of critical thinking training on patient outcomes.

CLINICAL EFFICACY OF DEXAMETHASONE VERSUS HYDROCORTISONE IN ACUTE EXACERBATION OF ASTHMA IN CHILDREN

R IMTIAZ — 2024-12-29

Background: Asthma is a prevalent chronic respiratory condition among children worldwide, significantly impacting their health, quality of life, and healthcare systems. Acute exacerbations of asthma require prompt and effective management to reduce morbidity. Objective: To compare the clinical efficacy and safety of dexamethasone versus hydrocortisone in children with acute asthma exacerbations. Study Design: Randomized controlled trial. Setting: Emergency Pediatric Medicine Department and General Medical Ward of the Children's Hospital, Lahore. Duration of Study: November 2023 to April 2024. Methods: Children aged 6–15 years presenting with acute asthma exacerbations were enrolled and randomly assigned to receive either dexamethasone or hydrocortisone. Baseline characteristics, including age, gender, weight, respiratory rate, oxygen saturation, asthma history duration, and initial FEV1, were recorded. The primary outcomes assessed included changes in respiratory parameters, duration of respiratory support, and length of hospital stay. Results: The study included 110 participants, with 55 patients in each group. The mean age was 9.5±3.45 years in the dexamethasone group and 9.4±2.91 years in the hydrocortisone group. Both groups showed comparable gender distribution (60% male and 58% male, respectively) and baseline characteristics. The mean respiratory rate was 32±4.2 bpm in the dexamethasone group versus 31±4.1 bpm in the hydrocortisone group, while oxygen saturation was 94±2% versus 93±2.4%, respectively. The mean hospital stay was shorter in the dexamethasone group (3.1±0.9 days) compared to the hydrocortisone group (3.6±1.1 days). Dexamethasone demonstrated faster improvement in respiratory parameters and earlier cessation of respiratory support. Conclusion: Dexamethasone is a more effective and convenient option than hydrocortisone for managing acute asthma exacerbations in children, offering faster clinical improvement and shorter hospital stays.

PREDICTING OUTCOME USING PEDIATRIC EARLY WARNING SYSTEM (PEWS) SCORE ON PICU ADMISSION: A STUDY FROM A LOWER-MIDDLE-INCOME COUNTRY

A REHMAN — 2024-12-30

Background: The Paediatric Early Warning System (PEWS) Score is a well-established tool for identifying clinical deterioration in hospitalised children and facilitating early intervention. While PEWS is primarily used in ward settings, its utility in predicting clinical outcomes at the time of admission to the Paediatric Intensive Care Unit (PICU), such as mortality, length of stay, and need for mechanical ventilation, has not been extensively studied, particularly in resource-limited settings. Understanding the prognostic value of PEWS in PICU could help optimise patient management and resource allocation in such environments. Objective: To assess the validity of the Paediatric Early Warning System (PEWS) score as a predictor of mortality in the Paediatric Intensive Care Unit (PICU) at The Children's Hospital Lahore, Pakistan. Study Design: Prospective cohort study. Settings: The Children's Hospital Lahore, Pakistan. Duration of Study: April to July 2024. Methods: A total of 180 children admitted to the PICU were included in the study. The PEWS score was recorded at the time of admission. The primary outcome was mortality, while secondary outcomes included length of stay and the requirement for mechanical ventilation. Logistic regression analysis was performed to assess the association between PEWS scores and clinical outcomes. Results: Out of the 180 children enrolled, the overall mortality rate was 16.6%. A significant association was found between a PEWS score ≥7 at admission and increased mortality, with 75% of the deceased patients (22 out of 30) having a PEWS score ≥7 (OR = 6.2, 95% CI: 2.8–14.1, p < 0.001). This indicates that children with a higher PEWS score were more than six times as likely to die compared to those with lower scores. Additionally, higher PEWS scores were linked to longer PICU stays. Children with PEWS scores ≥7 had an average PICU stay of 10.5 days, significantly longer than those with scores <7, who stayed an average of 4.3 days (OR = 3.4, 95% CI: 1.2–9.8, p = 0.02). Furthermore, the need for mechanical ventilation was significantly higher in patients with higher PEWS scores, with 55% of patients requiring ventilator support compared to only 12% in those with PEWS scores <7 (OR = 5.1, 95% CI: 1.8–14.5, p = 0.01). Conclusion: The PEWS score is a simple and effective tool for predicting mortality risk in the PICU, particularly in low-resource settings, helping optimise resource allocation and patient management. However, it is important to continue monitoring patients with lower PEWS scores, as the system may not identify all patients at risk of deterioration. Further research could explore the integration of PEWS with other clinical markers for improved predictive accuracy.

COMPARISON PRIMARY CLOSURE AND OPEN TECHNIQUE IN THE TREATMENT OF PILONIDAL SINUS SURGERY IN MTI-LADY READING HOSPITAL PESHAWAR

. WAJID — 2024-12-30

Background: Pilonidal sinus disease is a common condition that requires surgical intervention, with primary closure and open techniques being the two main approaches. While both methods aim to manage the disease and promote healing, they differ regarding postoperative recovery, complication rates, and overall outcomes. In many cases, primary closure offers benefits in terms of reduced recovery time and fewer complications, but the comparison between these two techniques remains underexplored in specific settings. This study aims to compare the clinical outcomes of primary closure and open techniques in the surgical management of pilonidal sinus. Objective: To compare the clinical outcomes of primary closure and open techniques in the surgical management of pilonidal sinus, focusing on wound healing time, hospitalisation duration, return to work, and postoperative complications. Study Design: Randomized controlled trial. Settings: The study was conducted at a tertiary care hospital. Duration of Study: April 2024 to November 2024 Methods: A total of 60 patients with pilonidal sinus were randomly assigned into two equal groups. Group A underwent excision with primary closure, while Group B underwent excision with the wound left open to heal by secondary intention. Primary outcomes included hospitalization duration, wound healing time, and time to return to work. Secondary outcomes included complications such as wound infection and recurrence. Statistical analysis was performed using appropriate tests, including t-tests and chi-square tests, with p-values ≤ 0.05 considered significant. Results: Group A (primary closure) demonstrated significantly shorter hospitalization (4.37 ± 0.999 vs. 5.80 ± 1.27 days, p < 0.0001), faster wound healing (17.57 ± 1.72 vs. 44.73 ± 3.34 days, p < 0.0001), and earlier return to work (13.60 ± 2.47 vs. 30.43 ± 2.86 days, p < 0.0001) compared to Group B (open technique). Wound infection rates were lower in Group A (6.7%) compared to Group B (23.3%), with a statistically significant difference (p = 0.01). Recurrence rates were also lower in Group A (10.0%) compared to Group B (30.0%). Conclusion: Primary closure is more effective than the open technique in the surgical management of pilonidal sinus, offering faster recovery times, fewer complications, and better overall patient outcomes. When performed appropriately, this technique should be considered the preferred approach for pilonidal sinus surgery.

COMPLETE REVERSAL OF TRANS-TENTORIAL AND SUB-FALCINE BRAIN HERNIATION WITH CRANIECTOMY: A SUCCESSFUL CASE REPORT

R PERVAIZ — 2024-07-05

Introduction: Brain herniation, or brain code, is a critical condition caused by elevated intracranial pressure, leading to abnormal brain tissue protrusion. Chronic herniations may be linked to developmental defects and remain asymptomatic, while acute herniations are life-threatening, especially after neurosurgery. Case Presentation: A 25-year-old female with Glioblastoma multiforme presented with facial weakness. Initially suspected as Bell’s Palsy, her condition rapidly worsened, leading to coma and signs of raised intracranial pressure. A CT scan revealed a brain tumor with associated edema, hemorrhage, and multiple herniations. Emergency craniectomy and subsequent medical management showed initial improvement, but she later developed ischemia and infarction, resulting in her death. Discussion: Timely diagnosis and intervention are crucial in managing brain herniation. Clinical signs and cranial nerve assessments are vital for diagnosis. Management focuses on reducing intracranial pressure through medical and surgical means. Early intervention is key to better outcomes, though the prognosis can be poor due to underlying conditions like Glioblastoma multiforme. Conclusion: Effective management of brain herniation requires timely surgical and medical intervention. This case illustrates the rapid progression and complexity of brain herniation, emphasizing the importance of early and comprehensive treatment.

INHALED ANTIBIOTICS FOR TREATING PNEUMONIA IN INVASIVELY VENTILATED PATIENTS IN THE INTENSIVE CARE UNIT

BA ABDELRAHMAN — 2024-11-30

Pneumonia in invasively ventilated patients is a significant concern in the intensive care unit (ICU), often associated with increased morbidity, prolonged hospital stays, and high mortality rates. The emergence of multidrug-resistant (MDR) pathogens further complicates management. Inhaled antibiotics (IABs) have gained attention as an adjunctive or alternative treatment modality to systemic antibiotics, offering direct drug delivery to the lungs with potentially enhanced efficacy and reduced systemic toxicity. This review explores the role of inhaled antibiotics in treating pneumonia in invasively ventilated patients, focusing on pharmacological considerations, clinical efficacy, safety profiles, and limitations. Relevant evidence is derived from databases such as PubMed, Scopus, Web of Science, and Google Scholar, incorporating the latest studies and clinical trials to provide a comprehensive understanding.