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Niranjan Kissoon

Publications and source records attributed to Niranjan Kissoon.

At least 19 recordsLinked to original sources
PubMed2005

Bench-to-bedside review: humanism in pediatric critical care medicine - a leadership challenge.

A humanistic approach to leadership is especially important in the case of children in the technology-rich intensive care unit (ICU) environment. Leaders should create a humanistic milieu in which the needs of critically ill children, their families and staff are never overlooked. Humanistic leaders are tactful, accessible, approachable and versatile, and have a sense of humour. Humanness in the ICU environment has many faces and poses a challenge to many in leadership positions. Humanistic leaders treat others as they hope they will become. They are constantly questioning themselves, seeking awareness of themselves and others, but most importantly they are constantly learning and evolving. Ultimately, humanistic leadership creates an ICU culture that supports all, is conducive to enriching lives, and is sensitive to the needs of patients and their families.

Attitude of Health Personnel↗
PubMed2005

Vitamin K deficiency mimicking child abuse.

Supplemental vitamin K is required for normal hemostasis in infancy. Infants born outside the hospital may not receive prophylactic vitamin K. They may suffer from bleeding into various tissues and are likely to present to the emergency department. This report describes an infant born at home who presented with intracranial bleeding and signs and symptoms consistent with child abuse. Further investigations confirmed the diagnosis of Vitamin K deficiency. Although it is important to consider child abuse when the history and examination are consistent with the diagnosis, it is equally important to consider other potential diagnoses including Vitamin K deficiency.

Child Abuse↗
PubMed2005

Influence of sex and beta2 adrenergic receptor haplotype on resting and terbutaline-stimulated whole body lipolysis.

beta 2 adrenergic receptors ( beta 2 ARs) are important mediators of lipolysis. The beta 2 AR gene is highly polymorphic. To determine the contribution of beta 2 AR polymorphisms to variability in whole body lipolysis, we compared basal and terbutaline-stimulated lipolytic rates (Ra) using tracer techniques in 14 healthy, non-obese males (n=7) and females (n=7) who were homozygous for Cys-19/Arg16/Gln27 or Arg-19/Gly16/Glu27 haplotypes. Fasting (overnight) Ra values were higher in females compared to males. Mean+/-SD Ra, Ra/body weight, Ra/fat free mass, Ra/fat, and Ra/energy expenditure rates in males and females were 155+/-46 vs 311+/-111 micromol/min (P=.007); 2.0+/-0.61 vs 5.2+/-2.3 micromol/(min kg) (P=.006); 2.5+/-0.75 vs 7.8+/-3.4 micromol/(min kg) (P=.003); 10+/-3.7 vs 17+/-7.4 micromol/(min kg) (P=.09); and 144+/-45.5 vs 392+/-111 micromol/d (P=.0001), respectively. Mean+/-SD basal glycerol concentrations were higher in females compared to males: 62+/-5.6 vs 36+/-17 micromol/L (P=.003). Basal glycerol concentrations and Ra values were similar by beta2 AR haplotype. Basal glucose and insulin concentrations tended to be higher in males compared to females and were similar by haplotype. Terbutaline-stimulated changes in glycerol concentrations were variable and are not related to either sex or haplotype. We conclude that compared to haplotype, sex is a more important determinant of basal lipolysis after a 12-hour fast in healthy, non-obese individuals.

Adrenergic beta-Agonists↗
PubMed2005

Aggressive management of dengue shock syndrome may decrease mortality rate: a suggested protocol.

OBJECTIVES: Dengue shock syndrome is a leading cause of mortality among Indian children. In January 2000, we instituted a protocol for aggressive management of children with dengue shock syndrome. The objective of this study was to compare outcomes (duration of ventilation, pediatric intensive care unit stay, incidence of acute respiratory distress syndrome, and intensive care unit and hospital mortality) before and after the protocol. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit at a tertiary teaching hospital. PATIENTS: One hundred and fourteen patients admitted between July 1997 and December 1999 received standard therapy recommended by the World Health Organization (WHO) and were designated as the WHO guidelines group (W), whereas 96 patients admitted between January 2000 and December 2001 were treated by our protocol and designated as the protocol group (P). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The patients in each group were equally matched in terms of age, Pediatric Risk of Mortality, and number with dengue hemorrhage fever grade IV, although the platelet counts were higher in the W group compared with the P group (geometric mean 42.2, confidence interval 36.9, 48.4 vs. geometric mean 36.7, confidence interval 33.3, 40.5, p < .05). Patients in the W group received less fluids in the first hour compared with the P group (median and interquartile range 20 mL/kg, 15 and 20 vs. 30 mL/kg, 20 and 60). Fluid was actively removed less often in the W group than the P group (6 of 111 vs. 45 of 96, p < .05). There was no difference in the need for ventilation or incidence of acute respiratory distress syndrome between groups, although among dengue hemorrhage fever grade IV patients, the number requiring ventilation (17 of 30 vs. 20 of 23, p < .05) and the incidence of acute respiratory distress syndrome (9 of 30 vs. 17 of 23, p < .05) were significantly greater in the W group compared with the P group. The duration of ventilation (1.5 +/- 1.7 vs. 4.2 +/- 2.9 days, p < .05) and length of intensive care unit stay (3.0 +/- 2.8 vs. 3.4 +/- 2.9 days, p < .05) were significantly less in the W group. The pediatric intensive care unit mortality (16.6% vs. 6.3%, p < .05) was significantly higher in the W group than in the P group. CONCLUSIONS: Patients with dengue shock syndrome are at high risk of mortality due to refractory shock and multiple organ failure. Survival was better for patients in the P group. Aggressive shock management and possibly the use of judicious fluid removal may decrease mortality rates in the severest forms of dengue shock syndrome.

Algorithms↗
PubMed2005

End-tidal carbon dioxide monitoring in pediatric emergencies.

End-tidal carbon dioxide (CO2) monitoring is useful in the prehospital setting, emergency department, intensive care unit, and operating room. Capnography provides valuable, timely information about the function of both the cardiovascular and respiratory systems. End-tidal CO2 monitoring is the single most useful method in confirming endotracheal tube position. It also provides information about dead space, cardiac output, and airway resistance. A thorough understanding of cardiopulmonary physiology and the technical nuances of capnometry is required for its optimal use in children. This review examines the basic physiology pertinent to end-tidal CO2 monitoring, its clinical applications, and evidence supporting its use in infants and children.

Capnography↗
PubMed2004

Modeling the metabolic effects of terbutaline in beta2-adrenergic receptor diplotypes.

OBJECTIVE: Our objective was to determine whether beta(2)-adrenergic receptor polymorphisms influence terbutaline-stimulated changes in glucose, insulin, and potassium concentrations in healthy adults. METHODS: Seven healthy adults homozygous for the Arg-19/Gly16/Glu27 haplotype (RGE) and seven homozygous for the Cys-19/Arg16/Gln27 haplotype (CRQ) volunteered to receive a 1-hour infusion of terbutaline (0.01 mg/kg). A 2-compartment pharmacokinetic model was fitted to the terbutaline concentrations. Concentrations of glucose and insulin were fitted simultaneously by use of a coupled feedback indirect response model. An indirect response model was also fitted to the plasma potassium concentration versus time data. The -2 log-likelihood ratio test was used to determine whether estimates of the covariates of diplotype and sex improved the model fittings. RESULTS: Demographic variables, anthropometric characteristics, and pharmacokinetics did not differ by diplotype. The coupled feedback model fitted the glucose and insulin concentration data well with excellent precision. Terbutaline stimulated production of glucose (S(1)) to a greater extent in RGE compared with CRQ diplotypes, as follows: S(1) = 0.039 +/- 0.007 (mean +/- SD) versus 0.0276 +/- 0.01, respectively (P <.05, -2 log-likelihood criterion). The baseline values, disposition rate constants for glucose (k(out1)) and insulin (k(out2)), production rate of insulin (S(2)), feedback effect of insulin on glucose (S(3)), and pharmacodynamic parameters for potassium did not differ by diplotype or sex. CONCLUSIONS: The beta(2) receptor diplotype influences receptor-stimulated glucose production in healthy, nonobese individuals, which is consistent with beta(2) receptor-mediated hepatic glycogenolysis. Future metabolic studies of this system should consider beta(2) receptor genetic variants.

Adolescent↗
PubMed2004

Exhaled nitric oxide reflects asthma severity and asthma control.

INTRODUCTION: This study was undertaken to a) evaluate whether exhaled nitric oxide (fraction of exhaled nitric oxide [FENO]) levels are reflective of asthma severity in concordance with the National Asthma Education and Prevention Program categorization and b) determine the usefulness of FENO using the single-breath exhalation technique for monitoring asthma control and compliance with steroid treatment. METHODS: Thirty patients with asthma (7-17 yrs old; 14 males and 16 females) that was mild (n=8), moderate (n=17), or severe (n=5) were included in the study. Fifteen patients were seen on more than one occasion for a total of 53 visits. Information obtained at each visit included asthma symptoms, beta-agonists and corticosteroids use, compliance to steroids, and forced expiratory volume in 1 sec (FEV1) and FENO measurements. Asthma control was judged by a pulmonologist based on overall evaluation of symptoms, FEV1 measurements, and the frequency of beta-agonists use at each visit. RESULTS: The mean +/- SD FENO was significantly different in the mild, moderate, and severe asthma categories (30 +/- 12, 65 +/- 48, 104 +/- 68, respectively; F(2,52)=6.02 p=.005). FENO was significantly correlated with asthma severity (r=.44, p=.001), compliance (r=-.75, p=.001), and control (r=-.51, p=.001). There were no statistically significant differences between asthma severity and compliance or FEV1. DISCUSSION: Our data suggest that a) FENO may be a practical tool to evaluate asthma severity and asthma control over time and b) FENO may be used as a marker of compliance with steroids even when FEV1 has not decreased significantly.

Adolescent↗
PubMed2004

Relevance of type of catheters for central venous pressure measurement.

OBJECTIVE: To compare simultaneous central venous pressure measurements from rigid polyurethane and soft tunneled silicone elastomere catheters. HYPOTHESIS: There will be no significant difference in central venous pressure readings between polyurethane and silastic catheters. SETTING: Bone Marrow Transplant Unit in a tertiary care children's hospital. PATIENTS: Five children undergoing bone marrow transplantation with preexisting polyurethane and silastic catheters. METHODS: Simultaneous central venous pressure readings were obtained by 2 observers blinded to the other readings and to the type of catheter. Readings were done in triplicate (total of 690 readings). Each triplicate was averaged to 1 data point yielding 115 paired central venous pressure measurements. RESULTS: No significant difference was demonstrated between polyurethane and silicone catheters (-1 +/- 3 cm H20). Using Bland and Altman method revealed no significant bias (mean = -1 cm H2O) and acceptable agreement between catheter types. CONCLUSION: Silicone and polyurethane catheters yield similar values of central venous pressures. Permanently implanted silicone elastomere catheters can be used to measure central venous pressure in the emergency setting.

Adolescent↗
PubMed2003

Effect of montelukast on time-course of exhaled nitric oxide in asthma: influence of LTC4 synthase A(-444)C polymorphism.

Leukotrienes (LT) mediate inflammation in asthma. The fraction of exhaled nitric oxide (FE(NO)) is thought to be a sensitive and reproducible method for assessing airway inflammation in asthmatics and the anti-inflammatory effects of drugs. A number of factors are known to contribute to intrapatient variation in FE(NO) which can confound interpretation. The aims of this study were to characterize the time-course of FE(NO), determine the effect of montelukast on the time-course of FE(NO), and evaluate the influence of the LTC(4) synthase A(-444)C polymorphism on montelukast-evoked changes in FE(NO). Following a 2-week run-in, 7 males and 5 females with asthma, 10-16 years old, received 5 or 10 mg of montelukast or an identical placebo at bedtime for 7 days in double-blind, crossover fashion, followed by a 7-day washout. FE(NO)was quantified every 30 min for 3 or 6 hr at baseline and on days 1, 2, 3, and 7 of treatment. A time-averaged value for FE(NO) was calculated (FE(NO)*), and % changes in FE(NO)* relative to baseline vs. time following placebo and montelukast were compared. The genotype of the A(-444)C polymorphism was determined by PCR and RFLP. FE(NO) varied markedly as a function of time in each patient. Time-averaged values of FE(NO) (FE(NO)*) during placebo and montelukast treatment were similar. Montelukast significantly reduced the slope of the % change in FE(NO)* vs. time curve in heterozygotes (n = 4), but not in A/A homozygotes (n = 8). These data suggest that heterozygotes respond better to montelukast compared to A/A homozygotes, at least with respect to changes in FE(NO). We conclude that assessment of inflammation or the anti-inflammatory effects of drugs in asthma based on single determinations of FE(NO) can be misleading. We further conclude that the A(-444)C polymorphism in the LTC(4) synthase gene probably contributes to interpatient variability in montelukast-evoked changes in FE(NO)* and warrants further study.

Acetates↗
PubMed2003

Choosing a volume expander in critical care medicine.

The debate concerning the choice of crystalloids or colloids for resuscitation of the critically ill child is still unsettled. Moreover, the use of albumin in critically ill patients has been increasingly questioned because of the lack of clear-cut advantages over crystalloids as well as the concern for cost and the very minor risk of infection. Despite several meta-analyses addressing these issues, there is no data that supports the use of albumin unequivocally in any specific disease states. The suggestion that the use of albumin increases mortality in critically ill patients is not supported by data. There may be niche areas such as hypoalbuminic states, cirrhosis and burns where albumin may have distinct benefits. Alternatively synthetic colloids may be useful, however, concerns about coagulation problems and organ dysfunction persists.

Blood Volume↗
PubMed2003

Severe acute respiratory syndrome: providing care while minimizing personal risks.

Severe acute respiratory syndrome (SARS) poses a threat to most countries because of easy and convenient travel across the globe in a matter of hours. SARS is a recently recognized infectious disease that may lead to death and severe pulmonary sequelae. It presents with non-specific signs and symptoms and because no definitive laboratory test is readily available, it poses a great risk to healthcare workers because quarantine of affected individuals may not occur early in its presentation. Healthcare workers should consider the diagnosis and institute prompt and thorough protective measures in suspected cases.

Humans↗
PubMed2002

Exhaled nitric oxide concentrations: online versus offline values in healthy children.

Exhaled nitric oxide (FE(NO)) is a noninvasive and practical method to assess airway inflammation. We conducted this investigation to determine the most appropriate flow rate to measure FE(NO) and to obtain reference values for FE(NO) in children. FE(NO) was measured in 112 healthy 6-18 year olds (60 males) at 4 expiratory flow rates (46, 31, 23, and 15 mL/sec) using a chemiluminescent nitric oxide analyzer. Offline and online analyses were done to determine FE(NO) intraclass correlation coefficients, the relationship between FE(NO) and expiratory flow rates, and the effects of age and gender on these measurements. The major findings were: 1) intraclass correlation coefficients for FE(NO) and flow rates ranged from 0.92-0.99 for offline values, and 0.99 for all online values; 2) variation at an expiratory flow rate of 46 mL/sec (SD, 9.39) was considerably less than at other flows, especially at 15 mL/sec (SD, 26.55); 3) FE(NO) increased as flow rates decreased for both offline and online values; 4) there were no significant differences and good agreement between offline bag and online FE(NO) values at 31 and 46 mL/sec expiratory flows; and 5) using multiple regression, significant predictors of FE(NO) were flow, body surface area, age, and FEF(25-75). We have provided FE(NO) values in healthy children and propose that the ideal expiratory flow rate for FE(NO) measurements in children using the single breath technique is between 30-50 mL/sec.

Adolescent↗
PubMed2002

Effect of beta2-agonist treatment and spirometry on exhaled nitric oxide in healthy children and children with asthma.

We set out to determine the effect of spirometry and bronchodilator therapy on exhaled nitric oxide (FE(NO)) values in children. We hypothesized that there will be no difference on FE(NO) values pre- and postspirometry and following bronchodilator therapy. Sixteen children [(mean = 14.4 +/- 1.2 years; range, 12-18 years; healthy controls (n = 6); asthmatics on inhaled steroids (n = 5); and asthmatics on no steroids (n = 5)] had exhaled nitric oxide (FE(NO)) measurements on 4 consecutive days as follows: pre- and postspirometry (day 1); pre- and postalbuterol metered dose inhaler (MDI) therapy (day 2); pre- and postspirometry and albuterol MDI therapy (day 3); and pre- and postspirometry and placebo MDI (day 4). FE(NO) was measured with a chemiluminescence analyzer, using the single vital capacity exhalation technique at an exhalation flow of 50 mL/sec. There were no statistically significant differences in FE(NO) values pre- and poststudy maneuvers under all experimental conditions in healthy children. However, in healthy children, clinically relevant (>10%) differences from baseline were observed on day 1 (3-18 min) and day 4 at 18 min. In children with asthma, FE(NO) values increased significantly by 11-19% from pretreatment levels at 8 and 18 min, postbronchodilator on day 2, and 12-17% at 8 and 18 min post bronchodilator and spirometry on day 3. Spirometry and treatment with a placebo (day 4) resulted in a decrease in FE(NO) values by 11% at 3 min postbaseline in patients on inhaled steroids. The changes observed were similar in children on vs. off inhaled steroids, and also in well-controlled vs. poorly controlled asthma. We conclude that FE(NO) values should be obtained consistently either pre- and at a specific time postalbuterol treatment or spirometry. Alternatively, changes in FE(NO) values should be interpreted in relationship to the timing of these maneuvers.

Adolescent↗
PubMed2002

Securing the child's airway in the emergency department.

Airway management is an important aspect of pediatric emergency care. Prompt, effective airway access can mean the difference between a good outcome and disability or death. Optimal management requires an understanding of the differences between children and adults with respect to airway anatomy and physiology and response to medications to facilitate airway access. In most cases, the emergency physician is called to secure a child's airway with little forewarning. This review details a logical and practical approach to the uncomplicated pediatric airway. Emphasis is also placed on recognition of the difficult airway and methods to render the difficulty less daunting. Good judgment and the appropriate skills are the prerequisites for success.

Airway Obstruction↗
PubMed2002

Acute asthma: under attack.

The burden of asthma (death, disability, and an increasing prevalence) makes it a major public health problem worldwide. In an effort to decrease this burden, investigators are studying many aspects of this disease. The role of race, ethnicity, infections, and pollutants as triggers, as well as the risk factors are now being defined. Research into methods to decrease acute exacerbations and improve emergency and in-hospital management, using standardized protocols and incentives for follow-up care, has yielded valuable information but has met with limited success. Adherence to the national guidelines has been poor and to some extent can be attributed to the lack of a practical method of measuring the degree of lung inflammation and cumbersome treatment protocols. Exhaled nitric oxide is a noninvasive marker of inflammation and may provide a rational method to titrate corticosteroid and leukotriene receptor antagonist therapy. The best route and dosing regimen for corticosteroid administration (oral vs intramuscular vs nebulized) are the subject of several studies, with no clear-cut winner. The burden of asthma in developing countries with limited financial resources has also triggered a search for simpler, cheaper, and practical methods for beta-agonist delivery using indigenous spacers. Recent research in asthma has unveiled our incomplete knowledge of the disease but has also provided a sense of where efforts should be expended. Research into the genetics and pharmacogenetics of asthma and into the societal factors limiting the delivery of optimal care is likely to yield useful and practical information.

Acute Disease↗