Master A.4yrs DOA DOD Duration of ventilation-70 days 2

Transcription

1 DEPARTMENT OF PAEDIATRICS STANLEY MEDICAL COLLEGE Dr P.KANCHANA (Post graduate ) 1

2 Master A.4yrs DOA DOD Duration of ventilation-70 days 2

3 4yr old boy admitted with C/o- fever-6days ALOC-3 days Vacant stare with posturing - one episode No h/o-trauma, Dog bite, Recent vaccination Recent h/o travel -salem Development-Normal 3

4 O/E -Responsive to voice. Afebrile,No pallor, No Icterus, No Rash RS-NVBS, efforts adequate CVS, Abd -NAD CNS - E3V4M5. PERL+ Lt UMN facial palsy Tone, DTR-N Power 4/5, Plantar- No neck stiffness/kernig Fundus -Normal 4

5 ú Acute Encephalitis 5

6 CSF Analysis CSF-9 cells.all lymphocytes Pr-10, Sugar-90 Gr stain & AFB neg C&S-no Growth.HSV & JE Neg Serology for JE equivocal IgM+ve Dengue & widal-neg 6

7 Hyper intensities in bil thalamus lt coronoaradiata centrum semiovale post putamen 7

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9 Day 2 seizures (status) GCS dropped intubated Extubated on day 6. Extubated and Re-intubated twice - posturing with stridor and secretions Tracheostomy done. 9

10 20th day: polyuria with dehydration Urine Na-114mEq /L Serum Na-132meq/L CEREBRAL SALT WASTING : Treated with NS supplementation Persisting polyuria with dehydration. Started on T. Fludrocortisone (0.05 mg/day) given for10days. Urine Na-24 meq/l 10

11 Polyuria not controlled and increasing (upto 14ml/kg/hr). Blood sugars, urea -normal Central DI was considered 11

12 Pl Osm-293 mosm/l U Osm-252mOsm/l Sr and Urine Osmolality was repeated following a dose of SC Vasopressin(2µg). Pl Osm-259 mosm/l U Osm-286mOsm/l. 12

13 Urine output was replaced adequately(0.45ns, 2.5%D) T.Desmopressin(0.3 mg/day) was started in view of persistent polyuria, after consulting Nephrologist Polyuria settled in 10 days 13

14 Nosocomial pneumonia and UTI. Treated with appropriate antibiotics 14

15 On day 76 he was weaned from ventilator On day 81 tracheostomy tube was changed to Fullers metal tube. On day 90 feeding tube was removed 15

16 Day 95: Conscious, recognizes and smiles at parents Oral feeds Temp, hydration, Urine Output N Tone all 4 limbs, no facial palsy 16

17 VENTILATOR WEANING FAILURE CEREBRAL SALT WASTING CENTRAL DIABETES INSIPIDUS 17

18 Weaning failure Normal blood gases Fluid balance Mental status Normal CXR Electrolyte disturbance Psychological factors 18

19 Neurological deficit secondary to brain injury may impose quite a challenge as to the optimal time for weaning and/or extubation. Many clinicians believe that extubation of brain-injured patients who lack a gag reflex, or comatose, or have significant respiratory secretions should be delayed. Crit Care Clin 23 (2007)

20 Characterized by hyponatremia, excessive natriuresis & volume depletion. Generally occurs in patients with cerebral injury, tumor, infection or stroke. Water and salt replacement is the primary management. If not improving Fludrocortisone may be tried. Duration of therapy (4 to 125days). (Pediatrics Dec;118(6)) 20

21 Yonsei 21 Med J July 1; 53(4):

22 Clinical Findings CSW SIADH Clinical Dehydration Present Absent Plasma Na Concentration Severely decreased Moderately Decreased Plasma Uric Acid Decreased Decreased Plasma BUN Increased Normal Urine Sodium Concentration More Increased Variable Urine Flow Rate More Increased Decreased Plasma ANP Concentration Increased Increased Plasma Renin Activity Decreased Decreased Treatment Saline Water Restriction 22

23 Diagnosis Plasma Osm>300mOsm/l Urine Osm<300mOsm/l Urine/plasma Osm ratio <1 Polyuria >4-5 ml/kg/hr for >2 hrs 23

24 Vasopressin and vasopressin analogues 24

25 Desmopressin (1-deamino-8-D-arginine vasopressin, ddavp) is the current drug of choice for long-term therapy of CDI. It can be given parenterally, orally, or intranasally. Oral tablets although 20 folds less potent than the intranasal form, are highly effective and safe in children, and have largely replaced the intranasal form. The recommended dose off ddavp is Oral: µg /day in three divided doses ; Intranasal:2-40 µg once or twice a day ; and, Parenteral: µg Indian J Endocrinol Metab September; 25

26 Neuro endocrine complications are a rare entity in cases with encephalitis. But they should always be expected in cases of encephalitis, especially in those children on prolonged ventilatory support. 26

27 THANK YOU 27