Muralidharan Jayashree

Introduction: Paediatric emergency medicine (PEM) in India is undergoing a period of rapid growth. A key step in the establishment of successful PEM research networks in high-income countries has been prioritisation of research questions. However, these may be less relevant to India due to differences in epidemiology (higher rates of infectious disease) and limited prehospital care. This gap highlights the importance of context-specific research priorities to address disparities in resource allocation and clinical outcomes. We report on a process to develop a prioritised list of research questions and topics aiming to improve the clinical care of children attending emergency departments across India. Methods: A nominal group technique (NGT) approach was used to set research priorities within a 1-day workshop attached to the Society for Emergency Medicine in India conference (EMCON2023) in October 2023. The workshop, which included 30 participants, was facilitated by four members of an established PEM research network from Australia and New Zealand. The priority-setting process included idea generation and recording, open discussion and clarification of ideas and voting. The NGT method facilitated balanced participation and focused discussions, ensuring all participants’ input was equally considered. A final list of 48 prioritised research topics was generated. Results: Top-ranking areas included prehospital care, septic shock, envenomation, timing of and physiological optimisation prior to intubation, point-of-care ultrasound, the role of structured clinical assessment and trauma. Conclusions: This study has, for the first time, identified multicentre research priorities in PEM for India. The prioritisation of prehospital care reflects the urgent need to address delayed interventions, particularly in rural areas. The presented list of research questions will guide research efforts over the coming years and form the basis for the development of a multicentre research network. This initiative lays the groundwork for long-term collaboration and capacity building in PEM research across India.

Adenoviral pneumonia is a significant cause of morbidity and mortality among children. There is limited data about the clinical profile, intensive care needs, and outcomes of children with adenoviral pneumonia from resource-limited settings. This retrospective study was conducted in the pediatric emergency room (PER) and pediatric intensive care unit (PICU) of a tertiary care hospital in North India over a period of a period of 2 years (July 2022 to June 2024). The data collection included demographic and clinical features, laboratory investigations, complications, treatment, intensive care needs, and outcomes. Eighty-five children were enrolled, majority were <1 year of age and males (71.7% each). All presented with fever and respiratory symptoms. The common complications were acute respiratory distress syndrome (ARDS) (47%), multiple organ dysfunction syndrome (MODS) (26%), shock (25%), and encephalopathy (25%). PICU admission was needed in 46% of children. The intensive care needs included invasive mechanical ventilation (48%), CPAP (39%), HFNC (9%), vasoactive drugs (25%), IVIG (8%), RRT (6%), and cidofovir (5%). The duration of ER, PICU, and hospital stay was 48 (24–96) hours, 7 (4–14) days, and 9 (5–18) days, respectively. The mortality rate was 22%. On multivariate analysis, the independent predictors of mortality were low admission pH, myocardial dysfunction, acute kidney (AKI), ARDS, shock, encephalopathy, MODS, and healthcare-associated infection (HCAI). Infants constituted the largest group of patients requiring admission for adenoviral infection to pediatric emergency in a tertiary care center. Common complications were ARDS, shock, MODS, and encephalopathy. Nearly half required PICU admission for organ support. The mortality rate was 22%; and low admission pH, myocardial dysfunction, AKI, ARDS, shock, encephalopathy, MODS, and HCAI were independent predictors of mortality. Vyasam S, Jayaram J, Sarkar S, Angurana SK, Raj S, Bora I, et al. Clinical Profile, Intensive Care Needs, and Outcome of Children with Adenoviral Pneumonia: A Retrospective Study from a Tertiary Care Hospital in North India. Indian J Crit Care Med 2025;29(7):586–591.

Objective To evaluate the efficacy and safety of early supplementation with insulin glargine (GI) during the acute management of paediatric diabetic ketoacidosis (DKA). Design Double-blinded randomised controlled trial conducted from July 2022 to June 2023. Setting Emergency department and paediatric intensive care unit of a tertiary care teaching hospital in North India. Participants Children between >1 month and ≤12 years presenting with DKA. Intervention Participants were randomised to receive a single subcutaneous dose of GI (0.3 U/kg) or volume-matched placebo within 1 hour of initiating intravenous regular insulin infusion. Outcomes The primary outcome was time to DKA resolution. Secondary outcomes included the rate of blood glucose decline, incidence of hypoglycaemia, hypokalaemia, rebound hyperglycaemia, treatment failure and total regular insulin dose received. Results 82 children were enrolled (glargine: n=42; control: n=40). The mean (SD) time to DKA resolution was 11 (6.4) hours in the glargine group versus 13.9 (7.4) hours in the control group (adjusted HR 1.05, 95% CI 0.65 to 1.69, p=0.84). Rebound hyperglycaemia (adjusted risk ratio (ARR) 0.57, 95% CI 0.35 to 0.92, p=0.02) and treatment failure (ARR 0.14, 95% CI 0.04 to 0.56, p=0.005) were significantly lower with glargine. Other secondary outcomes were similar across groups. Conclusions While early glargine supplementation did not accelerate DKA resolution, it was associated with reduced treatment failure and improved glycaemic stability post resolution. Its use was safe, feasible and not linked to increased adverse events. Trial registration number CTRI/2022/06/043076.

Introduction: Ringer’s lactate (RL), a balanced crystalloid by regenerating bicarbonate ion, may lead to early diabetic ketoacidosis (DKA) resolution and reduced hyperchloremia as compared with 0.9% saline (NS). Research design and methods: This was a double-blind randomized controlled trial conducted in the pediatric emergency and intensive care units of a teaching hospital. Children with type 1 diabetes mellitus (T1DM) aged 9 months to 12 years who presented in DKA were included. Participants were randomized to receive either NS or RL as initial fluid (used for both resuscitation and replacement). The primary outcome was time to resolution of DKA. Secondary outcomes included change in serum chloride and bicarbonate from baseline, total fluid received and incidence of acute kidney injury. Results: The study was conducted between December 2020 and December 2021, and 67 children were recruited (34 in the NS group and 33 in the RL group). The mean time to DKA resolution was shorter in the RL group compared with the NS group (12.9±7.9 vs 16.8±9 hours). The mean difference and HR for time to DKA resolution in the RL group compared with the NS group were 3.85 hours (95% CI 0.3 to 8) and 1.39 hours (95% CI 1.25 to 1.56), respectively. The rise in chloride from baseline was higher in the NS group as compared with the RL group at 4 and 8 hours (8.7±5.6 vs 3.9±5.1 mmol/L) and (10.8±7.7 vs 4.4±8.3 mmol/L), respectively. On the contrary, the rise in bicarbonate from baseline to 12 hours was significantly higher in the RL group as compared with the NS group (14.7±1.6 vs 12.9±3.1). Conclusions: The time to resolution of DKA was shorter in RL group as compared with the NS group. Regeneration of bicarbonate from lactate ion in the RL forms a strong physiological basis for this outcome as compared with hyperchloremia induced by NS. This makes RL a favorable option in children with DKA.

Objective: Fluid resuscitation is an important intervention in children with septic shock. The composition of resuscitation fluid is a matter of debate. Our aim was to study the effects of balanced salt solution ( BSS) versus normal saline (NS) for resuscitation in pediatric septic shock. Data sources: We searched MEDLINE, Embase, LILAC, Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. Study selection: Two independent authors screened title and abstracts and then full papers of included studies. Data extraction: Two authors extracted data from full papers independently. Random-effects model was used for analysis of RCTs. We used Cochrane's risk of bias tool for assessing the quality of studies. Primary outcome was mortality and secondary outcomes were rates of acute kidney injury (AKI), need for renal replacement therapy (RRT), and adverse effects (hyperchloremia, metabolic acidosis, and fluid overload); and duration of PICU and hospital stay. Data synthesis: Five RCTs with 992 children were included. Resuscitation with BSS versus NS was not associated with reduction in mortality (RR 0.82, 95% CI 0.45-1.50, p = 0.52; RCTs = 5); with similar results on sensitivity analysis (RR 0.76, 95% CI 0.41-1.41, p = 0.52; 4 RCTs = 4). However, resuscitation with BSS was associated with lower rates of AKI (sensitivity analysis RR 0.64, 95% CI 0.50-0.82, p = 0.0004; RCTs = 3); lesser need for RRT (RR 0.52, 95% CI 0.35-0.76, p = 0.0008; RCTs = 2); and lower rate of hyperchloremia (RR 0.74, 95% CI 0.62-0.87, p = 0.0002; RCTs = 3). The data is scant for other secondary outcomes (metabolic acidosis, fluid overload, and duration of PICU and hospital stay) to make any suggestions. The overall ‘risk of bias’ was low and unclear in most domains. Conclusion: Use of BSS as resuscitation fluid in pediatric septic shock was not associated with reduction in mortality. However, BSS was associated with decreased risk of AKI, need of RRT and hyperchloremia. Clinical Trial Registration (if any): PROSPERO (CRD42022332208).