KARNATAKA PEDICON 2006

Praveen Khilnani
Head Pediatric Pulmonology and Critical care,
Institute of pediatrics,
MAX superspeciality Hospital, New Delhi

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Introduction

1. Quality pediatric care requires specialized training and a special sensitivity that is perfected through caring for children full time.
2. From mild illness and injury to the most severe medical emergency, Children’s specially qualified clinical staff and affiliated physicians can provide the best healthcare.
3. Infant mortality rate 2005 (International)
4. Germany4.2 Greece5.5 Guatemala35.9
5. Hungary8.6
6. India 56.3
7. Iran41.6 Ireland5.4 Israel7.0 Italy5.9 Japan3.3 Kenya61.5
8. Korea, South7.0 Mexico20.9 Mozambique130.8
9. New Zealand5.8Nigeria98.8
10. Lowest Finland 3.6 Highest Angola 191.2
    Source: U.S. Census Bureau, International Database

Infant mortality rate
Year 2002

1. INDIA (70.5),
2. Kerala (14.1), Maharashtra (48.0), Tamil Nadu (52.6), Punjab (52.8),
3. West Bengal (53.6),
4. Karnataka (61.4), Himachal Pradesh (61.4), Gujarat (63.2), Andhra Pradesh (65.2), Bihar (67.0), Haryana (68.6), Assam (76.0), Rajasthan (83.1), Uttar Pradesh (85.1), Madhya Pradesh (94.0), Orissa (96.9) Source:The Office of the Registrar General, India

Vital rates for India – 1971 – 2000

Year	Crude Birth rate	Crude Death rate	Infant mortality rate
1971	36.9	14.9	129
1976	34.4	15.0	129
1981	33.9	12.5	110
1986	32.6	11.1	96
1991	*29.5	9.8	80
1996	*27.5	9.0	72
2000	25.8	8.5	68

Source : Sample Registration System, Office of the Registrar General,India(excludes J andK)

Common diseases requiring intensive care

• Respiratory distress,pneumonia,asthma
• Septic shock, hypotension
• Cardiac defects and failure
• Coma,encephalitis,dengue,malaria
• Accidents,head, chest ,abdominal injury
• Poisonings
• Burns
• Post surgery,heartsurgery,neurosurgery

Children are different

• From birth through adolescence, children have special health care needs that are different from those of adults. Their bodies respond differently to injury and illness.
• And most children do not understand – or know how to deal with – the experience of serious illness or hospitalization.

Why an ICU devoted solely to children?
Children and adults experience different kinds of health problems.

• Adults typically suffer from chronic, degenerative diseases that appear later in life after developing over many years,
• Children get immediate effects of Prematurity, Congenital abnormalities, Viral and infectious diseases
• Even diseases that are common to both children and adults may affect children differently.
• The cancers that affect adults are generally not found in pediatric patients.
• Children are more likely to suffer from leukemias, brain tumors and other cancers that develop in growing tissues.
• Juvenile diabetes, requires management that is different from the management needed when diabetes is diagnosed later in life
• AIDS often progresses more rapidly in children than in adults, although the virus is the same. ent differs from that of adults. Medications for adults are in standard doses as opposed to /kg/bsa dose
• Diagnostic/therapeutic equipment must often be tailored to fit a child's smaller size
• Children need support to cope with their disease or illness from those who are best able and trained to understand their growing minds and bodies.

Is all that really medically important? YES

• Causes of cardiac arrest are different
• Airway anatomy,cardiac and respiratory physiology is different
• Resuscitation(PALS) protocols are different
• Perioperative respiratory and cardiac care is different
• Emergency transport for critically ill /injured children requires pediatric trained team available round the clock

Current status of Pediatric intensive care services in INDIA
Government sectorInadequate services
Disorganized/ Poor infrastructure for large population and high mortality (example Delhi Kalawati Saran Childrens hospital)
Multiple small pediatric departments in government hospitals with medical colleges with either small or no PICU
Handfull of big PICUs at AIIMS,PGI etc.
Very few PICUs in the Government institutions in Eastern India
Overall: More is desired
Current status of PICUs in INDIA
Private sector

• Multiple small pediatric ICUs in private hospitals (Surat,Nagpur,Hyederabad,Indore,Bengal etc)and bigger private PICUs at Apollo group hospitals, Ganga ram,Hinduja,KKCT Chennai etc.
• n Better PICU services than government institutions BUT in larger picture given the large population GROSSLY INADEQUATE and unaffordable due to high cost

So whats different in pediatric care in the West?
More than 60 Childrens hospitals in the US and More than 100 PICUs in general hospitals. Each medical college affiliated institution has attached speciality services including PICU

• CHILDRENS HOSPITAL
• Treats all aspects of the patient, including emotional well-being and that of the child's family under one roof by pediatric trained and experienced personnel.
• Private Comprehensive and High Tech Care with Harvard university affiliation and training programs

Can we do it? In INDIA?
In private sector probably YES

• Though Investors And Land availability remains a challenge.
• Building materials, infrastructure
• TECHNOLOGY
• And the Trained
• Medical Personnel
• Are becoming more AVAILABLE

Can we do it? In INDIA?
In government sector? MAY BE Political will and speed of action in Government remains a challenge.

• THOUGH TECHNOLOGY And the Trained Medical Personnel Are becoming more AVAILABLE
  Big challenges for the Government sector are Organization&Finances
• ABSORB/SUBSIDIZE COST OF HIGH TECH UNAFFORDABLE ICU CARE TO COMMON MAN
• LACK OF CRITICAL CARE AND TRANSPORT FACILITIES
• LONG DISTANCES :TOO FEW TERTIARY CENTERS

Requirements of a Pediatric emergency an Intensive Care Service

• 24 hour Multi dsciplinary Casualty
• Emergency transport for critically ill /injured children wth pediatric trained team available round the clock
• Senior Pediatric emergency and PICU Consultant Incharge
• Space for designated PICU,Emergency and Intensive care equipment
• STRUCTURED TRAINING :DNB,Fellowship in pediatric specialities
• Staff (resident/nursung)education
• Hands on Training Workshops
• Clinical research program
• (MEDICAL COLLEGE AFFILIATED) And MCI,DNB recognized

FELLOWSHIP in Pediatric CRITICAL CARE
- For last 4 years

Guidelines for pediatric critical care in Indian Intensive care units
Are published IP jan 2002

• International Academic Participation Indian clinical data presentation is also important
• ISCCM Is advocating CRITICAL CARE to be listed as a recognized medical discipline in MCI
• As it is a life saving field of medicine overlapping with all medical desciplines

Summary

• More Pediatric intensive care services are needed in our country. CAN BE DONE!
• Govetnment sector is unable to cope up with the intensive care needs of population
• Private sector and government sector will have to work hand in hand
• MORE COMMITMENT IS NEEDED BY THE Government SECTOR to ORGANIZE AND FINANCE SUCH SERVICES THROUGHOUT INDIA TO SERVE CHILDREN OF INDIA

Karnataka Pedicon 2006 - Conference Abstracts.Pediatric Oncall [serial online] 2006 [cited 15 November 2006(Supplement 11)];3. Available from:
http://www.pediatriconcall.com/fordoctor/Conference_abstracts/
KARNATAKA_PEDICON/picu_scenario.asp