Sunit Singhi

Publications (332) View all

• Article: Aerosolized L-epinephrine vs budesonide for post-extubation stridor: A randomized controlled trial

  A. Sinha, M. Jayashree, S. Singhi
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  ABSTRACT: ObjectiveTo compare the efficacy and adverse effects of aerosolized L-epinephrine vs budesonide in the treatment of post-extubation stridor. Study designRandomized controlled trial. SettingPediatric intensive care unit (PICU) of a tertiary teaching and referral hospital. SubjectsSixty two patients with a stridor score ≥4 following extubation. InterventionPatients were randomized to receive either aerosolized L-epinephrine (n=32) or budesonide (n =30). Respiratory rate, heart rate, stridor score, blood pressure and oxygen saturation were recorded from 0 min to 24 hours. Outcome measuresStridor score remaining at ≥4, need for re-nebulization and re-intubation between 20 min −24 hours were primary outcome measures. Tachycardia (HR > normal for age), hypertension (BP >95th centile for age) and hypoxia (SpO2 <92% for 5 min) were secondary outcome measures. ResultsBoth drugs showed a significant and comparable decline in the median (95% CI) stridor scores from baseline to 60 min [4 (4.10–4.50) to 2.00 (1.46–2.67) for budesonide vs 4 (4.12–5.00) to 2.00 (1.31–2.75) for epinephrine]. At 2 hours, the stridor scores were significantly lower in the epinephrine as compared to budesonide group [0.00 (0.69–1.81) vs 3.00(1.75–3.32); P=0.02)]. However, the proportion of patients with stridor score ≥4 at any time between 20min–24 hrs (53.3% vs 53.1%; P=0.99), need for renebulization (40 % vs 43.8 %; P=0.76) and re-intubation (20% vs 25%, P=0.638), and adverse effects were similar in both groups. ConclusionsBoth aerosolized L-epinephrine and budesonide were equally effective in their initial therapeutic response in post-extubation stridor. However, epinephrine showed a more sustained effect. Key wordsBudesonide-Epinephrine-Extubation-Stridor
  Indian pediatrics 04/2012; 47(4):317-322. · 1.05 Impact Factor
• Article: Potential risk of hypoxaemia in patients with severe pneumonia but no hypoxaemia on initial assessment: a prospective pilot trial.

  S C Singhi, A K Baranwal, B Bharti
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  ABSTRACT: The World Health Organization recommends oxygen therapy for children under 5 years of age with pneumonia and lower chest indrawing. In patients with severe pneumonia who are initially normoxaemic, there is little information on the risk of subsequently developing hypoxaemia and the benefit of routine oxygen therapy. To study the incidence of subsequent hypoxaemia in initially normoxaemic children with pneumonia and lower chest indrawing. Children (n = 58, 3-59 mths) with pneumonia, lower chest indrawing and normoxaemia (SpO(2) >90%) were randomly assigned to receive supplemental oxygen (nasal prongs, 1-2 L/min flow) (n = 29) or room air (n = 29). Vital signs and SpO(2) were monitored continuously and recorded every 6 hours. Outcome variables were incidence of hypoxaemia, length of tachypnoea and lower chest indrawing. The two groups had similar demographic and clinical profiles. Thirty-one patients (53%) developed hypoxaemia later, without significant differences between the two arms (RR 0·61, 95% CI 0·36-1·04). Patients who developed hypoxaemia later were similar to those who did not, except for a lower SpO(2) on enrolment. However, they took more time to recover from tachypnoea (P<0·05), chest indrawing (P<0·05) and fever, indicating that they had more severe disease. Early oxygen therapy did not alter the course of disease. About half of the normoxaemic patients with severe pneumonia developed hypoxaemia after enrolment, indicating a significant potential risk. Children hospitaled with severe pneumonia might benefit from routine oxygen therapy. Alternatively, oxygen might be provided to those who develop hypoxaemia identified by a pulse oximeter.
  Paediatrics and international child health. 01/2012; 32(1):22-6.
• Article: Randomized controlled trial of interrupted versus continuous sedative infusions in ventilated children.

  Kunal Gupta, Vipul K Gupta, Muralindharan Jayashree, Jayashree Muralindharan, Sunit Singhi
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  ABSTRACT: To compare daily interruption vs. continuous sedative infusions in mechanically ventilated children with respect to lengths of mechanical ventilation and intensive care unit stay. Prospective randomized controlled trial. Pediatric intensive care unit of a tertiary care teaching and referral hospital. One hundred two patients mechanically ventilated for >48 hrs. Patients were randomized to receive either continuous (group 1) or interrupted (group 2) sedative infusion (midazolam bolus of 0.1 mg/kg, followed by infusion, to achieve a Ramsay score of 3-4). Each patient in group 2 had daily interruption of infusion at 8:00 AM till he/she became fully awake (response to verbal commands) or so agitated/uncomfortable that he/she needed restarting of infusion (whichever was earlier) at a dose 50% less than the previous dose. Primary outcome variables were the lengths of mechanical ventilation and intensive care unit stay, while the number and percentage of days awake on sedative infusions, frequency of adverse events, and total dose of sedatives required were the secondary outcome variables. Of the 102 patients included in the study, 56 were randomized into the continuous sedation protocol and 46 into the interrupted sedation protocol. Both were statistically similar with respect to demography, primary diagnosis, severity of illness score (Pediatric Risk of Mortality I and III), indication for mechanical ventilation, and initial ventilatory variables except that the patients under the interrupted arm had lower peak inspiratory pressure and positive end-expiratory pressure requirements at the start of ventilation (p = .002 and p = .028, respectively). The mean (SD) length of mechanical ventilation in the interrupted sedation protocol was significantly less than that in the continuous sedation protocol (7.0 ± 4.8 days vs. 10.3 ± 8.4 days; p = .021). Similarly, the difference in the median duration of pediatric intensive care unit stay was significantly less in the interrupted sedation as compared to the continuous sedation protocol (10.7 days vs. 14.0 days; p = .048). The mean total dose of midazolam and the total calculated cost of midazolam in the former were significantly less compared to those of the latter (7.1 ± 4.7 mL vs. 10.9 ± 6.9 mL, p = .002; 4827 ± 5445 rupees vs. 13,865 ± 25,338 rupees, p = .020). The frequencies of adverse events in both the groups were however similar. The length of mechanical ventilation, duration of intensive care unit stay, total dose of midazolam, and average calculated cost of the therapy were significantly reduced in the interrupted as compared to the continuous group of sedation.
  Pediatric Critical Care Medicine 01/2011; 13(2):131-5. · 3.13 Impact Factor
• Article: Changing trends and predictors of outcome in patients with acute poisoning admitted to the intensive care.

  M Jayashree, S Singhi
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  ABSTRACT: Acute poisoning in children is a medical emergency and preventable cause of morbidity and mortality. Knowledge about the nature, magnitude, outcome and predictors of outcome is necessary for management and allocation of scant resources. This is a retrospective study conducted in the Pediatric Intensive Care Unit (PICU) of an urban multi speciality teaching and referral hospital in North India from January 1993 to June 2008 to determine the epidemiology, clinical profile, outcome and predictors of outcome in children with acute poisoning. Data of 225 children with acute poisoning was retrieved from case records with respect to demographic profile, time to presentation, PRISM score, clinical features, investigations, therapeutic measures, complications and outcome in terms of survival or death. Survivors and non-survivors were compared to determine the predictors of mortality. Acute poisoning constituted 3.9% of total PICU admissions; almost all (96.9%) were accidental. The mean age of study patient's was 3.3 ± 3.1 (range 0.10-12) years with majority (61.3%) being toddlers (1-3 years). In the overall cohort, kerosene (27.1%) and prescription drugs (26.7%) were the most common causative agents followed by organophosphates (16.0%), corrosives (7.6%), carbamates (4.9%) and aluminum phosphide (4.9%). However the trends of the three 5-year interval (1993 till the end of 1997, 1998 till the end of 2002 and 2003 till the end of June 2008) revealed a significant decrease in kerosene, aluminum phosphide and iron with increase in organophosphate compound poisoning. Ninety nine (44%) patients required supplemental oxygen, of which nearly half (n = 42; 42.4%) needed mechanical ventilation. Twenty (8.9%) died; cause of death being iron poisoning in five; aluminum phosphide in four; organophosphates in three and one each because of kerosene, diesel, carbamate, corrosive, sewing machine lubricant, isoniazid, salicylate and maduramycin poisoning. There has been a significant decrease in the mortality over the years. The non-survivors were older, had a higher PRISM score and hypotension at admission and higher need for oxygen and ventilation. On multiple logistic regression analysis hypotension at admission was the most significant predictor of death (adjusted odds ratio: 5.59; 95% confidence interval: 1.38-22.63; p = 0.016). Acute poisoning in children over the past 15 years has shown a changing trend with significant decrease in kerosene, iron and aluminum phosphide and an increase in organophosphate and prescription drugs. The overall mortality has decreased significantly. Hypotension at admission was the most significant predictor of death.
  Journal of Tropical Pediatrics 10/2010; 57(5):340-6. · 1.39 Impact Factor
• Article: Invasive zygomycosis in India: experience in a tertiary care hospital.

  A Chakrabarti, S S Chatterjee, A Das, N Panda, M R Shivaprakash, A Kaur, S C Varma, S Singhi, A Bhansali, V Sakhuja
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  ABSTRACT: To report the natural history and clinical course of zygomycosis from a single tertiary care centre in India where doctors maintain an institutional zygomycosis registry. The clinical and laboratory data collected prospectively from patients with antemortem diagnosis for invasive zygomycosis, and retrospectively from autopsy diagnosed cases, over an 18 month period (July 2006-December 2007) were combined and analysed. During the period 75 cases (50 cases/year) of zygomycosis were reported. Antemortem diagnosis could be made in 81% of cases and 9% of patients had nosocomial zygomycosis. The spectrum of disease included rhino-orbito-cerebral (48%), pulmonary (17%), gastrointestinal (13%), cutaneous (11%), renal and disseminated zygomycosis (5% each). Uncontrolled type 2 diabetes (58%) and diabetic ketoacidosis (38%) in the rhino-orbito-cerebral type, renal failure (69%) in the pulmonary type, prematurity (70%) in the gastrointestinal type, and breach of skin (88%) in cutaneous zygomycosis, were the significant (p<0.05) underlying illnesses. Rhizopus oryzae (69%) was the most common isolate followed by Apophysomyces elegans (19%). Overall mortality was 45% in patients who could be treated. Outcome was significantly poor when surgical debridement could not be performed or the patients were treated only with amphotericin B deoxycholate. On multivariate analysis, patients with a Glasgow Coma Score (GCS) >or=9 had a better prognosis. Zygomycosis is a threat in uncontrolled diabetes. New risk factors such as renal failure and chronic liver disease require attention. A elegans is an emerging agent in India. The need for surgical debridement in addition to medical treatment is emphasised. GCS is an independent marker of prognosis in cases of invasive zygomycosis.
  Postgraduate medical journal 11/2009; 85(1009):573-81. · 1.38 Impact Factor