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"No Newborn Or Child Should Die For Lack Of Tertiary Or Quaternary Intensive Care Services"
Dr Dinesh Kumar Chirla, Director, Intensive Care Services, Rainbow Children’s Hospital talks about the importance of intensive care facilities at a children’s hospital. Excerpts of a conversation with BW Businessworld
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Why are intensive care services needed in a children’s hospital in the first place?
The incidence of neonatal mortality rate is 20.3 per thousand live births in our country and under five years of age mortality rate is 35.73 per thousand live births. Prematurity, birth asphyxia and sepsis are the commonest problems for which newborn babies need intensive care services, apart from congenital problems detected antenatally during the foetal scan or after birth. Children with pneumonias, severe gastroenteritis, dengue fevers, cancer, heart disease, seizures, liver failure, trauma following surgery, post-transplant — all need intensive care services. The levels of intensive care services can be graded from 1 to 4, based on the support they need.
To save some very sick children we will need advanced intensive care services like ECMO, high frequency ventilation, neuromonitoring, CRRT (dialysis), nitric oxide therapy and other supportive therapies. For pre-term babies, we are now able to save those born as early as within 24 weeks of gestation and weighing 500 grams at birth. This is possible with expert medical and nursing care and advanced infrastructure. To be able to save critically ill children and newborn babies, every children’s hospital will need intensive care services. At Rainbow, we have established the most advanced intensive care services for newborn babies and children and are able to save the sickest and smallest child and newborn babies.
How important are intensive care services in determining the efficacy of a children’s hospital?
Intensive care services are an integral part of any children’s hospital. Most children come to the hospital because of emergencies. There are two kinds of intensive care services in any children’s hospital — a Newborn Intensive Care (NICU) and a Paediatric Intensive Care (PICU). In a good children’s hospital, they constitute anywhere between 25 per cent and 30 per cent of the total beds. Intensive care services are the fulcrum of all the care provided for any sick child in any paediatric speciality. It has been proven that the outcomes of post-surgical patients, including transplant, is 20 per cent better in a children’s hospital.
During epidemics like dengue, H1N1 and Covid-19, when children had conditions called MIS-C, we were able to save many lives because of good intensive care support. Children became unstable very fast and we needed to be very meticulous in recognising early warning signs of deterioration and also in carefully determining the drug doses, fluid management and age and weight appropriate ventilation. This improves the outcome and survival. Following surgery, including transplants (both liver and kidney), bone marrow transplant (BMT), neurosurgery, cardiac surgery and trauma, children need PICU support to improve the outcome as they are unstable after surgery and need intensive monitoring.
Children need dialysis, ECMO, neuromonitoring, all of which are necessary for the improved survival of critically ill children. In Newborn Intensive Care Units (NICU), we admit babies who are born pre-term, have breathing difficulty, difficult transition after birth and surgical problems, among other issues. To save the smallest baby (the smallest baby we saved weighed 375 grams at birth) we need advanced intensive care and monitoring, apart from expert nursing and medical care.
How important is the role of an intensive care unit in supporting other specialities in a children’s hospital?
As like subspecialists for adults, now paediatric subspecialists are well recognised, like paediatric cardiologists,paediatric neurologists, paediatric gastroenterologists, paediatric hemato-oncologists, paediatric pulmonologists, developmental paediatricians, endocrinologists, orthopaedic surgeons, and so on. Children in sub-speciality, when they get sicker, will need intensive care support for survival and better outcome. If a child has refractory seizures, acute liver failure, kidney failure, or a child with altered sensorium, postcardiac surgery, an oncology child with severe infection — they all need intensive monitoring and PICU support for better outcomes. Apart from sub-speciality knowledge, they need intensive care support to ensure that the child is stabilised both from oxygenation, maintenance of blood pressure, management of infection and ensuring that the child’s life is set for the future. Another role of intensive care is to integrate all sub-specialities under one roof to ensure that when patients get sicker, they are given intensive care and provided the best care.
What more do we need in children’s intensive care services at the moment? And what does the future hold in this realm of specialisation?
I have seen the journey of intensive care in India over the last two decades. We started by providing tertiary intensive care services and have now graduated to offering quaternary intensive care. We are taking care of patients following liver transplant, kidney transplant and post BMT. We are providing ECMO services, neurosurgical services, saving pre-term babies — born before 24-25 weeks of gestation — providing renal dialysis, CRRT for providing dialysis for new born babies, and providing transport oscillation while transporting sick babies. So this advanced support is now properly developed in a few centres in the country, like within the Rainbow Children’s Hospital chain. A few other centres also provide these services. We visualise that these types of services should be available in every state capital of India. They should have one such major hub that can provide quaternary services, so that every newborn and every child gets the best care. And we should be able to save every life. We should be able to give every life the chance to survive, and every parent a chance to smile.
Can you highlight any critical cases that were treated successfully at Rainbow Children’s Hospital’s intensive care units?
The first case that comes to mind is that of Cherry. Cherry was born at 25 weeks of gestation with a birth weight of 375 grams and is a Limca Book record holder and South Asia’s smallest baby to survive. The parents had come from Raipur and no one gave her any chance of survival. It was more than three months’ journey in NICU, but at the end of it, she made it, after being on respiratory support for nearly 105 days. Seeing her smiling, walking, running was so fruitful. The Guinness Book of World Records lists us for the largest gathering of children born pre-term under one roof. We had a gathering of 445 pre-term babies who have survived in that list in 2016.
Another incidence that comes to mind involves Rainbow Children’s Hospital’s Newborn Emergency Transport, when we first picked up a newborn at 26 weeks of gestation, born to a couple after 14 years of marriage. The baby survived and is now nearly 20 years old. Now, we are the largest neonatal and paediatric emergency transport service provider in the country. Recently, for the first time in the county, we started high frequency oscillation and nitric oxide during transportation. Then there was a child who survived after being on ECMO for more than a month. It was very rewarding for the team to see him absolutely normal. We get a lot of satisfaction from successful organ transplants in children. Transplants are offered to critically ill children. It is so satisfying to see them go home recovered. So far Rainbow Children’s Hospital has successfully enabled 13 liver transplants, 20 kidney transplants and 60 BMT. I would also like to mention an EXIT procedure. A baby was born with a huge neck mass, detected antenatally. Nearly 20 doctors from different specialities — foetal medicine, obstetrics, anaesthesia, neonatology, surgery and ENT — were there in the delivery room to ensure that the baby survives. An EXIT procedure was done for the first time when the foetus was still in the mother’s womb. The baby stayed in NICU for two months.