Dr.Basavaraju.G.

V
Dr.Keshava murthy.M.L
Dr.Pushpa


DR KIRANKUMAR
Dr.Divyashree.
Dr.Naushad
Dr,Anusha
Dr.Shivprakash


PICU 1 PICU 2 PICU 3
Total cases 148 213 115 476
Direct
admission
120 199 74 393
Transfer In
cases
28 14 41 83
DAMA cases 10 12 21 43
Deaths 25 3 5 33
may june july
Total no. Of cases 476
No. of deaths 33
No. of DAMA cases 43
No. of ventilated
cases
36
Total no of referred 8
Total no admission refused
by attender
10
Total no of referred due to
non availability of ventilator
6
Total no of reffered due to
non availability of PICU bed
0
<1 yr 1 5 yr >5yr TOTAL
Febrile
convulsion
7 4 0 11
Seizure
disorder
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
<1yr 1 5 yr >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
<1 yr 1 5 yr >5yr TOTAL
CCHD 3 0 0 3
ACHD 5 6 1 12
PPHN 2 1 0 3
< 1 yr 1 5 yr > 5 yr TOTAL
Acute GE 23 3 1 27
Chronic
liver disease
0 1 3 4
Hepatitis 0 1 2 3
Wilsons
disease
0 1 2 3
<1 YRS 1-5 YRS >5 YRS TOTAL
HTN 1 2 3
ARF
AGN 1 2 3
NEPHROTIC
SYNDROME
1 4 5
CRF 2 2
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 a
period of 11 days
OP 1
KEROSENE 1
GOOD NIGHT 1
MULTIPLE TABLETS 1
DROWNING 2
BLUNT TRAUMA ABDOMEN 1
HEAD INJURY 8
SUBGLOTTIC GRANULOMA 1
SNAKE BITE 2
PROTEIN LOSING ENTEROPATHY 1
CONG HYDROCEPHALUS 1
NUTRITIONAL ANEMIA 11
THALLESEMIA 1
SICKLE CELL ANEMIA 1
APLASTIC ANEMIA 2
LEUKEMIA 1
Bugs in ICU


Total no of blood culture sent-362
No of culture grown- 20
1)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- 35
No of culture grown- 22
NFGNB-6(cipro,oflox,meropenem, piptaz)
Klebsiella-5(oflox,meropenam, piptaz)
MRSA-2( VANCO, LINEZOLID)
Pseudomonas-7( mrp,piptaz)
Enterobacter-2 (mrp,oflox,amikacin)




Bugs in ICU
CSF- 28
No growth

ascitic fluid-1
Pseudomonas ( piptaz, oflox, meropenem)

Urine- citrobacter-2( piptaz)
Name - SUNANDA
Age - 11yrs
Sex - female
Ip no 103719
Address Gujana halli, kunegal tumkur, karnataka
D.O.A 06/07/14
D.O.D 07/07/14 @ 3 am
Duration 1 day
Diagnosis ? Tetanus with autonomic disturbances.
11 yrs old female child sunanda admitted with
complaints of

Difficulty in opening the mouth 1 day

Abnormal movements of both upper limbs and
lower limbs, multiple episodes x 1 day,

p/h 15 days back

pt had fever , nausea, vomiting , generalised weakness
for 4 days
mild jaundice noticed on day 4 of fever

Shown to a local doctor treated with IM injection





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 involving
all the 4 limbs with exageratted reflexes, with
abnormal arching of the body
b/l pupils reactive, normal size
P/A liver 2 cm BRCM span of 7 cm




Provisionally diagnosed as a case of tetanus
In view of tetanus pt was started on C Penicillin, tetanus
immunoglobulins, diazepam
Chlorpromazine was planned but not started( non
availability of drug)

Subsequently pt had fluctuations in the heart rate, blood
pressure, excussive sweating
Autonomic disturbance was suspected in view of that pt
was started on midazolam infusion and magnesium
sulphate , subsequently pt had arrythmias and
succumbed secondary to autonomic disturbance





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
Learning points

Anticipate complications when there is autonomic
disturbance.
?Availabilty of the drug
Name Atiya taj
Age 9yrs
Sex female
Ip no 104093
Address Gammana halli gubbi taluk, tumkur,
karnataka
D.O.A 19/7/14
D.O.D 19/7/14
Diagnosis AGN with ARF with ventricular
arrythmias

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 referred
here
At admission HR 102/min, pulse not palpable, RR 36/min, BP
not recordable, CFT > 5secs, peripheries cold. spo2 75% RA. GCS
12/15
R/S there 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
Out side reports
Hb-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 an
ECG was taken which shown ventricular arrythmias,
Suspected as a case AGN with electrolyte disturbances with ? ARF
NS 3 Boluses 20ml/kg were given.subsequently calcium gluconate
was started and ceftriaxone was given
Pt was started on ionotropes( noradrenaline and adrenaline added)
after fluid boluses .
For arrythmias lignocaine was started
But pt was succembed secondary to ventricular arrythmias
Hb-11.5
TLC-9000
P72,L23
Platelets-5.45 lacs
p/s NNBP with neutrophilia with reactive thrombocytosis
CRP-35
C3- 71 mg/dl(89-135)
Learning points
Early referral & transportation & intervation
Communication

Name gowtham
Age 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
Diagnosis diptheria
Child admitted with
c/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 rajarajeshwari
medical college there pt had cardiac arrest ,cpr was done
and pt was intubated and reffered here,
At rajarajeshwari hospital , while intubating resident noticed that
there was a whitish yellow membrane in the pharyngotonsillar
area.
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
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(<0.1),
CKMB-100
Dobutamine was added subsequently
After 36 hr of admission pt Hb started decreasing(8.5), urine out
was nil for > 12 hrs, urea and creatinine started increasing ( U 194,
CR -3.9)
pt had features of sepsis with bleeding from RT Tube, and oral
cavity. Started fluid according to ARF regime,Whole blood
transfusion was given, inj piptaz was added. aPTT (56)was
deranged FFP was given .
subsequent electrolyes showed hyperkalemia, inj calcium, K bind ,
asthaline neb was started. Pt collapsed on day 3 of admission due
DIC


3/7/14 4/7/14 5/7/14
Hb 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
3/7/14 4/7/14 5/7/14
Na+ 135 130 130
K+ 5.4 5.3 6.3
CL- 101 105 100
Urea 117 176 194
cr 1.1 2.8 3.9
crp 163
We were not able to give ADS because of non availability
Not able to do Peritoneal dialysis because of
thrombocytopenia

Name kaveri
Age 15 yrs
Sex female
Ip no 103618
Address madugeri v mallube tq kolar karnataka .
D.O.A 02/7/14
D.O.D 9/7/14
Diagnosis ? SLE
? LEPTOSPIROSIS.
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


Pt shown in jalappa hospital kolar there they have
noticed anemia (2.2) Hb and thrombocytopenia
treated with a PRBC and platelet transfusions and
referred 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
Pt was treated with fluid boluses RL, treated with
CEFTRIAXONE, doxycycline, pantoprazole, PRBC
was given in view of pallor and 2 points of platelet
transfusions were given in view of
thrombocytoopenia
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
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 15,80
0
14 100 12 100 1100
0
1160
0
11700
DC P75 P82 P76 P69 P68 P74
PCV 19.8 18.7 25.1 19.2 16.2
PC 2000 13,00
0
34,00
0
1500
0
1300
0
4000
PT 18.6(1
5)
15(15)
APT
T
38(30
)
30(30
)
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
2/7/14 P/S- occ fragmented cells, polchromatophillic cells marked
increased, occ nucleated RBC, NEUTROPHILIC
LEUCOCYTOSIS,sever thrombocytopenia
4/7/14 Rare Nucleated RBCS, no definative anticoagulants seen, neutrophilc
leucocytosis, severe thrombocytopenia, minimal toxic changes
6/7/14 Fragmented RBCS, OCC N RBC, relative neutrophilia, severe
thrombocytopenia
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 segment
consolidation

There was gradual improvement in nasal and gum
bleeding
Nephrology opinion- ? SLE
Dr. anand sir opinion -? SLE
In view of SLE METHYLPREDNISOLNE was started on
8/7/14.
On 8
th
night ,Pt again had bleeding from gums and nose
which was associated with headache and altered sensoriun
and pallor
PRBC , Platelets ,FFP transfusions were given
pt succumbed secondary to ?intracerebral bleed.
Learning points
? CAUSE
? Methyprednisolone might have started earlier
Name bharath
Age 3yrs, 5 mths
Sex male
Ip no 103631
Address vinayaka nagar kabadahalli v tumkur,Karnataka
D.O.A 03/7/14
D.O.D 09/7/14
Diagnosis ?rickettesial encephalitis
Child admitted with
c/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 soles
x 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 meningeal
irritation
No neurological deficits, cranial nerves were normal
P/A- hepatomegaly 5-6 cm BRCM span of 10 cm
No splenomegaly
R/S and CVS were N
PROVISIONALLY DIAGNOSED as a case of rickettesial encephalitis

In view of that pt was treated with doxycycline and azithromycin .and
eptoin for convulsions
After admission pt had multiple episodes of convulsion treated with
phenobarb and 3 % Nacl for raised ICT
ON DAY OF ADMISSION pt was intubated for multiple episodes of
convulsions 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 high
grade 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


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 P78
PC 96000 68000 1.1 lac 1.95 lac
CRP >100 81 >100
Ns1AG NEG
WEIL
FELIX
NEG
3/7 4/7 5/7 6/7 7/7 8/7
Na 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
REPEAT weil felix neg
IgM DENGUE neg
blood culture-neg
tracheal aspirate- neg

Learning points

VAP BUNDLES