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  1. Article ; Online: Hemodynamic Management Strategies in Pediatric Septic Shock: Ten Concepts for the Bedside Practitioner.

    Ranjit, Suchitra / Natraj, Rajeswari

    Indian pediatrics

    2024  Volume 61, Issue 3, Page(s) 265–275

    Abstract: The three pathophysiologic contributors to septic shock include varying combinations of hypovolemia (relative > absolute), decreased vascular tone or vasoplegia, and myocardial dysfunction. The three pillars of hemodynamic support include fluid boluses, ... ...

    Abstract The three pathophysiologic contributors to septic shock include varying combinations of hypovolemia (relative > absolute), decreased vascular tone or vasoplegia, and myocardial dysfunction. The three pillars of hemodynamic support include fluid boluses, vasopressors with or without inotrope infusions. The three end-points of hemodynamic resuscitation include an adequate cardiac output (CO), adequate mean arterial pressure (MAP) and diastolic blood pressure (DBP) for organ perfusion, and avoiding congestion (worse filling) parameters. Only 33-50% of septic patients show post-fluid bolus CO improvements; this may be sustained in ≥10% on account of sepsis-mediated glycocalyx injury. A pragmatic approach is to administer a small bolus (10 mL/kg over 20-30 min) and judge the response based on clinical perfusion markers, pressure elements, and congestive features. Vasoplegia marked by low DBP is a major contributor to hypotension in septic shock. Hence, a strategy of restricted fluid bolus with early low-dose norepinephrine (NE) (0.05-0.1 µg/kg/min) can be helpful. NE may also be useful in septic myocardial dysfunction (SMD) as an initial agent to maintain adequate coronary perfusion and DBP while minimizing tachycardia and providing inotropy. Severe SMD may benefit from additional inotropy (epinephrine/dobutamine). Except vasopressin, most vasoactive drugs may safely be administered via a peripheral route. The lowest MAP (5th centile for age) may be an acceptable target, provided end-organ perfusion is satisfactory. A clinical individualized approach combining the history, serial physical examination, laboratory analyses, available monitoring tools, and repeated assessment to individualize circulatory support may to lead to better outcomes than one-size-fits-all algorithms.
    MeSH term(s) Humans ; Child ; Shock, Septic/therapy ; Shock, Septic/diagnosis ; Vasoplegia ; Sepsis/diagnosis ; Norepinephrine ; Hemodynamics ; Hypotension
    Chemical Substances Norepinephrine (X4W3ENH1CV)
    Language English
    Publishing date 2024-01-09
    Publishing country India
    Document type Journal Article
    ZDB-ID 402594-5
    ISSN 0974-7559 ; 0019-6061
    ISSN (online) 0974-7559
    ISSN 0019-6061
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  2. Article: Prognostic Markers in Pediatric Critical Care: Data From the Diverse Majority.

    Carter, Michael J / Ranjit, Suchitra

    Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

    2024  Volume 25, Issue 3, Page(s) 271–273

    MeSH term(s) Child ; Humans ; Prognosis ; Critical Care ; Intensive Care Units, Pediatric
    Language English
    Publishing date 2024-03-04
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2052349-X
    ISSN 1947-3893 ; 1529-7535
    ISSN (online) 1947-3893
    ISSN 1529-7535
    DOI 10.1097/PCC.0000000000003408
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  3. Article: BESTFIT-T3: A Tiered Monitoring Approach to Persistent/Recurrent Paediatric Septic Shock - A Pilot Conceptual Report.

    Natraj, Rajeswari / Ranjit, Suchitra

    Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine

    2023  Volume 26, Issue 7, Page(s) 863–870

    Abstract: Objective: Persistent shock (PS) or recurrent shock (RS) after initial fluids and vasoactives can be secondary to myriad complex mechanisms, and these patients can have a high mortality. We developed a noninvasive tiered hemodynamic monitoring approach ... ...

    Abstract Objective: Persistent shock (PS) or recurrent shock (RS) after initial fluids and vasoactives can be secondary to myriad complex mechanisms, and these patients can have a high mortality. We developed a noninvasive tiered hemodynamic monitoring approach which included, in addition to basic echocardiography, cardiac output monitoring and advanced Doppler studies to determine the etiology and provide targeted therapy of PS/RS.
    Design: Prospective observational study.
    Setting: Tertiary Care Pediatric Intensive Care Unit, India.
    Methods: A pilot conceptual report describing the clinical presentation of 10 children with PS/RS using advanced ultrasound and noninvasive cardiac output monitoring. Children with PS/RS after initial fluids and vasoactive agents despite basic echocardiography underwent BESTFIT + T3 (
    Results: Among 10/53 children with septic shock and PS/RS over a 24-month study period, BESTFIT + T3 revealed combinations of right ventricular dysfunction, diastolic dysfunction (DD), altered vascular tone, and venous congestion (VC). By integrating information obtained by BESTFIT + T1-3 and the clinical context, we were able to modify the therapeutic regimen and successfully reverse shock in 8/10 patients.
    Conclusion: We present our pilot results with BESTFIT + T3, a novel approach that can noninvasively interrogate major cardiac, arterial, and venous systems that may be particularly useful in regions where expensive rescue therapies are out of reach. We suggest that, with practice, intensivists already experienced in bedside POCUS can use the information obtained by BESTFIT + T3 to direct time-sensitive precision cardiovascular therapy in persistent/recurrent pediatric septic shock.
    How to cite this article: Natraj R, Ranjit S. BESTFIT-T3: A Tiered Monitoring Approach to Persistent/Recurrent Paediatric Septic Shock - A Pilot Conceptual Report. Indian J Crit Care Med 2022;26(7):863-870.
    Language English
    Publishing date 2023-02-14
    Publishing country India
    Document type Case Reports
    ZDB-ID 2121263-6
    ISSN 1998-359X ; 0972-5229
    ISSN (online) 1998-359X
    ISSN 0972-5229
    DOI 10.5005/jp-journals-10071-24246
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  4. Article ; Online: Organizing and Leading a Multidisciplinary PICU.

    Mysore, Mohan Ram / Ranjit, Suchitra

    Indian journal of pediatrics

    2023  Volume 90, Issue 3, Page(s) 251–260

    Abstract: Pediatric critical care units (PICUs) have come a long way over the past four decades. They continue to be clinical areas that are resource-intensive. PICUs require a team of highly engaged and well-trained professionals working together to change the ... ...

    Abstract Pediatric critical care units (PICUs) have come a long way over the past four decades. They continue to be clinical areas that are resource-intensive. PICUs require a team of highly engaged and well-trained professionals working together to change the trajectory of critical illness. Consequently, it requires strong physician and nursing leadership to lead the team of dedicated individuals to perform at the highest level. A dyad of a PICU Medical Director and a PICU Nursing Director is a good construct for administrative leadership. Several options of models exist-open versus closed or a hybrid model. A 24 × 7 coverage of the PICU with skilled personnel is important to provide timely care but is not always possible due to personnel constraints. Indian PICUs have also evolved and made significant strides in their governance and coverage models. Policies and standard operating procedures (SOPs) govern the care that is delivered and may need to be updated regularly. The NABH reviews these as part of their accreditation process. A multidisciplinary committee structure to review aspects of PICU function and outcomes on a regular basis is vital. Certain guiding principles should determine the philosophy of the PICU, and the leaders in the PICU need to model behavior in keeping with these principles. PICU outcomes should be measured and tracked; a root-cause analysis should be triggered when appropriate; and interventions should be made using the PDSA (plan-do-study-act) cycle of process improvement when outcomes fall short of expectations. Adverse events should ideally be disclosed, but this represents a challenge in the current environment. Indian PICUs continue to evolve rapidly, and establishing a database for comparative analysis of outcomes is a natural next step.
    MeSH term(s) Child ; Humans ; Intensive Care Units, Pediatric ; Physicians ; Critical Illness
    Language English
    Publishing date 2023-01-21
    Publishing country India
    Document type Journal Article ; Review
    ZDB-ID 218231-2
    ISSN 0973-7693 ; 0019-5456
    ISSN (online) 0973-7693
    ISSN 0019-5456
    DOI 10.1007/s12098-022-04427-2
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  5. Article: Challenges and Solutions in translating sepsis guidelines into practice in resource-limited settings.

    Ranjit, Suchitra / Kissoon, Niranjan

    Translational pediatrics

    2021  Volume 10, Issue 10, Page(s) 2646–2665

    Abstract: Sepsis and septic shock are major contributors to the global burden of disease, with a large proportion of patients and deaths with sepsis estimated to occur in low- and middle-income countries (LMICs). There are numerous barriers to reducing the large ... ...

    Abstract Sepsis and septic shock are major contributors to the global burden of disease, with a large proportion of patients and deaths with sepsis estimated to occur in low- and middle-income countries (LMICs). There are numerous barriers to reducing the large global burden of sepsis including challenges in quantifying attributable morbidity and mortality, poverty, inadequate awareness, health inequity, under-resourced public health, and low-resilient acute health care delivery systems. Context-specific approaches to this significant problem are necessary on account of important differences in populations at-risk, the nature of infecting pathogens, and the healthcare capacity to manage sepsis in LMIC. We review these challenges and propose an outline of some solutions to tackle them which include strengthening the healthcare systems, accurate and early identification of sepsis the need for inclusive research and context-specific treatment guidelines, and advocacy. Specifically, strengthening pediatric intensive care units (PICU) services can effectively treat the life-threatening complications of common diseases, such as diarrhoea, respiratory infections, severe malaria, and dengue, thereby improving the quality of pediatric care overall without the need for expensive interventions. A thoughtful approach to developing paediatric intensive care services in LMICs begins with basic fundamentals: training healthcare providers in knowledge and skills, selecting effective equipment that is resource-appropriate, and having an enabling leadership to provide location-appropriate care. These basics, if built in sustainable manner, have the potential to permit an efficient pediatric critical care service to be established that can significantly improve sepsis and other critical care outcomes.
    Language English
    Publishing date 2021-11-11
    Publishing country China
    Document type Journal Article ; Review
    ZDB-ID 2901309-4
    ISSN 2224-4344 ; 2224-4344 ; 2224-4336
    ISSN (online) 2224-4344
    ISSN 2224-4344 ; 2224-4336
    DOI 10.21037/tp-20-310
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  6. Article: Hyperglycemia in the pediatric intensive care unit: Innocent bystander or villain of the piece?

    Ranjit, Suchitra

    Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine

    2014  Volume 18, Issue 1, Page(s) 6–7

    Language English
    Publishing date 2014-01-16
    Publishing country India
    Document type Journal Article
    ZDB-ID 2121263-6
    ISSN 1998-359X ; 0972-5229
    ISSN (online) 1998-359X
    ISSN 0972-5229
    DOI 10.4103/0972-5229.125424
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  7. Article: Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction.

    Natraj, Rajeswari / Bhaskaran, Anu Kirthiga / Rola, Philippe / Haycock, Korbin / Siuba, Matthew Tt / Ranjit, Suchitra

    Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine

    2023  Volume 28, Issue 5, Page(s) 447–452

    Abstract: Background: Right ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and ... ...

    Abstract Background: Right ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and adversely affect encapsulated organs such as the kidneys.
    Primary objective: To investigate the association between systemic venous congestion, as estimated by Venous Excess Ultrasound (VExUS), and the occurrence of acute kidney injury (AKI) in children with RVD following congenital heart surgery. Secondary objectives included comparing changes in VExUS scores after initiating treatment for RVD and venous congestion.
    Methods and results: This was a prospective observational study in children with RVD. The VExUS study was performed on day 1, day 2, and day 3 and categorized as VExUS-1, VExUS-2, and VExUS-3. Among 43 patients with RVD and dilated inferior vena cava, 19/43 (44%), 10/43 (23%), and 12/43 (28%) were VExUS-2 and VExUS-3, respectively. There was an association between severe RVD and elevated pulmonary artery systolic pressures and a VExUS score >2. A significant association was observed between central venous pressure (CVP) measurements and VExUS. Among 31 patients with a high VExUS score >2, 18 (58%) had AKI. Additionally, improvement in CVP and fluid balance was associated with improving VExUS scores following targeted treatment for RVD.
    Conclusion: VExUS serves as a valuable bedside tool for diagnosing and grading venous congestion through ultrasound Doppler. An elevated VExUS score was associated with the occurrence of AKI, and among the components of VExUS, portal vein pulsatility may be useful as a predictor of AKI.
    How to cite this article: Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MTT, Ranjit S. Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction. Indian J Crit Care Med 2024;28(5):447-452.
    Language English
    Publishing date 2023-09-01
    Publishing country India
    Document type Journal Article
    ZDB-ID 2121263-6
    ISSN 1998-359X ; 0972-5229
    ISSN (online) 1998-359X
    ISSN 0972-5229
    DOI 10.5005/jp-journals-10071-24705
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  8. Article: Hyperferritinemia in Severe Dengue Infection: Single-Center Retrospective Cohort Study.

    Lakshmanan, Chidhambharam / Ranjit, Suchitra / Natraj, Rajeswari / Venkatachalapathy, Priyavarthini / Kumar, Vasanth S / Lum, Lucy Chai See

    Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

    2023  Volume 24, Issue 9, Page(s) e409–e416

    Abstract: Objectives: Hyperferritinemia in the critical phase of dengue infections may correlate with severe dengue ( sd ) disease, and our primary objective was to examine the association between ferritin level on day 1 of PICU admission and 2009 World Health ... ...

    Abstract Objectives: Hyperferritinemia in the critical phase of dengue infections may correlate with severe dengue ( sd ) disease, and our primary objective was to examine the association between ferritin level on day 1 of PICU admission and 2009 World Health Organization (WHO) criteria for sd . Our secondary objective was outcome in relation to care. It is unclear whether immunomodulatory therapy during the critical phase may restore immune homeostasis and mitigate disease severity.
    Design, setting, and patients: Retrospective cohort study of children with dengue 1 month to 16 years old with admission ferritin greater than or equal to 500 ng/mL requiring PICU admission. Demographics, clinical, and laboratory parameters, presence of the 2009 WHO sd criteria and outcomes were analyzed. Immunomodulatory therapy was used when there was persistent hyperinflammation beyond the critical phase of plasma leakage.
    Interventions: None.
    Measurements and main results: Fifty-five patients were admitted in the critical phase of dengue with median (interquartile range) ferritin levels of 8,105 ng/mL (2,350-15,765 ng/mL). Patients with at least one WHO sd category had higher ferritin levels compared to those without any sd criteria, with the highest levels in eight patients with all three sd categories. In our cohort of 55, 52 patients (94%) recovered with standard supportive therapy. Recovery was associated with decreased ferritin levels that occurred in parallel with improved circulation and platelet counts; this included 22 of 24 patients with admission ferritin levels greater than or equal to 10,000 ng/mL and two with ferritin greater than 1,00,000 ng/mL. Immunomodulation was used in three patients with unremitting fever, persistent hyperferritinemia, and progressive multiple organ dysfunction beyond the critical phase, of whom two died.
    Conclusions: Hyperferritinemia in the critical phase of sd is associated with the number of 2009 WHO sd criteria present. Our data also indicate that many patients with sd recover well with supportive care.
    MeSH term(s) Child ; Humans ; Severe Dengue ; Retrospective Studies ; Hyperferritinemia ; Ferritins ; Platelet Count
    Chemical Substances Ferritins (9007-73-2)
    Language English
    Publishing date 2023-05-01
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2052349-X
    ISSN 1947-3893 ; 1529-7535
    ISSN (online) 1947-3893
    ISSN 1529-7535
    DOI 10.1097/PCC.0000000000003250
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  9. Article ; Online: Fluid Overload in Acute Asthma Exacerbation and Clinical Outcomes. Is There an Association?

    Ranjit, Suchitra / Sankar, Jhuma

    American journal of respiratory and critical care medicine

    2018  Volume 197, Issue 9, Page(s) 1095–1096

    MeSH term(s) Asthma ; Child ; Extravascular Lung Water ; Humans ; Water-Electrolyte Balance
    Language English
    Publishing date 2018-02-27
    Publishing country United States
    Document type Editorial ; Comment
    ZDB-ID 1180953-x
    ISSN 1535-4970 ; 0003-0805 ; 1073-449X
    ISSN (online) 1535-4970
    ISSN 0003-0805 ; 1073-449X
    DOI 10.1164/rccm.201801-0091ED
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  10. Article: Scope, Safety, and Feasibility of Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: A Single-center Experience.

    Balasubramanian, Karthik Kumar / Venkatachalapathy, Priyavarthini / Margabandhu, Saravanan / Natraj, Rajeshwari / Sridaran, Vasanth Kumar / Lakshmanan, Chidhambharam / Ranjit, Suchitra

    Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine

    2023  Volume 27, Issue 10, Page(s) 766–770

    Abstract: Background: Indications for therapeutic plasma exchange (TPE) in the pediatric intensive care unit (PICU) are expanding. We aimed to study the demographics, clinical indications, and outcomes of patients who have undergone TPE in our PICU.: Materials ... ...

    Abstract Background: Indications for therapeutic plasma exchange (TPE) in the pediatric intensive care unit (PICU) are expanding. We aimed to study the demographics, clinical indications, and outcomes of patients who have undergone TPE in our PICU.
    Materials and methods: This is a retrospective study performed among children aged from 1 month to 16 years of age. Demographics, indications, therapeutic response, serious adverse events (SAE), PICU length of stay (LOS), and death during hospitalization were studied as outcome variables.
    Results: Therapeutic plasma exchange was performed in 115 sessions on 24 patients for 12 different indications falling under various American Society for Apheresis (ASFA) categories. Therapeutic plasma exchange was performed on ten, four, and ten children for ASFA category I, II, and III indications, respectively. The most common indications were thrombotic microangiopathy (TMA) (8/24) and acute liver failure (ALF) (6/24). During those 115 sessions, a total of five serious adverse events (SAEs) occurred, accounting for 4.3% of the cases. Minor adverse events occurred in 12 sessions (10.4%). Therapeutic response was good in 17 patients (71%) including 5 patients who underwent standard volume TPE (SV-TPE) for ALF. Median PICU LOS was 9 (range 2-120) days. The mortality rate was 12.5% (3/24).
    Conclusion: Therapeutic plasma exchange is effective in various clinical conditions involving various organ systems. It is an excellent therapeutic modality in children with ALF, irrespective of the exchange volume and TMA. However, SAEs do occur in the minority.
    How to cite this article: Balasubramanian KK, Venkatachalapathy P, Margabandhu S, Natraj R, Sridaran VK, Lakshmanan C,
    Language English
    Publishing date 2023-10-27
    Publishing country India
    Document type Journal Article
    ZDB-ID 2121263-6
    ISSN 1998-359X ; 0972-5229
    ISSN (online) 1998-359X
    ISSN 0972-5229
    DOI 10.5005/jp-journals-10071-24541
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