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Titre
Date
Durée
Pediatric Critical Care Board Review Part 2
25 Oct 2026
00:35:45
A child with DKA develops a worsening headache, altered mental status, and bradycardia: the hosts explain why suspected cerebral injury should be treated before imaging. Dr. Pradip Kamat and Rahul Damania bring that same bedside focus to a rapid-fire pediatric critical care board review, covering medication dosing, kidney and electrolyte emergencies, endocrine crises, and liver failure. Along the way, they explain why a normal anion gap can hide acidosis when albumin is low, how a dangerously wide QRS in hyperkalemia changes the treatment order, and why acute liver failure can meet criteria even without obvious encephalopathy. Short cases, clear answers, and practical physiology make this a focused review for the PICU and the boards.
Show Highlights:
Medication dosing in acute kidney injury, including loading versus maintenance doses
Phenytoin’s nonlinear kinetics and extended-infusion beta-lactam antibiotics
Kidney and electrolyte disorders, including metabolic alkalosis, hypokalemia, and anion-gap interpretation
Hyponatremia, sodium correction, cerebral salt wasting, and pseudohyponatremia
Hyperkalemia management, rhabdomyolysis, and kidney replacement therapy
Diabetic ketoacidosis and suspected cerebral injury
Endocrine emergencies, including adrenal crisis, thyroid storm, and hypoglycemia
Metabolic disorders, including urea cycle disorders and hyperammonemia
Pediatric acute liver failure and lactulose’s role in ammonia management
Nutrition assessment and the effects of inflammation on albumin and prealbumin
References:
Medication questions
FDA Dilantin prescribing information: saturable metabolism and interpretation of unbound phenytoin in hypoalbuminemia and renal/hepatic disease.
Fuhrman & Zimmerman’s Pediatric Critical Care, 6th edition: background pharmacology, renal physiology, acid–base, and endocrine chapters.
Glaser N, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022;23:835–856.Full guideline.
Kuppermann N, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378:2275–2287. The trial did not find significant neurologic outcome differences among the fluid regimens studied.
Additional background and references are provided in the linked hypoglycemia and hyperammonemia episodes.
Liver and nutrition questions
Squires JE, et al. NASPGHAN Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr. 2022;74:138–158.Full position paper.
Squires RH, et al. Intravenous N-acetylcysteine in Pediatric Patients with Non-Acetaminophen Acute Liver Failure. Hepatology. 2013;57:1542–1549.
Evans DC, et al. The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper. Nutr Clin Pract. 2021;36:22–28.PubMed.
A hemoglobin increase from 8 to 12 can boost oxygen delivery far more than raising oxygen saturation from 88% to 98%—but that doesn’t mean transfusing every child to 12 is the right call. In part one of this pediatric Critical Care Board Review, Dr. Pradip Kamat, Dr. Rahul Damania, and Dr.Monica Gray connect high-yield equations to urgent bedside decisions: when intubation may improve a failing heart, why a normal blood gas can hide impending respiratory failure, and how hyperventilation can lower intracranial pressure while dangerously reducing cerebral blood flow. They also tackle ventilator waveforms, ECMO anticoagulation, transfusion complications, and the test-taking strategies that make physiology easier to apply under pressure.
Show Highlights:
Board-preparation strategies and physiology-based clinical reasoning
Oxygen delivery, oxygen content, and hemoglobin’s role
Cardiac shunts, Qp:Qs, and duct-dependent congenital heart disease
Cardiopulmonary interactions, ventilation, and hemodynamics
Rhythm disturbances, CPR, and ECMO perfusion concepts
Gas exchange, alveolar gas equation, and oxygenation indices
Ventilator pressures, waveforms, time constants, and dead space
Cerebral perfusion, traumatic brain injury, and neurologic emergencies
Neuromuscular respiratory failure, seizures, and brain death assessment
Anticoagulation, transfusion complications, sickle cell disease, and other hematologic emergencies
Fuhrman & Zimmerman’s Pediatric Critical Care, 6th ed. (Elsevier) — chapters on cardiopulmonary interactions, respiratory physiology and mechanical ventilation, neurocritical care, and hematologic emergencies. (add chapter numbers)
Emeriaud G, et al. Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med. 2023;24(2):143–168.
Greer DM, et al. Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination: Consensus Guideline. Neurology. 2023.
Kochanek PM, et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition. Pediatr Crit Care Med. 2019;20(3S Suppl 1):S1–S82.
Kapur J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). N Engl J Med. 2019;381:2103–2113.
Lacroix J, et al. Transfusion Strategies for Patients in Pediatric Intensive Care Units (TRIPICU). N Engl J Med. 2007;356:1609–1619.
Valentine SL, et al. Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children (TAXI). Pediatr Crit Care Med. 2018;19(9):884–898.
128: Beta Blocker Toxicity in the PICU: Slow Heart, Fading Mind, and Falling Sugar
06 Sep 2026
00:23:03
In this episode of *PICU Doc on Call*, Drs. Pradip Kamat and Rahul Damania dive into the topic of beta-blocker toxicity. They walk through a case of a 15-year-old who comes in with bradycardia, hypotension, hypoglycemia, and altered mental status after an intentional ingestion. Using a board-style question, they break down how to tell the difference between beta-blocker and calcium channel blocker poisoning and review key points about cardiac physiology and receptor signaling.
Drs. Kamat and Damania discuss management strategies, including glucagon, high-dose insulin therapy, vasopressors, calcium, and ECMO as a last resort. They also spend some time focusing on specific agents like propranolol and sotalol, highlighting what makes their toxicologic profiles unique. This is a high-yield episode packed with pearls for pediatric intensivists!
Show Highlights:
Clinical case of a 15-year-old patient with bradycardia and hypotension due to intentional drug ingestion
Beta-blocker toxicity and its clinical features
Differentiation between beta-blocker and calcium channel blocker toxicity
Key physiological concepts related to cardiac action potentials and beta receptor function
Clinical presentation and diagnostic workup for beta-blocker toxicity
Management strategies for beta blocker overdose, including airway control and fluid resuscitation
Specific toxicologic profiles of common beta-blockers (e.g., propranolol, sotalol, metoprolol)
Importance of recognizing hypoglycemia and CNS effects in beta-blocker toxicity
Summary of critical management steps and take-home points for pediatric intensivists
Encouragement for further learning and engagement on related topics
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 126. Toxidromes and their treatment. Joshi P. Pages 1504-1505
Reference 1: Rogers textbook of Pediatric Intensive Care: Chapter 36: Poisoning. Nares M, Jeyapalan A, Weisman R: pages 525-543
Reference 2: Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR; American Heart Association. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023 Oct 17;148(16):e149-e184. doi: 10.1161/CIR.0000000000001161. Epub 2023 Sep 18. PMID: 37721023.
Suarez F, Koyfman A, Long B. Pearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity. J Emerg Med. 2026 May;84:1-11. doi: 10.1016/j.jemermed.2026.01.021. Epub 2026 Jan 27. PMID: 41833262.
Hello From the Otherside! Transport Calls
23 Aug 2026
00:21:10
In this episode of PICU Doc on Call, third-year PICU fellow Dr. Alexandria Edwards joins Drs. Pradip Kamat, Monica Gray, and Rahul Damania for a quick and practical dive into pediatric transport medicine. Dr. Edwards walks us through her go-to framework for handling transport calls, highlighting the importance of systematically checking vitals, respiratory support, the physical exam, labs, and any interventions. The team uses a real-life case of a 12-year-old with severe status asthmaticus to talk through how to pick the right transport mode, why it’s best to avoid intubation if you can, and how to make sure you’re on the same page with the ICU team before the patient arrives. The main message? Build a solid, structured approach to transport calls and practice it every time.
Show Highlights:
Overview of pediatric intensive care unit (PICU) fellowship and training
Importance of transport medicine in the PICU setting
Framework for handling transport calls effectively
Key considerations for assessing patient stability during transport
Importance of vital signs and current patient status in decision-making
Strategies for communicating with referring providers
Discussion of a specific case involving a pediatric patient with asthma exacerbation
Decision-making process for mode of transport (ground vs. air)
Role of critical care transport teams in patient transfer
Tips for preparing the receiving ICU team for incoming patients
We welcome your feedback and reviews. Please visit our website at https://picudoconcall.org/, where you can find our episodes.
Metformin Overdose in the Pediatric ICU | A Case of Low pH
09 Aug 2026
00:20:28
In this episode, Drs. Pradip Kamat, Monica Gray, and Rahul Damania talk through a heartbreaking case involving a 14-year-old girl with a history of psychiatric illness who intentionally took 45 tablets of metformin and empagliflozin. Things went downhill quickly—she developed severe lactic acidosis, hypoglycemia, acute kidney injury, and eventually suffered a cardiac arrest that required ECMO and continuous dialysis. Sadly, even with the most aggressive care, she didn’t make it. The doctors walk listeners through the pharmacology and toxicity of metformin and empagliflozin, discuss how these drugs can cause harm, and share key management strategies. They really stress the importance of early recognition, using extracorporeal therapies, and working as a multidisciplinary team when dealing with severe pediatric overdoses of antidiabetic medications.
Show Highlights:
Case study of a 14-year-old girl with intentional ingestion of an oral antidiabetic agent
Presentation of severe lactic acidosis, hypoglycemia, acute kidney injury, and cardiac arrest
Discussion of the pharmacology and toxicology of metformin and empagliflozin
Mechanisms of metformin toxicity and its effects on metabolic processes
Differentiation between types of lactic acidosis related to metformin
Importance of early recognition and management of metformin toxicity
Supportive care strategies for managing severe metformin overdose
Role of extracorporeal therapies, including ECMO and dialysis, in treatment
Multidisciplinary approach involving intensivists, nephrologists, and toxicologists
Clinical implications and outcomes of severe metformin toxicity in pediatric patients
Resources:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter: Nothing found
Reference 1: Noites I, Figueiredo M, Shchomak Z, Boto L, Camilo C. Fatal Pediatric Metformin-Associated Lactic Acidosis: When Severity Goes Unnoticed. Cureus. 2026 Feb 16;18(2):e103719.
Reference 2: Bebarta VS, Pead J, Varney SM. Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatr Emerg Care. 2015 Aug;31(8):589-90.
Capnography in the PICU | Take My Breath Away
26 Jul 2026
00:21:35
In this episode of *Pediatric Critical Care Insights*, Dr. Monica Gray and Dr. Pradip Kamat chat about how capnography, specifically end-tidal CO2 monitoring, is used in the pediatric ICU. They walk through a real-life case of a 9-year-old with respiratory failure from influenza A, showing how ETCO2 monitoring helps confirm endotracheal tube placement, guides ventilation, spots cardiac arrest, and even helps assess the quality of CPR. Along the way, they break down how to interpret capnography waveforms, discuss different types of devices, and explain the key physiological concepts. The episode is packed with practical, bedside tips for intensivists caring for critically ill kids.
Show Highlights:
Importance of capnography (end-tidal CO2 monitoring) in the pediatric intensive care unit (PICU)
Clinical case study of a 9-year-old boy with respiratory failure due to influenza A
Use of capnography for confirming endotracheal tube placement and assessing ventilation status
Detection of cardiac arrest and guidance for CPR quality through ETCO2 monitoring
Overview of capnography physics and physiology, including terminology distinctions
Types of capnography: mainstream vs. sidestream, and their applications in pediatric patients
Assumptions for accurate ETCO2 approximation of arterial CO2 and conditions affecting this relationship
Analysis of capnography waveform phases and their clinical significance
Prognostic value of ETCO2 during cardiac arrest and its correlation with patient outcomes
Practical applications of ETCO2 monitoring in critical care, focusing on airway, breathing, and circulation management
References:
Noninvasive respiratory monitoring and assessment of gas exchange. David F. Butler; Kenneth A. Schenkman. Fuhrman and Zimmerman's Pediatric Critical Care, 43, 483-491.e3
Humphreys S, Schibler A, von Ungern-Sternberg BS. Carbon dioxide monitoring in children—A narrative review of physiology, value, and pitfalls in clinical practice. Pediatr Anaesth. 2021;31:839–845. https://doi.org/10.1111/pan.14208
Lasa JJ, Dhillon GS, Duff JP, et al. Part 8: Pediatric Advanced Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2026;157(1):e2025074351
O'Flaherty. Capnography: principles and practice. London: BMJ Publishing Group; 1994.
Aminiahidashti H, Shafiee S, Zamani Kiasari A, Sazgar M. Applications of End-Tidal Carbon Dioxide (ETCO2) Monitoring in Emergency Department; a Narrative Review. Emerg (Tehran). 2018;6(1):e5. Epub 2018 Jan 15. PMID: 29503830; PMCID: PMC5827051.
Start Off Strong: Tips and Tricks for 1st-year PICU Fellows
12 Jul 2026
00:18:16
In this special episode of *PICU Doc on Call*, hosts Dr. Monica Gray and Dr. Rahul Damania welcome new pediatric critical care fellows across the U.S. with practical advice for day one of fellowship. Joined by third-year PICU fellow Dr. Alexandra Bryant, the episode covers three key areas: navigating PICU logistics, protecting mental health, and managing the overwhelming volume of critical care knowledge. Dr. Bryant shares candid insights from her own training journey, offering actionable strategies for success. The hosts remind listeners that fellowship is a learning process and that new fellows can make a meaningful impact.
Show Highlights
Introduction to pediatric critical care fellowship for new fellows and learners
Key insights and advice for first-year fellows in pediatric intensive care
Importance of understanding logistics in the PICU environment
Strategies for effective communication and collaboration within the PICU team
Managing mental health and self-care during fellowship
Techniques for absorbing and retaining vast knowledge in pediatric critical care
Recommendations for organizing study materials and resources
Emphasis on lifelong learning and accessing information effectively
Practical tips for time management and responsibility organization
Suggested resources for mindfulness and emotional support in medical training
Time Constants in the PICU | PICU Doc on Call Shorts
05 Jul 2026
00:18:58
In this episode of *PICU Doc on Call Shorts*, pediatric ICU physicians Dr. Pradip Kamat and Dr. Rahul Damania discuss respiratory time constants and their clinical relevance in pediatric critical care. Using a case of a six-year-old with near-fatal status asthmaticus on mechanical ventilation, they explain how prolonged time constants from high airway resistance cause air trapping, dynamic hyperinflation, and intrinsic PEEP. They emphasize recognizing these issues through ventilator waveforms and highlight that increasing respiratory rate can worsen hypercapnia in obstructive disease. Key management strategies include reducing respiratory rate, extending expiratory time, and accepting permissive hypercapnia to ensure hemodynamic stability.
Show Highlights
Respiratory time constants and their clinical significance in pediatric patients
Case study of a six-year-old boy with near-fatal status asthmaticus
Management of severe obstructive respiratory failure in pediatric patients
Understanding airway resistance and lung compliance in relation to time constants
Impact of ventilator settings on patient outcomes, including air trapping and intrinsic PEEP
Importance of adequate expiratory time to prevent dynamic hyperinflation
Recognizing signs of inadequate expiratory time in mechanically ventilated patients
Strategies for managing hypercapnia and optimizing ventilator settings
Differences in time constants related to various pediatric respiratory conditions
Key takeaways for pediatric critical care practice and ventilator management
References
Depta F, Kallet RH, Gentile MA, Kassis EN. Expiratory time constants in mechanically ventilated patients: rethinking the old concept — a narrative review. Intensive Care Medicine Experimental. 2025;13:40. The review summarizes the definition of expiratory time constant, the relationship to resistance and compliance, the 63/86/95/98/99% rule, and clinical applications in obstructive and acute lung injury states.
Depta F, et al. Six methods to determine expiratory time constants in mechanically ventilated patients: a prospective observational physiology study. Intensive Care Medicine Experimental. 2024. This study describes expiratory time constant as a parameter that can guide respiratory rate and I:E adjustment to support complete exhalation.
Alibrahim O, Rehder KJ, Miller AG, Rotta AT. Mechanical Ventilation and Respiratory Support in the Pediatric Intensive Care Unit. Pediatric Clinics of North America. 2022;69(3):587–605. This pediatric review specifically discusses passive exhalation, the expiratory time constant, and why asthma and bronchiolitis require longer expiratory times to avoid gas trapping.
Arnal JM. Monitoring respiratory mechanics in mechanically ventilated patients. Hamilton Medical Knowledge Base. This source provides a practical bedside description of time constants, waveform-based respiratory mechanics, and typical RCexp ranges, while emphasizing dependence on resistance and compliance.
Emeriaud G, López-Fernández YM, Iyer NP, et al.; PALICC-2 Group; PALISI Network. Executive summary of the second international guidelines for the diagnosis and management of pediatric ARDS. Pediatric Critical Care Medicine. 2023;24(2):143–168. The PALICC-2 guideline framework supports lung-protective ventilation in PARDS, including attention to tidal volume, PEEP, plateau pressure, and driving pressure.
Sweet Dreams: Procedural Sedation in the PICU
21 Jun 2026
00:33:53
In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat explore procedural sedation in the pediatric ICU. They cover sedation levels, pre-screening, risk stratification using ASA classifications, and medication selection tailored to each patient's hemodynamic and respiratory status. Through real-world case discussions involving respiratory failure, septic shock, and acute neurological decline, they highlight the importance of end-tidal CO2 monitoring and early adverse event recognition. Key takeaways include avoiding the term "conscious sedation," preparing rescue plans, and prioritizing patient safety through careful assessment and monitoring.
Show Highlights:
Definitions and levels of sedation (minimal, moderate, deep sedation, and general anesthesia)
Importance of terminology in procedural sedation
Monitoring sedation levels using scales like the Richmond Agitation-Sedation Scale (RASS)
Pre-screening and risk stratification considerations for pediatric patients
ASA physical status classification system for assessing patient risk
Unique challenges of procedural sedation in critically ill children
Adverse events associated with pediatric procedural sedation, particularly respiratory complications
Management strategies for specific cases requiring sedation (e.g., respiratory failure, septic shock)
Importance of end-tidal CO2 monitoring during sedation
Key takeaways for safe sedation practices in the pediatric ICU setting
References:
Nir Atlas; Rahul C. Damania; Pradip P. Kamat In Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 135, 1624-1628
Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia byCommittee on Quality Management and Departmental Administration. Last Amended: October 23, 2024.
Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019 Jun;143(6):e20191000. doi: 10.1542/peds.2019-1000. PMID: 31138666.x
Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006 Mar 4;367(9512):766-80. doi: 10.1016/S0140-6736(06)68230-5. PMID: 16517277.
Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth. 2024 Mar;132(3):491-506. doi: 10.1016/j.bja.2023.11.050. Epub 2024 Jan 6. PMID: 38185564.
Smith, Heidi A. B. MD, MSCI (Chair)1,2; Besunder, James B. DO, FCCM3,4; Betters, Kristina A. MD1; Johnson, Peter N. PharmD, BCPS, BCPPS, FCCM, FPPA, FASHP5,6; Srinivasan, Vijay MBBS, MD, FCCM7,8; Stormorken, Anne MD9,10; Farrington, Elizabeth PharmD, FCCM11; Golianu, Brenda MD12,13; Godshall, Aaron J. MD14; Acinelli, Larkin CPNP-AC, ACHPN15; Almgren, Christina CPNP16; Bailey, Christine H. MD17; Boyd, Jenny M. MD18,19; Cisco, Michael J. MD20; Damian, Mihaela MD, MPH21,22; deAlmeida, Mary L. MD23,24; Fehr, James MD13,25; Fenton, Kimberly E. MD, FCCM14; Gilliland, Frances DNP, CPNP-AC/PC26,27; Grant, Mary Jo C. CPNP-AC, PhD, FAAN28; Howell, Joy MD29; Ruggles, Cassandra A. PharmD, BCCCP, BCPPS30; Simone, Shari DNP31,32; Su, Felice MD21,22; Sullivan, Janice E. MD33,34; Tegtmeyer, Ken MD, FAAP, FCCM35,36; Traube, Chani MD, FCCM29; Williams, Stacey CPNP-AC37; Berkenbosch, John W. MD, FAAP, FCCM (Chair)33,34. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatric Critical Care Medicine 23(2):p e74-e110, February 2022. | DOI: 10.1097/PCC.0000000000002873
Benzoni T, Agarwal A, Cascella M. Procedural Sedation. [Updated 2025 Mar 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK551685/
Kerson AG, DeMaria R, Mauer E, Joyce C, Gerber LM, Greenwald BM, Silver G, Traube C. Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children. J Intensive Care. 2016 Oct 26;4:65. doi: 10.1186/s40560-016-0189-5. PMID: 27800163; PMCID: PMC5080705.
Tel-Dan SF, Shavit D, Nates R, Samuel N, Shavit I. Emergency Physician-Administered Sedation for Thoracostomy in Children With Pleuropneumonia. Pediatr Emerg Care. 2021 Dec 1;37(12):e1209-e1212. doi: 10.1097/PEC.0000000000001975. PMID: 31929389.
Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med. 2022 Dec;80(6):485-496. doi: 10.1016/j.annemergmed.2022.05.002. Epub 2022 Jun 23. PMID: 35752522.
Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, Gelman B; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006 Sep;118(3):1087-96. doi: 10.1542/peds.2006-0313. PMID: 16951002.
Pink Toes and Blue Brain on VA ECMO (North South Syndrome on ECMO)
07 Jun 2026
00:24:00
In this episode of *PICU Doc on Call*, Dr. Monica Gray and Dr. Pradip Kamat are joined by fellow Dr. Hope Vancleve to discuss a complex case of a 12-year-old with MRSA septic shock requiring VA ECMO. The conversation covers sepsis-induced myocardial dysfunction, including its pathophysiology, diagnosis, and management. The hosts also explore differential hypoxia, or Harlequin syndrome, a serious VA ECMO complication causing upper body deoxygenation, and discuss monitoring strategies and circuit reconfiguration to prevent cerebral and myocardial ischemia.
Show Highlights:
Clinical case discussion of a 12-year-old male patient with MRSA septic shock.
Complications of sepsis, including sepsis-induced myocardial dysfunction and refractory shock.
Management strategies for septic shock, including antibiotic therapy and fluid resuscitation.
Use of venoarterial ECMO support in pediatric patients with severe cardiac dysfunction.
Pathophysiology of sepsis-induced myocardial dysfunction and its impact on cardiac function.
Differential hypoxia (North-South syndrome) in patients on femoral VA ECMO.
Diagnostic approaches for sepsis-induced myocardial dysfunction, including echocardiography and biomarkers.
Importance of monitoring and managing end-organ function in septic patients.
Strategies for addressing differential hypoxia in ECMO patients, including circuit reconfiguration.
Discussion of the risks and benefits of various ECMO configurations and management techniques.
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter
Reference 1: Torre DE, Pirri C. Harlequin Syndrome in Venoarterial ECMO and ECPELLA: When ECMO and Native or Impella Circulations Collide - A Comprehensive Review. Rev Cardiovasc Med. 2025 Aug 26;26(8):39992. doi: 10.31083/RCM39992. PMID: 40927093; PMCID: PMC12415751.
Of Rats & Men: Approach to Coumadin Overdose in the PICU
24 May 2026
00:20:39
In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat discuss a 15-year-old girl who attempted suicide by ingesting rat poison, acetaminophen, ibuprofen, and amlodipine. The episode focuses on long-acting anticoagulant rodenticides (LAARs), such as brodifacoum, which inhibit vitamin K epoxide reductase, causing delayed coagulopathy. Key topics include clinical presentation, diagnostic evaluation, and management, emphasizing vitamin K1 as the primary antidote and prothrombin complex concentrate or fresh-frozen plasma for major bleeding. The patient stabilized with aggressive supportive care, including vasoactive agents and NAC therapy, alongside psychiatric intervention. Listen to learn more!
Show Highlights
Clinical case of a 15-year-old girl who attempted suicide through polypharmacy ingestion
Ingestion of multiple substances, including chewable rat poison, acetaminophen, ibuprofen, and amlodipine
Discussion of toxicology related to long-acting anticoagulant rodenticides (LAARs) like brodifacoum
Symptoms and clinical presentation following acute ingestion, including metabolic acidosis and elevated lactate
Diagnostic evaluation and laboratory findings, including coagulation studies and liver function tests
Management strategies for LAAR poisoning, including the use of vitamin K and supportive care
Importance of monitoring for delayed coagulopathy and serial INR testing
Consideration of calcium channel blocker toxicity in the context of the patient's clinical instability
Overview of the mechanisms of action of LAARs and their impact on vitamin K-dependent clotting factors
Key take-home points regarding the recognition and management of rodenticide ingestion in pediatric patients
References
Reference: King N, Tran MH. Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management. Transfus Med Rev. 2015 Oct;29(4):250-8.
Reference 2: Feinstein DL, Akpa BS, Ayee MA, et al. The emerging threat of superwarfarins: history, detection, mechanisms, and countermeasures. Ann N Y Acad Sci. 2016 Jun;1374(1):111-22.
Mind Your Scope: Bronchoscopy Pearls for the Pediatric Intensivist
10 May 2026
00:16:10
In this episode of PICU Doc on Call, Dr. Monica Gray and Dr. Pradip Kamat chat about flexible fiberoptic bronchoscopy (FFB) in the pediatric ICU. They walk through a case involving an eight-year-old who’s dealing with respiratory failure after a stem cell transplant. Along the way, they talk about when and why you might use bronchoscopy both for diagnosis and treatment—plus how to approach sedation and what effects the procedure can have on the heart and lungs. They also dive into important topics like managing hypoxia, handling increased airway and pulmonary vascular resistance, and what to keep in mind if your patient has a traumatic brain injury. The episode wraps up with tips for managing fever after the procedure and a quick look at how rigid bronchoscopy compares.
Show Highlights:
Use of flexible fiberoptic bronchoscopy (FFB) in the pediatric ICU (PICU)
Indications for performing bronchoscopy (diagnostic and therapeutic)
Management of sedation and analgesia during bronchoscopy
Cardiovascular effects associated with bronchoscopy procedures
Respiratory effects and complications during bronchoscopy
Special considerations for bronchoscopy in patients with traumatic brain injury (TBI)
Post-procedure complications, including fever and its management
Overview of rigid bronchoscopy and its indications
Importance of understanding physiological changes during bronchoscopy
Educational focus on acute pediatric care for current and aspiring PICU interns
References:
Reference 1: Sachdev A, Chhawchharia R. Flexible Fiberoptic Bronchoscopy in Pediatric Practice. Indian Pediatr. 2019 Jul 15;56(7):587-593. PMID: 31333214.
Reference 2: Li SX, Tao XF, Wu HJ, Jin F, Zhu GH, Wang YS, Tang LF, Chen ZM, Wu L. Advances in pediatric flexible bronchoscopy. World J Pediatr. 2025 Oct;21(10):945-956. doi: 10.1007/s12519-025-00967-7. Epub 2025 Oct 4. PMID: 41045338; PMCID: PMC12578761.
Reference 3: Truitt BA, Kasi AS, Kamat PP, Fundora MP, Simon DM, Guglani L. Cryoextraction via flexible bronchoscopy in children with tracheobronchial obstruction. Pediatr Pulmonol. 2023 Sep;58(9):2527-2534. doi: 10.1002/ppul.26540. Epub 2023 Jun 23. PMID: 37350368.
Isoflurane in the PICU
26 Apr 2026
00:12:10
In this episode of "PICU Doc on Call," Drs. Monica Gray and Pradip Kamat from Children's Healthcare of Atlanta dive into the use of inhaled anesthetics, especially isoflurane, in the pediatric ICU. We’re focusing on those tough cases: refractory status asthmaticus and status epilepticus.
We’ll chat about why isoflurane is our go-to over other agents like sevoflurane, desflurane, or nitrous oxide, and break down its bronchodilatory and anticonvulsant properties. We’ll also touch on important pharmacology concepts, such as MAC and the blood-gas partition coefficient, and discuss how we approach dosing and ventilator management when using isoflurane.
Of course, we’ll also discuss the potential adverse effects that can come with prolonged use, and why it’s important to stop other sedatives and beta-agonists once you start isoflurane. Join us as we walk through the practical aspects and pearls for using inhaled anesthetics in the PICU!
Show Highlights:
Use of inhaled anesthetics in pediatric intensive care units (PICU)
Focus on isoflurane for managing refractory status asthmaticus and status epilepticus
Comparison of inhaled anesthetic agents: isoflurane, sevoflurane, nitrous oxide, and desflurane
Importance of minimum alveolar concentration (MAC) and blood-gas partition coefficient in anesthetic pharmacodynamics
Mechanism of action of isoflurane in airway management and bronchodilation
Clinical administration techniques for isoflurane in critically ill children
Ventilator management principles for intubated children with status asthmaticus
Role of isoflurane in refractory and super-refractory status epilepticus
Potential adverse effects and considerations for prolonged isoflurane use
Summary of pharmacologic concepts essential for safe isoflurane therapy in pediatric patients
References:
Rogers Text Book of Pediatric Intensive Care: Chapter 47: Acute Severe Asthma. Stewart C, Brilli RJ. pages 763-775
Reference 1: Stetefeld HR, Schaal A, Scheibe F, Nichtweiß J, Lehmann F, Müller M, Gerner ST, Huttner HB, Luger S, Fuhrer H, Bösel J, Schönenberger S, Dimitriadis K, Neumann B, Fuchs K, Fink GR, Malter MP; IGNITE Study Group, with support from the German Neurocritical Care Society (DGNI). Isoflurane in (Super-) Refractory Status Epilepticus: A Multicenter Evaluation. Neurocrit Care. 2021 Dec;35(3):631-639. doi: 10.1007/s12028-021-01250-z. Epub 2021 Jul 20. PMID: 34286464; PMCID: PMC8692280.
Reference 2: Zeiler FA, Zeiler KJ, Teitelbaum J, Gillman LM, West M. Modern inhalational anesthetics for refractory status epilepticus. Can J Neurol Sci. 2015 Mar;42(2):106-15. doi: 10.1017/cjn. 2014.121. Epub 2015 Jan 9. PMID: 25572922.
Reference 3: Werner HA. Status asthmaticus in children: a review. Chest. 2001 Jun;119(6):1913-29. doi: 10.1378/chest. 119.6.1913. PMID: 11399724.
Reference 4: Gill B, Bartock JL, Damuth E, Puri N, Green A. Case report: Isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation. Front Med (Lausanne). 2022 Nov 8;9:1051468. doi: 10.3389fmed. .2022.1051468. PMID: 36425104; PMCID: PMC9679515.
The Tylenol Trouble & the NAC comeback: Navigating Acetaminophen Toxicity in the PICU
12 Apr 2026
00:30:50
In this episode of *PICU Doc on Call*, Drs. Monica Gray, Pradip Kamat, and Rahul Damania chat about a 17-year-old girl who ended up with acute liver failure after she intentionally took 22.5 grams of acetaminophen. She came in 48 hours later with really high transaminases and an INR of 5.5, so she was admitted to the PICU. The hosts break down how acetaminophen affects the body, walk through its four clinical stages, and discuss how to manage it—focusing on N-acetylcysteine as the primary antidote. They also touch on other treatments, like fomepizole. Thankfully, this patient recovered without needing a liver transplant, which really shows how important it is to have a team approach with intensivists, hepatologists, toxicologists, and psychiatry all working together.
Show Highlights:
Clinical case presentation of a 17-year-old girl with acetaminophen ingestion leading to acute liver failure
Mechanism of acetaminophen toxicity and its metabolic pathways
Epidemiology of acetaminophen toxicity in pediatric populations
Pathophysiology of acetaminophen overdose and its effects on liver function
Clinical manifestations and progression of acetaminophen toxicity through various stages
Evaluation and diagnostic criteria for assessing acetaminophen toxicity
Management strategies for acetaminophen overdose, including the use of N-acetylcysteine (NAC).
Discussion of adjunctive therapies such as fomepizole in severe cases.
Importance of supportive care in managing complications of acute liver failure
An interdisciplinary approach to treatment involving various medical specialties
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.
Reference 1: 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Brooks DE, Dibert KW, Rivers LJ, Pham NPT, Ryan ML. Clin Toxicol (Phila). 2020;58(12):1360.
Reference 2: Pepin L, Matsler N, Fontes A, Heard K, Flaherty BF, Monte AA. Fomepizole Therapy for Acetaminophen-Induced Liver Failure in an Infant. Pediatrics. 2023 Oct 1;152(4):e2022061033. doi:10.1542/peds. 2022-061033. PMID: 37681263.
Reference 4. Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr. 2022 Jan 1;74(1):138-158. doi: 10.1097/MPG.0000000000003268. PMID: 34347674.
Don’t Poke It, Spray It: The Intranasal Medication Playbook
29 Mar 2026
00:20:49
In this episode of "PICU Doc on Call," Drs. Monica Gray, Pradip Kamat, and Rahul Damania discuss the use of intranasal medications in pediatric intensive care. Using the case of a four-month-old infant needing an MRI, they explore when and why intranasal drugs are preferred over IV access, the science behind nasal drug delivery, safe administration techniques, and common medications used. The episode highlights the benefits of intranasal sedation—such as rapid onset and needle-free delivery—while emphasizing teamwork and careful monitoring for safe, effective pediatric care.
Show Highlights:
Use of intranasal medications in pediatric intensive care settings
Case study of a four-month-old infant requiring sedation for an MRI.
Advantages of intranasal delivery over IV access
Pharmacokinetics and neuroanatomy related to intranasal drug absorption
Techniques for safe and effective administration of intranasal medications
Comparison of intranasal dosing to oral and IV routes
Common intranasal medications used in the pediatric ICU
Importance of timing and monitoring during sedation procedures
Teamwork and communication in administering intranasal medications
Clinical applications and implications for patient comfort and care delivery
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.
Reference 1: Tsze DS, Woodward HA, McLaren SH, Leu CS, Venn AMR, Hu NY, Flores-Sanchez PL, Stefan BR, Shen ST, Ekladios MJ, Cravero JP, Dayan PS. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. 2025 Sep 1;179(9):979-986. doi: 10.1001/jamapediatrics. 2025.2181.
Reference 2: Prescott MG, Iakovleva E, Simpson MR, Pedersen SA, Munblit D, Vallersnes OM, Austad B. Intranasal analgesia for acute moderate to severe pain in children - a systematic review and meta-analysis. BMC Pediatr. 2023 Aug 18;23(1):405. doi: 10.1186/s12887-023-04203-x.
Reference 3: Chabowski L, Mahboobi Z, Navolokina A. Intranasal ketamine for procedural sedation in children. Am J Emerg Med. 2023 Jun;68:195. doi: 10.1016/j.ajem.2023.04.013.
Reference 4: Sulton C, Kamat P, Mallory M, Reynolds J. The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Emerg Care. 2020 Mar;36(3):138-142. doi: 10.1097/PEC.0000000000001199.
Mean Arterial Pressure in the PICU
15 Mar 2026
00:11:12
In this special “PICU Doc On Call Shorts” episode, pediatric ICU physicians Dr. Monica Gray, Dr. Pradip Kamat, and Dr. Rahul Damania break down the concept of Mean Arterial Pressure (MAP). Using a case of a six-year-old in septic shock, they discuss how to calculate MAP, normal pediatric values, and the physiological determinants and clinical significance of MAP. The hosts highlight MAP’s role in guiding management of critically ill children, review autonomic and endothelial regulation, and reinforce learning with a board-style question. This episode emphasizes practical bedside application for pediatric interns and ICU providers.
Show Highlights:
Overview of Mean Arterial Pressure (MAP) and its clinical significance in pediatric critical care.
Introduction of a clinical case involving a 6-year-old child in septic shock.
Explanation of the formula for calculating MAP and its application to the clinical case.
Discussion of normal reference values for MAP in children and their clinical implications.
Physiological determinants of MAP, including cardiac output and systemic vascular resistance.
Role of the autonomic nervous system in regulating MAP through baroreceptor reflexes.
Importance of maintaining adequate MAP for organ perfusion, particularly in critically ill patients.
Clinical applications of MAP monitoring and management strategies in the PICU.
Summary of key takeaways regarding MAP calculation, physiological determinants, and clinical relevance.
Mention of related topics, such as invasive versus non-invasive blood pressure monitoring.
References:
DeMers D, Wachs D. Physiology, Mean Arterial Pressure. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
Pediatric Blood Pressure Metrics and Hypotension Thresholds (details the task force data used to derive the 5th and 50th percentile MAP estimation formulas for children)
Berlin DA, Bakker J. Starling curves and central venous pressure. Crit Care. 2015 Feb 16;19(1):55.
Magder S. Volume and its relationship to cardiac output and venous return. Crit Care. 2016 Sep 10;20(1):271
Von Willebrand Disease in the PICU
08 Feb 2026
00:24:53
In this episode of "PICU Doc on Call," Drs. Pradip Kamat and Rahul Damania dive into a pediatric ICU case involving a 4-year-old girl who presents with severe anemia and bleeding, ultimately diagnosed with von Willebrand disease (VWD). They chat about the causes and different types of VWD, walk through the key clinical features, and break down how to diagnose and manage this condition. Drs. Kamat and Damania highlight the important roles of desmopressin and factor concentrates in treatment. Throughout the episode, they stress the need to recognize VWD in kids who have mucosal bleeding and offer practical tips for intensivists on lab evaluation and treatment strategies for this common inherited bleeding disorder.
Show Nighlights:
Clinical case discussion of a 4-year-old girl with severe anemia and bleeding symptoms
Diagnosis of von Willebrand disease (VWD) and its significance in pediatric critical care
Etiology and pathogenesis of von Willebrand disease
Classification of von Willebrand disease into types (Type 1, Type 2 with subtypes, Type 3)
Clinical manifestations and symptoms associated with VWD
Diagnostic approach for identifying von Willebrand disease, including laboratory tests
Management strategies for VWD, including desmopressin and von Willebrand factor concentrates
Role of adjunctive therapies such as antifibrinolytics and hormonal treatments
Importance of multidisciplinary collaboration in managing complex bleeding disorders
Overview of the pathophysiology of von Willebrand factor and its role in hemostasis
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.
Reference 1: Leebeek FW, Eikenboom JC. Von Willebrand's Disease. N Engl J Med. 2016 Nov 24;375(21):2067-2080.
Reference 2: Ng C, Motto DG, Di Paola J. Diagnostic approach to von Willebrand disease. Blood. 2015 Mar 26;125(13):2029-37.
Platton S, Baker P, Bowyer A, et al. Guideline for laboratory diagnosis and monitoring of von Willebrand disease: A joint guideline from the United Kingdom Haemophilia Centre Doctors' Organisation and the British Society for Hematology. Br J Haematol 2024 May;204(5):1714-1731.
Mohinani A, Patel S, Tan V, Kartika T, Olson S, DeLoughery TG, Shatzel J. Desmopressin as a hemostatic and blood-sparing agent in bleeding disorders. Eur J Haematol. 2023 May;110(5):470-479. doi: 10.1111/ejh.13930. Epub 2023 Feb 12. PMID: 36656570; PMCID: PMC10073345.
Management of Rectal Bleeding in the PICU
25 Jan 2026
00:18:26
In this episode of "PICU Doc On Call," Drs. Pradip Kamat and Rahul Damania discuss the acute management of a 14-year-old boy with severe rectal bleeding and hypertension, ultimately diagnosed with inflammatory bowel disease (IBD). They review the approach to pediatric lower GI bleeding, diagnostic workup, and imaging, emphasizing early recognition and resuscitation. They outline IBD management, including steroids, biologics such as infliximab, and nutritional support, while highlighting the importance of screening for infections before immunosuppression. The episode provides practical insights for PICU physicians on handling acute GI emergencies in children.
Show Nighlights:
Clinical case of a 14-year-old male with hypertension and rectal bleeding.
Diagnosis of inflammatory bowel disease (IBD) following significant blood loss.
Approach to pediatric rectal bleeding and its implications.
Diagnostic workup including laboratory tests and imaging modalities.
Management strategies for IBD in acute pediatric care.
Importance of early recognition and resuscitation in cases of shock.
Physiological principles related to blood loss and shock in children.
Differential diagnoses for lower gastrointestinal bleeding in pediatrics.
Initial evaluation and stabilization protocols for pediatric patients.
Nutritional support and multidisciplinary care in managing IBD.
References:
Romano C, Oliva S, Martellossi S, et al. Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology. World J Gastroenterol. 2017;23(8):1326-1337.
Pai AK, Fox VL. Gastrointestinal bleeding and management. Pediatr Clin North Am. 2017;64(3):543-561.
Padilla BE, Moses W. Lower gastrointestinal bleeding and intussusception. Surg Clin North Am. 2017;97(1):63-80.
Kaur M, Dalal RL, Shaffer S, Schwartz DA, Rubin DT. Inpatient management of inflammatory bowel disease-related complications. Clin Gastroenterol Hepatol. 2020;18(11):2417-2428.
Bouhuys M, Lexmond WS, van Rheenen PF. Pediatric inflammatory bowel disease. Pediatrics. 2022;150(6):e2022059341.
Rosen MJ, Dhawan A, Saeed SA. Inflammatory bowel disease in children and adolescents. JAMA Pediatr. 2015;169(11):1053-1060.
Conrad MA, Rosh JR. Pediatric Inflammatory Bowel Disease. Pediatr Clin North Am. 2017 Jun;64(3):577-591.
Turner D, Ruemmele FM, Orlanski-Meyer E, et al. Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Aug;67(2):257-291, correction can be found in J Pediatr Gastroenterol Nutr 2020 Dec;71(6):794.
Approach to Hypoglycemia in the PICU
28 Dec 2025
00:27:46
In this episode of "PICU Doc on Call," Dr. Pradip Kamat and Dr. Rahul Damania dive into a fascinating case of a 9-month-old infant who comes in with hypoglycemia and seizures. Together, they break down the basics of glucose metabolism, walk through the causes of hypoglycemia, and discuss the best diagnostic strategies and acute management steps. They put a special spotlight on using diazoxide for hyperinsulinemic hypoglycemia, discussing not only how it works but also its potential side effects. The conversation also discusses dietary interventions for metabolic disorders and highlights the importance of rapid diagnosis and personalized treatment.
Show Highlights:
Pediatric hypoglycemia and its implications in infants
Case study of a 9-month-old infant with hypoglycemia and seizures
Physiology of glucose metabolism and its regulation
Causes of hypoglycemia, categorized into primary and secondary etiologies
Diagnostic approaches for identifying the cause of hypoglycemia
Initial management strategies for acute hypoglycemia
Long-term treatment options based on underlying causes
Importance of timely diagnosis and intervention in the PICU setting
Pharmacologic management of hyperinsulinemic hypoglycemia, including the use of diazoxide
Multidisciplinary care and follow-up for pediatric patients with hypoglycemia
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 84 Alder M et al. Pediatric Sepsis. Pages 1293-1309
Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024. Crit Care Med. 2024 Apr 1;52(4):e161-e181. doi: 10.1097/CCM.0000000000006174. Epub 2024 Jan 19. PMID: 38240484.
Rosenfeld E, Thornton PS. Hypoglycemia in Neonates, Infants, and Children. 2023 Aug 22. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. South Dartmouth (MA):MDText.com, Inc.; 2000–. PMID: 37665756.
Rayas MS, Salehi M. Non-Diabetic Hypoglycemia. 2024 Jan 27. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. South Dartmouth (MA):MDText.com, Inc.; 2000–. PMID: 27099902.
Nakrani MN, Wineland RH, Anjum F. Physiology, Glucose Metabolism. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK560599/
Chen X, Feng L, Yao H, Yang L, Qin Y. Efficacy and safety of diazoxide for treating hyperinsulinemic hypoglycemia: A systematic review and meta-analysis. PLoS One. 2021 Feb 11;16(2):e0246463. doi: 10.1371/journal.pone.0246463. PMID: 33571197; PMCID: PMC7877589.
Kucharczyk P, Albano G, Deisl C, Ho TM, Bargagli M, Anderegg M, Wuest S, Konrad D, Fuster DG. Thiazides Attenuate Insulin Secretion Through Inhibition of Mitochondrial Carbonic Anhydrase 5b in β -Islet Cells in Mice. J Am Soc Nephrol. 2023 Jul 1;34(7):1179-1190. Doi: 10.1681/ASN.0000000000000122. Epub 2023 Apr 17. PMID: 36927842; PMCID: PMC10356162.
Desaturation in the Intubated Patient in the PICU
23 Nov 2025
00:30:36
Today, Dr. Monica Gray, Dr. Pradip Kamat, and Rahul Damania discuss a critical case involving a 10-year-old boy who developed post-intubation desaturation. Using the DOPE mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure), they systematically troubleshoot the emergency, highlighting the importance of teamwork, capnography, and manual ventilation. The team emphasizes structured approaches, simulation training, and essential bedside tools to ensure rapid, effective management of acute deterioration in intubated children, turning a life-threatening crisis into a controlled, solvable situation.
Show Highlights:
Clinical case discussion of a ten-year-old boy with post-intubation desaturation in the pediatric ICU
Use of the "DOPE" mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure) for troubleshooting
Systematic approaches in emergency situations in pediatric critical care
Assessment and management of sudden desaturation in intubated patients
Evaluation of potential causes of desaturation, including tube displacement and obstruction
Role of equipment failure in acute deterioration and strategies to address it
Significance of continuous capnography and manual ventilation techniques
Prevention strategies for unplanned extubation in pediatric ICU settings
Emphasis on teamwork, communication, and simulation training in crisis management
Review of literature insights related to hypoxemia and equipment issues in pediatric intubation
References:
Topjian AA, et al. Part 4: Pediatric Basic and Advanced Life Support—2020 AHA PALS Guidelines. Circulation. 2020.Foundational pediatric resuscitation guidance endorsing early switch to manual ventilation and structured troubleshooting for the deteriorating intubated child.
Cook TM, et al. Major complications of airway management in the UK: NAP4. British Journal of Anaesthesia. 2011.Seminal audit highlighting ICU/ED airway failures and the critical role of waveform capnography in preventing unrecognized esophageal intubation.
Volpicelli G, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Medicine. 2012. High-impact consensus placing lung ultrasound at the bedside to rapidly diagnose pneumothorax during post-intubation deterioration.
Prekker ME, et al. Video vs direct laryngoscopy for ED intubation—randomized trial. New England Journal of Medicine. 2023.NEJM RCT showing higher first-pass success with video laryngoscopy—relevant to preventing displacement/misplacement drivers of desaturation.
Chrimes N, et al. Preventing unrecognised oesophageal intubation: consensus guideline. Anaesthesia. 2022.Modern, practice-changing guidance: sustained waveform capnography is the mainstay to exclude esophageal placement and avert catastrophic hypoxemia.
Paroxysmal Nocturnal Hemoglobinuria in the PICU
09 Nov 2025
00:21:59
Welcome to "PICU Doc on Call," the podcast where the world of pediatric critical care comes alive! Today, Dr. Monica Gray, Dr. Pradip Kamat, and Rahul Damania delve into a fascinating case involving a 16-year-old male presenting with headache, photophobia, anemia, and cerebral venous thrombosis. After some detective work, the diagnosis? Paroxysmal nocturnal hemoglobinuria, or PNH.
Join us as we break down the pathogenesis and clinical features of PNH, walk through the diagnostic workup, and discuss management strategies, especially the game-changing role of complement inhibitors like Eculizumab. We’ll also review this patient’s clinical journey, highlighting the key pearls for recognizing and treating PNH in the pediatric intensive care unit.
So, tune in to hear more!
Show Highlights:
Clinical case presentation of a 16-year-old male with symptoms including headache, photophobia, and anemia
Diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) and its clinical significance
Pathogenesis of PNH, including the role of the PIGA gene mutation and GPI-anchored proteins
Clinical features and complications associated with PNH, such as thrombosis and hemolysis
Diagnostic workup for PNH, including laboratory tests and flow cytometry
Management strategies for PNH, focusing on complement inhibitors like Eculizumab
Importance of supportive care in the PICU for patients with PNH
Discussion of emerging therapies and advancements in PNH treatment
Patient outcome and clinical course following treatment for PNH
Key takeaways regarding the diagnosis and management of PNH in pediatric intensive care
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care.
Reference 2 Waheed A, Shammo J, Dingli D. Paroxysmal nocturnal hemoglobinuria: Review of the patient experience and treatment landscape. Blood Rev. 2024 Mar;64:101158.
Reference 3: Kokoris S, Polyviou A, Evangelidis P, Grouzi E, Valsami S, Tragiannidis K, Gialeraki A, Tsakiris DA, Gavriilaki E. Thrombosis in Paroxysmal Nocturnal Hemoglobinuria (PNH): From Pathogenesis to Treatment. Int. J. Mol. Sci. 2024 Nov 11;25(22):12104.
Brains & Drains: The EVD survival guide for the PICU
26 Oct 2025
00:31:05
In today’s episode, Dr. Monica Gray and Dr. Pradip Kamat sit down with neurosurgeon Dr. Neal Laxpati, MD, PhD, to chat about intracranial pressure (ICP) monitoring in pediatric critical care. Using real case studies, they dive into how and when to use external ventricular drains (EVDs) and ICP bolts, walking listeners through setup, potential risks, and everyday challenges. The group discusses device complications, ways to prevent infections, how to interpret waveforms, and shares practical bedside tips. It’s a must-listen for intensivists looking for hands-on advice and key insights to help optimize care for kids with brain injuries or hydrocephalus.
Show Highlights:
Pediatric critical care unit (PCU) case discussions
Intracranial pressure (ICP) monitoring in pediatric patients
Case studies involving a 10-year-old girl with diffuse midline glioma and a 16-year-old male with a ruptured arteriovenous malformation (AVM)
Cerebrospinal fluid (CSF) physiology and its role in ICP management
Types of ICP monitoring devices: external ventricular drains (EVDs) and intraparenchymal monitors
Indications and complications associated with ICP monitoring
Interpretation of ICP waveforms and their clinical significance
Management strategies for elevated ICP and CSF drainage
Risks and challenges of ICP monitoring, including infection and device malfunction
Importance of interdisciplinary communication and meticulous bedside care in pediatric critical care settings
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 118. Traumatic brain injury. Kochaneck et al. Page 1375 -1400
Rogers textbook:
Reference 1: Forsyth RJ, Parslow RC, Tasker RC, Hawley CA, Morris KP; UK Paediatric Traumatic Brain Injury Study Group; Paediatric Intensive Care Society Study Group (PICSSG). Prediction of raised intracranial pressure complicating severe traumatic brain injury in children: implications for trial design. Pediatr Crit Care Med. 2008 Jan;9(1):8-14. doi: 10.1097/01.PCC.0000298759.78616.3A. PMID: 18477907.
Reference 2: Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol. 2019 Nov 26;10:1261. doi: 10.3389/fneur.2019.01261. PMID: 32038449; PMCID: PMC6988791.
May the Flow Be with You: Practical Hemodynamics in the PICU
12 Oct 2025
00:32:27
Ever wondered how PICU teams make those critical calls about blood pressure and vasoactive meds? On this episode, Dr. Monica Gray and Dr. Pradip Kamat dive into the real-world questions that come up during pediatric intensive care rounds. They break down the pros and cons of arterial line versus non-invasive cuff measurements, talk through blood pressure targets for tough cases like sepsis and brain injury, and share practical tips for weaning kids off vasoactive drugs. With a focus on the latest guidelines and research, Monica and Pradip offer actionable advice to help you fine-tune hemodynamic management for your sickest patients. Tune in!
Show Highlights:
Relationship between blood pressure and cardiac output in pediatric patients
Comparison of arterial line (invasive) versus non-invasive cuff measurements for blood pressure monitoring in the PICU
Blood pressure targets for critical illnesses such as sepsis, traumatic brain injury, and respiratory failure in children
Strategies for weaning vasoactive medications in critically ill pediatric patients
Importance of accurate blood pressure measurement and monitoring in the PICU
Discussion of organ autoregulation and its impact on blood pressure management
Clinical assessment and individualized care in setting blood pressure goals
Recommendations for initial vasoactive agents in pediatric septic shock
Challenges and considerations in vasoactive medication selection and weaning
Need for further research on pediatric vasoactive medication management strategies
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 110. Alder M et al. Pediatric Sepsis. Pages 1293-1309.
Rogers Textbook of Pediatric Critical Care Medicine. Chapter 88. Fitzgerald J et al. Bacterial Sepsis.Pages 1469-1485.
Reference 1 Weiss S. Vasoactive Selection for Pediatric Septic Shock-Where to begin. JAMA Network Open, 2025;8(4):e254726.
Reference 2 Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD; Society of Critical Care Medicine Pediatric Sepsis Definition Task Force. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024 Feb 27;331(8):665-674.
Burgers, Fries, and Weak Thighs - A Case of Familial Hypokalemic Periodic Paralysis
28 Sep 2025
00:21:17
Welcome to PICU Doc on Call, the podcast where we break down real-life cases from the pediatric intensive care unit and share practical insights for clinicians everywhere! I’m Dr. Monica Gray, and I’m joined by my co-host, Dr. Pradip Kamat.
Today, we’re diving into a fascinating case: a 13-year-old boy who suddenly developed muscle weakness and was found to have severe hypokalemia. After some detective work, he was diagnosed with familial hypokalemic periodic paralysis, a rare but important condition to recognize in the PICU.
We’ll discuss the genetic underpinnings, classic clinical features, and common triggers associated with this disorder. Additionally, we’ll guide you through the differential diagnosis, key management strategies, such as potassium supplementation, and explain why genetic testing is so crucial. We’ll also cover essential considerations for anesthesia and cardiac monitoring in these patients.
Whether you’re a pediatric intensivist or just interested in acute neuromuscular care, stick around for some practical pearls you can use on your next shift!
Show Highlights:
Clinical case discussion of a 13-year-old male patient with muscle weakness and hypokalemia
Diagnosis and management of familial hypokalemic periodic paralysis
Genetic basis and mutations associated with hypokalemic periodic paralysis (CACNA1S and SCN4A)
Reference 3: Statland JM, Fontaine B, Hanna MG, Johnson NE, Kissel JT, Sansone VA, Shieh PB, Tawil RN, Trivedi J, Cannon SC, Griggs RC. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle Nerve. 2018 Apr;57(4):522-530.
Choose your Potion: Intubation Medication
07 Sep 2025
00:35:25
Learn how to sharpen your pediatric intubation skills and make evidence-based decisions at the bedside. Today, Dr. Pradip Kamat, Dr. Monica Gray, and Dr. Rahul Damania expertly dissect the nuances of selecting optimal induction agents for critically ill children in the PICU. Through engaging, real-world case scenarios, our hosts guide you through drug choices in complex situations such as cardiogenic shock, septic shock, and elevated intracranial pressure—always prioritizing hemodynamic stability and patient safety. Gain valuable insights into the advantages, limitations, and clinical pearls of agents like propofol, fentanyl, ketamine, and midazolam, along with practical strategies for rapid sequence intubation, neuromuscular blockade, and individualized patient care. Don’t miss this high-yield discussion, packed with actionable knowledge!
Show Highlights:
Induction agents for endotracheal intubation in critically ill children
Clinical scenarios highlighting optimal choices of induction agents and neuromuscular blockers
Importance of maintaining hemodynamic stability during intubation
Pharmacology and clinical considerations of various induction agents (e.g., propofol, ketamine, fentanyl, etomidate)
Use of neuromuscular blocking agents (NMBAs) in pediatric intubation
Differences between depolarizing and non-depolarizing neuromuscular blockers
Risks associated with specific induction agents in patients with cardiac dysfunction or septic shock
Modified rapid sequence intubation (RSI) techniques for unstable patients
Key takeaways for managing critically ill pediatric patients requiring intubation
Practical tips for optimizing intubation conditions and minimizing complications
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care 6th Edition. Chapters 127 - 135, Pages 1510 - 1610
Hendrix JM, Regunath H. Intubation Endotracheal Tube Medications. [Updated 2025 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459276/
Agrawal, Dewesh. Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis. UpToDate. Last updated Dec 4, 2024.
Vanlinthout LE, Geniets B, Driessen JJ, Saldien V, Lapré R, Berghmans J, Uwimpuhwe G, Hens N. Neuromuscular-blocking agents for tracheal intubation in pediatric patients (0-12 years): A systematic review and meta-analysis. Paediatr Anaesth. 2020 Apr;30(4):401-414. doi: 10.1111/pan.13806. Epub 2020 Mar 9. PMID: 31887248.
Tarquinio KM, Howell JD, Montgomery V, Turner DA, Hsing DD, Parker MM, Brown CA 3rd, Walls RM, Nadkarni VM, Nishisaki A; National Emergency Airway Registry for Children; Pediatric Acute Lung Injury and Sepsis Investigators Network. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med. 2015 Mar;16(3):210-8. doi: 10.1097/PCC.0000000000000319. PMID: 25581629.
Conway JA, Kharayat P, Sanders RC Jr, Nett S, Weiss SL, Edwards LR, Breuer R, Kirby A, Krawiec C, Page-Goertz C, Polikoff L, Turner DA, Shults J, Giuliano JS Jr, Orioles A, Balkandier S, Emeriaud G, Rehder KJ, Kian Boon JL, Shenoi A, Vanderford P, Nuthall G, Lee A, Zeqo J, Parsons SJ, Furlong-Dillard J, Meyer K, Harwayne-Gidansky I, Jung P, Adu-Darko M, Bysani GK, McCarthy MA, Shlomovich M, Toedt-Pingel I, Branca A, Esperanza MC, Al-Subu AM, Pinto M, Tallent S, Shetty R, Thyagarajan S, Ikeyama T, Tarquinio KM, Skippen P, Kasagi M, Howell JD, Nadkarni VM, Nishisaki A; National Emergency Airway Registry for Children (NEAR4KIDS) and for the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI). Ketamine Use for Tracheal Intubation in Critically Ill Children Is Associated With a Lower Occurrence of Adverse Hemodynamic Events. Crit Care Med. 2020 Jun;48(6):e489-e497. doi: 10.1097/CCM.0000000000004314. PMID: 32317603.
Zanza C, Piccolella F, Racca F, Romenskaya T, Longhitano Y, Franceschi F, Savioli G, Bertozzi G, De Simone S, Cipolloni L, La Russa R. Ketamine in Acute Brain Injury: Current Opinion Following Cerebral Circulation and Electrical Activity. Healthcare (Basel). 2022 Mar 17;10(3):566. doi: 10.3390/healthcare10030566. PMID: 35327044; PMCID: PMC8949520.
Zeiler FA, Teitelbaum J, West M, Gillman LM. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care. 2014 Aug;21(1):163-73. doi: 10.1007/s12028-013-9950-y. PMID: 24515638.
Splenic Sequestration (Sickle Cell) in the PICU
24 Aug 2025
00:28:51
Ready for a deep dive into a real-life pediatric ICU situation? Today, Dr. Pradip Kamat, Dr. Monica Gray, and Dr. Rahul Damania will walk you through the case of a seven-year-old girl with Hemoglobin SC (HbSC) disease, who presents with abdominal swelling, pneumonia, low oxygen, and pain.
In this episode, our team unpacks the spleen’s anatomy and its crucial role in immunity, then zooms in on how sickle cell disease can throw a wrench in splenic function. You’ll hear how they approach the diagnosis and management of acute splenic sequestration crisis, sharing clinical pearls along the way. Plus, they’ll break down why quick recognition is so important and discuss strategies for both immediate and long-term care in pediatric sickle cell patients. Don’t miss these practical insights from the frontlines of pediatric critical care!
Show Highlights:
Case study of a seven-year-old girl with hemoglobin SC disease
Presentation of symptoms: abdominal distension, pneumonia, hypoxia, and body pain
Discussion of acute splenic sequestration crisis as a complication of sickle cell disease
Anatomy and physiology of the spleen
The role of the spleen in sickle cell disease and how sickled cells affect splenic function
Acute splenic sequestration crisis, including clinical features and laboratory evaluations
Management strategies for acute splenic sequestration crisis in the ICU
Importance of blood transfusions and supportive care in treatment
Prophylactic measures to prevent recurrence of splenic sequestration
Educational emphasis on recognizing clinical signs and the need for timely intervention
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 88. Hemoglobinopathies. Baender, MA, Marsh Anne. Pages: 1457-1470
Rogers' textbook of pediatric intensive care: Hematologic Emergencies. McCory MC, Bhar S, and Blaine E. Pages 2003-2005
Brousse V, Buffet P, Rees D. The spleen and sickle cell disease: the sick(led) spleen. Br J Haematol. 2014 Jul;166(2):165-76. doi: 10.1111/bjh 12950. Epub 2014 May 26. PMID: 24862308.
Waleed S, Aldabsa M, Gouher S. Splenic Sequestration Induced by Parvovirus B19: A Case Report. Cureus. 2024 May 23;16(5):e60937. doi: 10.7759/cureus. 60937. PMID: 38915956; PMCID: PMC11195323.
Solanki DL, Kletter GG, Castro O. Acute splenic sequestration crises in adults with sickle cell disease. Am J Med. 1986 May;80(5):985-90. doi: 10.1016/0002-9343(86)90649-2. PMID: 3706382.
Karna B, Jha SK, Al Zaabi E. Hemoglobin C Disease. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559043/
Emerging Neurologic Autoimmune Disorders (MOGAD) in the PICU
10 Aug 2025
00:27:42
Welcome to "PICU Doc on Call," the podcast where real cases meet real expertise at the bedside! Join Dr. Monica Gray, Dr. Pradip Kamat, and Dr. Rahul Damania as they unravel the mysteries of pediatric critical care. In today’s episode, our team dives into the compelling case of a previously healthy seven-year-old girl who arrives with seizures, right arm weakness, and sudden respiratory failure. Together, they’ll break down the diagnosis and management of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease, also known as MOGAD. This autoimmune demyelinating disorder can challenge even the most seasoned clinicians.
Tune in as our experts walk you through the clinical features, essential diagnostic workup, and the critical importance of early immunosuppressive therapy. Whether you’re at the bedside or on the go, this episode is packed with practical pearls and a multidisciplinary approach to recognizing and treating acute pediatric neuroimmunological emergencies in the PICU. Let’s get started!
Show Highlights:
Presentation of a complex pediatric case involving a seven-year-old girl with new-onset seizures and acute respiratory failure
Discussion of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD) as an autoimmune demyelinating disorder
Overview of the clinical presentation and diagnostic criteria for autoimmune encephalitis
Importance of a broad differential diagnosis, including infectious and autoimmune causes, in pediatric patients with seizures and neurological deficits
Diagnostic approach involving MRI, lumbar puncture, and antibody testing for MOGAD
Management strategies for MOGAD, including stabilization, seizure control, and immunosuppressive therapy
Neurocritical care considerations for monitoring and treating elevated intracranial pressure
Long-term management challenges and the need for multidisciplinary care in pediatric patients with MOGAD
Discussion of potential outcomes and the risk of relapse in children with MOGAD.
Emphasis on the importance of early and comprehensive diagnostic testing to avoid misdiagnosis
Gole S, Anand A. Autoimmune Encephalitis. [Updated 2023 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK578203/
Salama S, Khan M, Pardo S, Izbudak I, Levy M. MOG antibody-associated encephalomyelitis/encephalitis. Mult Scler. 2019 Oct;25(11):1427-1433. doi: 10.1177/1352458519837705. Epub 2019 Mar 25. PMID: 30907249; PMCID: PMC6751007
Lancaster E. The Diagnosis and Treatment of Autoimmune Encephalitis. J Clin Neurol. 2016 Jan;12(1):1-13. doi: 10.3988/jcn.2016.12.1.1. PMID: 26754777; PMCID: PMC4712273.
Fisher KS, Illner A, Kannan V. Pediatric neuroinflammatory diseases in the intensive care unit. Semin Pediatr Neurol. 2024 Apr;49:101118. Doi: 10.1016/j.spen.2024.101118. Epub 2024 Feb 1. PMID: 38677797.
Hébert J, Muccilli A, Wennberg RA, Tang-Wai DF. Autoimmune Encephalitis and Autoantibodies: A Review of Clinical Implications. J Appl Lab Med. 2022 Jan 5;7(1):81-98. Doi: 10.1093/jalm/jfab102. PMID: 34996085.
Lopez JA, Denkova M, Ramanathan S, Dale RC, Brilot F. Pathogenesis of autoimmune demyelination: from multiple sclerosis to neuromyelitis optica spectrum disorders and myelin oligodendrocyte glycoprotein antibody-associated disease. Clin Transl Immunology. 2021 Jul 26;10(7):e1316. doi: 10.1002/cti2.1316. PMID: 34336206; PMCID: PMC8312887.
Cardiopulmonary Interactions in the PICU
27 Jul 2025
00:20:24
Have you ever wondered what happens when a toddler gets into something they definitely shouldn’t? Today, Dr. Monica Gray, Dr. Pradip Kamat, and Dr. Rahul Damania discuss the case of an 18-month-old boy who accidentally ingested concentrated bleach, presenting with stridor, drooling, and vomiting. They review the clinical approach to caustic ingestions in children, including airway management, diagnostic workup, and the roles of endoscopy, steroids, and multidisciplinary care. The episode also highlights potential complications such as esophageal strictures and cancer, emphasizes prevention strategies, and provides key takeaways for intensivists managing similar pediatric emergencies. If you’re an intensivist or just want to know what to do in a pediatric emergency, don’t miss these essential takeaways for managing one of the scariest situations in the ER.
Show Highlights:
Case study of an 18-month-old boy who ingested concentrated bleach
Clinical presentation including symptoms like stridor, drooling, and vomiting
Management strategies for caustic ingestions in children
Importance of airway management and monitoring in cases of caustic ingestion
Diagnostic workup including imaging and endoscopy
Differential diagnosis considerations for similar presentations (e.g., button batteries, laundry detergent pods)
Mechanism of injury caused by alkaline substances like bleach
Long-term complications associated with caustic ingestions, such as esophageal strictures and cancer
Multidisciplinary approach to treatment involving various medical specialties
Prevention strategies to reduce the incidence of accidental caustic ingestions in children
References:
American Academy of Pediatrics – Pediatric Care Online: Esophageal Caustic Injury (AAP clinical guidance on caustic ingestions).
Fuhrman & Zimmerman’s Pediatric Critical Care textbook – Chapters on toxicology and gastrointestinal emergencies (covering caustic injury management and critical care approach).
Hoffman RS, et al. “Ingestion of Caustic Substances.” New England Journal of Medicine. 2020; 382(18):1739-1748. A comprehensive review of caustic ingestion injuries and management.
Arnold M, Numanoglu A. “Caustic ingestion in children – a review.” Semin Pediatr Surg. 2017;26(2):95-104. Review of epidemiology, pathophysiology, and treatment of caustic injuries in kids.
Johnson CM, Brigger MT. “The public health impact of pediatric caustic ingestion injuries.” Arch Otolaryngol Head Neck Surg. 2012;138(12):1111-1115. (Epidemiology study showing declining incidence).
Pediatric Critical Care Medicine (PCCM) Journal – various case reports and series on caustic ingestion (for case-based insights), and annual National Poison Data System reports (for statistics on pediatric poisonings).
Tringali A, et al. ESGE/ESPGHAN Pediatric GI Endoscopy Guidelines (Endoscopy, 2017) – Includes recommendations for endoscopy timing and steroid use in caustic ingestions.
Usta M, et al. “High doses of methylprednisolone in the management of caustic esophageal burns.” Pediatrics. 2014;133(6):E1518-24. (Key study demonstrating steroids benefit in grade 2b injuries).
Royal Children’s Hospital Melbourne – Clinical Practice Guidelines: Caustic Ingestions (2019) – Practical hospital guidelines emphasizing early intubation for airway threat, endoscopy within 24h, IV PPI, and supportive care.
Salty Saga of Hyponatremia and Hypotension in the PICU
29 Jun 2025
00:39:31
Today, Dr. Monica Gray, Dr. Pradip Kamat, and Dr. Rahul Damania discuss two real-life pediatric cases of hyponatremia in the PICU. They talk through a case of a six-month-old baby with severe sodium depletion and a teenager dealing with cancer-related hyponatremia. The team breaks down the pathophysiology, walks us through the diagnostic workups, and discusses the careful management needed for these cases. They emphasize the importance of correcting sodium levels gradually and addressing the root cause of the problem. They share practical tips for intensivists and highlight why staying vigilant and following evidence-based care is so crucial when managing critically ill kids with electrolyte disturbances. Tune in to hear more!
Show Highlights:
Discussion of hyponatremia in pediatric patients, particularly in the PICU
Presentation of two case studies illustrating different presentations of hyponatremia
Examination of the pathophysiology of hyponatremia, including its classification into hypovolemic, euvolemic, and hypervolemic types
Overview of diagnostic investigations for hyponatremia, including volume status assessment and serum/urine electrolyte measurements
Management strategies for hyponatremia, emphasizing the importance of gradual correction of sodium levels
Risks associated with rapid correction of hyponatremia
Importance of fluid management in different types of hyponatremia
Role of pharmacological interventions in specific cases, such as SIADH
Clinical presentation and symptoms associated with hyponatremia in pediatric patients
Emphasis on continuous monitoring of sodium levels and clinical status during treatment
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 71. Fluid and electrolyte issues in pediatric critical illness. Evans I, Joyce E. Page 866-872
Rogers' textbook of Pediatric Intensive Care Chapter 108: Disorders of Water, Sodium and Potassium homeostasis: Schneider J & Glater-Welt L. Pages 1868-1880
Harrison’s Principles of Internal Medicine Volume 1. Chapter 53: Fluid and Electrolyte Disturbances. Mount D. Pages 338-347
Cardiopulmonary Interactions (basics) in the PICU
15 Jun 2025
00:28:40
Today, Dr. Rahul Damania, Dr. Pradip Kamat, and Dr. Monica Gray, pediatric intensivists, sit down to chat about the diagnosis and management of acute myocarditis in children. They focus on a real-life case involving a one-month-old infant who presented with poor feeding, respiratory distress, and fever. Together, they break down the possible causes, key clinical signs, diagnostic approaches, and treatment options for pediatric myocarditis. Throughout the discussion, they highlight the importance of early recognition, a multidisciplinary team approach, and supportive care in improving outcomes for these critically ill infants. This episode is packed with practical insights and is designed to help pediatric intensivists tackle this challenging and potentially life-threatening condition. Tune in to hear more!
Show Highlights:
Definition and etiology of acute myocarditis in pediatric patients
Clinical case presentation of a one-month-old infant with acute myocarditis
Symptoms and clinical manifestations of acute myocarditis in children
Diagnostic approaches for identifying acute myocarditis, including echocardiography and laboratory tests
Management strategies for acute myocarditis, including intensive care and medication
Importance of recognizing atypical presentations in infants
Prognosis and risk factors associated with acute myocarditis
Role of multidisciplinary collaboration in managing acute myocarditis
Impact of viral infections on the development and severity of myocarditis
Outcomes and potential complications related to acute myocarditis in pediatric patients
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 108. Life-threatening viral diseases and their treatment. Vora S et al. Pages 1273-1278
Rogers’ textbook of Pediatric Intensive Care. Chapter 74: cardiomyopathy, myocarditis, and mechanical circulatory support. Harmon WG et al. Pages 1247-1255
Robinson J, Hartling L, Vandermeer B, Sebastianski M, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev. 2020 Aug 19;8(8): CD004370. Doi: 10.1002/14651858.CD004370.pub4. PMID: 32835416
Approach to Carbon Monoxide (CO) Poisoning in the PICU
25 May 2025
00:22:57
In this episode of "PICU Doc on Call," pediatric intensivists Dr. Rahul Damania, Dr. Pradip Kamat, and Dr. Monica Gray discuss a critical case involving a 16-year-old male who experienced severe carbon monoxide poisoning after being found unresponsive in a garage. They chat about the pathophysiology, clinical manifestations, diagnostic workup, and management of carbon monoxide toxicity. Furthermore, they cover the importance of early oxygen administration, recognizing potential delayed neurological sequelae, and keeping an eye out for cardiac complications. Tune in and hear more about a comprehensive approach to treatment and the significance of multidisciplinary support for achieving the best patient outcomes.
Show Highlights:
Case presentation of a 16-year-old male with severe carbon monoxide poisoning
Pathophysiology of carbon monoxide toxicity and its effects on hemoglobin
Clinical manifestations and symptoms associated with carbon monoxide poisoning
Diagnostic workup for suspected carbon monoxide exposure
Management principles for treating carbon monoxide poisoning in pediatric patients
Sources and scenarios leading to carbon monoxide poisoning
Complications arising from carbon monoxide exposure including neurological injuries
Importance of early oxygen administration and monitoring in treatment
Discussion of hyperbaric oxygen therapy and its indications
Key takeaways for clinicians regarding the management and follow-up of carbon monoxide poisoning cases
We welcome you to share your feedback, subscribe & place a review on our podcast! Please visit our websitepicudoconcall.org.
References:
Tapking, C., et al. (2021). Burn and inhalation injury. In J. J. Zimmerman & A. T. Rotta (Eds.), Fuhrman and Zimmerman’s Pediatric Critical Care (6th ed., pp. 1347–1362). Elsevier.
Nañagas KA, Penfound SJ, Kao LW. Carbon Monoxide Toxicity. Emerg Med Clin North Am. 2022 May;40(2):283-312. doi: 10.1016/j.emc.2022.01.005. Epub 2022 Apr 5. PMID: 35461624.
Smollin C, Olson K. Carbon monoxide poisoning (acute). BMJ Clin Evid. 2010 Oct 12;2010:2103. PMID: 21418677; PMCID: PMC3217756.
Palmeri R, Gupta V. Carboxyhemoglobin Toxicity. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
Oxygen Extraction Ratio (O₂ ER) in the PICU
11 May 2025
00:25:26
Welcome to another exciting episode of PICU Doc on Call! Today, we're diving deep into the world of pediatric critical care with our expert hosts, Dr. Rahul Damania, Dr. Pradip Kamat, and Dr. Monica Gray. Get ready to unravel the mysteries of the oxygen extraction ratio (O2ER) and its pivotal role in managing pediatric acute respiratory distress syndrome (ARDS) and multi-organ dysfunction.
Picture this: a seven-year-old girl battling severe pneumonia that spirals into ARDS and septic shock. Our hosts walk you through this gripping case, shedding light on calculating O2ER and why central venous oxygen saturation (ScvO2) is a game-changer. They'll share their top strategies for optimizing oxygen delivery and cutting down on oxygen demand.
But that's not all! This episode is all about the holistic approach to managing critically ill pediatric patients. Tune in to discover how these insights can lead to better outcomes for our youngest and most vulnerable patients. Don't miss out on this vital conversation!
Show Highlights:
Clinical significance of the oxygen extraction ratio (O2ER) in pediatric critical care
Importance of understanding oxygen delivery and consumption in critically ill patients
Calculation and interpretation of O2ER and its relationship to central venous oxygen saturation (ScvO2)
Physiological concepts related to oxygenation, including intrapulmonary shunting and ventilation-perfusion mismatch
Management strategies for increasing oxygen delivery and reducing oxygen demand in ARDS and septic shock
Interventions such as blood transfusions, sedation, and optimization of cardiac output
Implications of lactic acidosis and anaerobic metabolism in the context of inadequate oxygen delivery
Holistic approach to patient management, focusing on both numerical values and overall metabolic needs
We welcome you to share your feedback, subscribe & place a review on our podcast! Please visit our websitepicudoconcall.org.
References:
Fuhrman B.P. & Zimmerman J.J. (Eds.). Pediatric Critical Care, 6th ed. Elsevier; 2021. (Key concepts of oxygen delivery, consumption, and extraction in shock states are discussed in Chapter 13) .
Nichols D.G. (Ed.). Roger’s Textbook of Pediatric Intensive Care, 5th ed. Wolters Kluwer; 2016. (Comprehensive review of oxygen transport and utilization in critically ill children, including ARDS and shock).
Lucking S.E., Williams T.M., Chaten F.C., et al. Dependence of oxygen consumption on oxygen delivery in children with hyperdynamic septic shock and low oxygen extraction. Crit Care Med. 1990;18(12):1316–1319. doi:10.1097/00003246-199012000-00002.
Ronco J.J., Fenwick J.C., Tweeddale M.G., et al. Pathologic dependence of oxygen consumption on oxygen delivery in acute respiratory failure. Chest. 1990;98(6):1463–1466. doi:10.1378/chest.98.6.1463 .
Carcillo J.A., Davis A.L., Zaritsky A. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock. Crit Care Med. 2002;30(6):1365–1378. (ACCM guidelines emphasizing ScvO₂ targets in shock) .
Emeriaud G, López-Fernández YM, Iyer NP, et al; PALICC-2 Group; PALISI Network. Executive summary of the second international guidelines for the diagnosis and management of pediatric ARDS (PALICC-2). Pediatr Crit Care Med. 2023;24(2):143–168. doi:10.1097/PCC.0000000000003147.
A Case of Pertussis in the PICU
27 Apr 2025
00:34:06
In this episode, Dr. Rahul Damania, Dr. Pradip Kamat, and Dr. Monica Gray dive into a critical case involving a five-week-old baby facing acute respiratory failure due to pertussis. They chat about how this condition shows up, how it's diagnosed, and the best ways to manage it, especially considering the serious complications it can cause in infants, like pulmonary hypertension and the potential need for ECMO. The conversation underscores the importance of catching it early and providing supportive care, while also highlighting how crucial vaccination is in preventing pertussis. Tune in to learn how severe this disease can be and why staying alert in pediatric care is so important.
Show Highlights:
Clinical case of a five-week-old infant with acute respiratory failure and pertussis diagnosis
Epidemiology and public health impact of pertussis, including vaccination rates and outbreak patterns
Pathophysiology of pertussis and its effects on respiratory health, particularly in infants
Clinical presentation of pertussis, including stages of the disease and atypical symptoms in infants
Diagnostic approaches for pertussis, including laboratory findings and PCR testing
Management strategies for severe pertussis, including supportive care and antibiotic therapy
Potential complications associated with pertussis, especially in young infants
Differential diagnosis considerations for pertussis and distinguishing features from other infections
Importance of vaccination in preventing pertussis and reducing morbidity and mortality
ECMO as a treatment option for severe cases and its associated challenges, and outcomes
We welcome you to share your feedback, subscribe & place a review on our podcast! Please visit our website picudoconcall.org.
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter and Rogers texbook of Pediatric intensive care -both do not have any Pertussis mentioned in their index.
Rowlands HE, Goldman AP, Harrington K, Karimova A, Brierley J, Cross N, Skellett S, Peters MJ. Impact of rapid leukodepletion on the outcome of severe clinical pertussis in young infants. Pediatrics. 2010 Oct;126(4):e816-27. doi: 10.1542/peds.2009-2860. Epub 2010 Sep 6. PMID: 20819895.
Lauria AM, Zabbo CP. Pertussis. [Updated 2022 Oct 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519008/
Berger JT, Carcillo JA, Shanley TP, Wessel DL, Clark A, Holubkov R, Meert KL, Newth CJ, Berg RA, Heidemann S, Harrison R, Pollack M, Dalton H, Harvill E, Karanikas A, Liu T, Burr JS, Doctor A, Dean JM, Jenkins TL, Nicholson CE; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Collaborative Pediatric Critical Care Research Network (CPCCRN). Critical pertussis illness in children: a multicenter prospective cohort study. Pediatr Crit Care Med. 2013 May;14(4):356-65. doi: 10.1097/PCC.0b013e31828a70fe. PMID: 23548960; PMCID: PMC3885763.
Cousin, V.L., Caula, C., Vignot, J. et al. Pertussis infection in critically ill infants: meta-analysis and validation of a mortality score. Crit Care 29, 71 (2025). https://doi.org/10.1186/s13054-025-05300-2
Domico M, Ridout D, MacLaren G, Barbaro R, Annich G, Schlapbach LJ, Brown KL. Extracorporeal Membrane Oxygenation for Pertussis: Predictors of Outcome Including Pulmonary Hypertension and Leukodepletion. Pediatr Crit Care Med. 2018 Mar;19(3):254-261. doi: 10.1097/PCC.0000000000001454. PMID: 29319632.
Tuan, Ta Anh MD, PhD1; Xoay, Tran Dang MD1; Nakajima, Noriko MD, PhD2; Nakagawa, Satoshi MD3; Phuc, Phan Huu MD, PhD1; Hung, Dau Viet MD, PhD1; Dung, Nguyen Trong MD1; Dong, Ngo Tien MD1; Dung, Tran Ba MD1; Thuy, Phung Thi Bich PhD4; Hai, Le Thanh MD, PhD5; Dien, Tran Minh MD, PhD6. Pertussis Infants Needing Mechanical Ventilation and Extracorporeal Membrane Oxygenation: Single-Center Retrospective Series in Vietnam. Pediatric Critical Care Medicine 22(9):p e471-e479, September 2021. | DOI: 10.1097/PCC.0000000000002723
Management of Upper Airway Obstruction | Croup in the PICU
13 Apr 2025
00:32:34
In today’s episode, Dr. Rahul Damania and Dr. Pradip Kamat welcome their new co-host, Dr. Monica Gray. They’ll dive into the topic of upper airway obstruction in children and explore a case involving a 12-month-old girl who presents with stridor and fever. Throughout the discussion, they delve into the underlying causes, possible diagnoses, and management strategies. Key takeaways include the significance of keeping the child calm, ensuring proper positioning, and utilizing treatments such as dexamethasone and Racemic epinephrine. They’ll also touch on advanced therapies and serious infections like epiglottitis. The episode highlights the importance of recognizing stridor, knowing when to consider PICU admission, and the effectiveness of low-dose dexamethasone. Tune in to learn more!
Show Highlights:
Overview of upper airway obstruction in pediatric patients
Case presentation of a 12-month-old girl with stridor and fever
Discussion on the pathophysiology of stridor and its clinical significance
Differential diagnoses for stridor, including croup, epiglottitis, and foreign body aspiration
Management strategies for upper airway obstruction, including stabilization and medication
Importance of calming the child and optimal positioning during treatment
Use of dexamethasone and racemic epinephrine in managing croup
Advanced therapies, such as Helios, for specific cases
Indicators for pediatric intensive care unit (PICU) admission
Key clinical points and takeaways for healthcare professionals managing airway emergencies
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 47 Otteson T, Richardson C, Shah J: Diseases of the upper Airway. Pages 524-535
Rogers Textbook of Pediatric Intensive Care: Chapter 25; Ong May Soo Jacqueline, Tijssen J, Bruins BB and Nishisaki A: Airway management. Pages 341-365
Reference: Aregbesola A, Tam CM, Kothari A, Le ML, Ragheb M, Klassen TP. Glucocorticoids for croup in children. Cochrane Database Syst Rev. 2023 Jan 10;1(1):CD001955. doi: 10.1002/14651858.CD001955.pub5. PMID: 36626194; PMCID: PMC9831289.
Measly Business - A Guide for the Pediatric Intensivist
30 Mar 2025
00:30:38
In this episode of PICU DOC on Call, Dr. Rahul Damania and Dr. Pradip Kamat discuss the resurgence of measles in the United States. They explore the virus's pathophysiology, clinical features, diagnostic methods, treatment options, and complications. They emphasize the critical role of vaccination in preventing measles outbreaks and address the historical context and public health challenges related to vaccine hesitancy. The speakers highlight the severe complications of measles, especially in immunocompromised patients, and advocate for robust vaccination efforts to protect vulnerable populations and prevent the spread of this preventable disease. Tune in to hear more!
Show Highlights:
Resurgence of measles in the United States
Historical context of measles outbreaks and vaccination impact
Current statistics and recent cases of measles
Pathophysiology of the measles virus
Clinical features and progression of measles infection
Diagnostic approaches for confirming measles
Differential diagnosis considerations for fever and rash
Treatment options and the role of vaccination
Complications associated with measles, including severe outcomes
Public health challenges related to vaccine hesitancy and advocacy for immunization
In this episode of PICU DOC on Call, Dr. Rahul Damania and Dr. Pradip Kamat chat about a challenging case involving a 15-year-old girl dealing with acute myocarditis and worsening respiratory failure. They explore the intricate dance between the heart and lungs, especially how positive pressure ventilation can affect heart function. They cover important topics like cardiac output, preload, and afterload, and discuss the delicate balance needed to manage myocarditis effectively. The episode offers practical tips for optimizing care for critically ill children, underscoring the importance of personalized treatment plans and teamwork in pediatric critical care. Tune in!
Show Highlights:
Clinical case of a 15-year-old girl with acute myocarditis and respiratory failure
Importance of understanding cardiopulmonary interactions in pediatric critical care
Effects of positive pressure ventilation on cardiac function
Key concepts of cardiac output, preload, and afterload in the context of myocarditis
Challenges of managing hemodynamic instability in critically ill pediatric patients
Differences between spontaneous breathing and positive pressure ventilation
Strategies for optimizing preload and fluid management in myocarditis patients
Tailoring ventilatory support and transitioning to invasive mechanical ventilation
Monitoring for arrhythmias and managing myocardial function with inotropic support
Importance of frequent assessments and collaboration with cardiac ICU teams for patient care
Management Strategies
Optimizing Preload:
Volume depletion is common in patients with hypotension and tachycardia. A careful fluid challenge is important to restore circulatory volume, but fluid overload should be avoided, especially with impaired left ventricular function.
Tailoring Ventilatory Support:
Adjust BiPAP settings to improve oxygenation without overloading the heart with excessive positive pressures.
Use the optimal level of PEEP to recruit alveoli while maintaining adequate venous return to the heart.
Supporting Myocardial Function:
Inotropic support (e.g., milrinone) may be necessary to improve myocardial contractility. Milrinone also provides vasodilation, which can reduce afterload but must be used cautiously due to its potential to lower blood pressure.
Frequent Reassessments:
Bedside echocardiography and regular monitoring of biomarkers (lactate, BNP) and clinical status are essential for ongoing evaluation.
In severe cases, advanced therapies like ECMO may be required if the patient’s hemodynamic status continues to deteriorate.
Traumatic Brain Injury in the PICU | Non-Neurological Organ Dysfunction (NNOD)
12 Jan 2025
00:30:27
Today, pediatric intensivists Dr. Pradip Kamat and Dr. Rahul Damania discuss a complex case of a 12-year-old girl who suffered a seizure and unresponsiveness due to a subarachnoid hemorrhage from a ruptured aneurysm. They explore the multi-system effects of traumatic brain injury (TBI) and intracranial hemorrhage, focusing on non-neurologic organ dysfunction.
They’ll also highlight the impact on cardiovascular, respiratory, renal, and hepatic systems, emphasizing the importance of understanding these interactions for better patient management.
Tune in to hear relevant studies and management strategies to improve outcomes in pediatric TBI cases.
In This Episode:
Clinical case of a 12-year-old girl with seizure and unresponsiveness due to subarachnoid hemorrhage from a ruptured aneurysm
Management of non-neurologic organ dysfunction in traumatic brain injury (TBI) and intracranial hemorrhage
Multi-system effects of brain injuries, including cardiovascular, respiratory, renal, and hepatic complications
Importance of recognizing non-neurologic organ dysfunction in pediatric patients
Epidemiology and prevalence of non-neurologic organ dysfunction in patients with aneurysms or subarachnoid hemorrhage
Mechanisms of organ dysfunction following brain injury, including inflammatory responses and cytokine release
Management strategies for cardiovascular complications in TBI patients.
Discussion of respiratory complications, such as acute lung injury and ARDS, in the context of TBI
Renal and hepatic dysfunction associated with traumatic brain injury and their management
Emphasis on the need for a comprehensive understanding of organ interactions to improve patient outcomes in pediatric critical care
Conclusion
In summary, the episode underscores the complex interplay between brain injury and multi-system organ dysfunction. The hosts emphasize the need for a comprehensive understanding of these interactions to improve patient outcomes in pediatric TBI cases. They advocate for a team-based approach to management, focusing on individual patient physiology and the delicate balance required to address the challenges posed by non-neurologic organ dysfunction.
Connect With Us!
We hope you found value in this case-based discussion. Please share your feedback, subscribe, and leave a review on our podcast. For more resources, visit our website at PICUoncall.org.
Thank you for joining us, and stay tuned for our next episode!
Little Lungs Big Bugs: Approach to Bacterial PNA
05 Jan 2025
00:26:25
Welcome to another insightful episode of PICU on Call, a podcast dedicated to current and aspiring intensivists. In this episode, our hosts, Dr. Pradip Kamat, Dr. Rahul Damania, and their colleague, Dr. Jordan Dent, delve into the complexities of managing pneumonia in pediatric patients. The discussion is anchored around a clinical case involving a 10-year-old girl presenting with difficulty breathing and a fever, suggestive of pneumonia. We will break down the key themes and insights from the case, providing a comprehensive guide to understanding and managing pediatric pneumonia.
Case Presentation
The episode begins with a detailed case presentation:
Patient: 10-year-old girl, 28-week preemie with chronic lung disease.
Symptoms: Progressive respiratory distress over eight days, worsening cough, increased work of breathing, hypoxemia (oxygen saturation in the low 80s despite supplemental oxygen).
Findings: Chest X-ray reveals bilateral lower lobe infiltrates and a left-sided pleural effusion. Lab results show elevated CRP and a positive respiratory PCR for a bacterial pathogen.
This case sets the stage for an in-depth discussion on the various aspects of pediatric pneumoRisk Factors for Pneumonia
Understanding the risk factors for pneumonia is crucial for early identification and prevention.
These risk factors can be categorized into three main groups:
Host Factors
Incomplete Immunization Status: Children who are not fully vaccinated are at higher risk
Young Age: Infants and young children have immature immune systems, making them more susceptible
Lower Socioeconomic Status: Limited access to healthcare and poor living conditions can increase risk
Environmental Factors
Exposure to Tobacco Smoke: Secondhand smoke can damage the respiratory tract and impair immune function
Seasonal Variations: Pneumonia cases peak during fall and winter due to increased circulation of respiratory viruses
Contact with Other Children: Daycare settings and schools can facilitate the spread of infections
Healthcare-Associated Factors
Prolonged Mechanical Ventilation: Increases the risk of ventilator-associated pneumonia (VAP)
Nasogastric Tube Placement: Can introduce pathogens into the respiratory tract.
Neuromuscular Blockade: Impairs the ability to clear secretions
Inadequate Humidification: Dry air can damage the respiratory mucosa
Pathogenesis of Pneumonia
Pneumonia occurs when pathogens invade the lower respiratory tract, triggering an inflammatory response. This leads to fluid accumulation and white blood cell infiltration in the alveoli, resulting in:
Decreased Lung Compliance: The lungs become stiffer and harder to expand.
Increased Airway Resistance: Narrowing of the airways makes breathing more difficult.
Ventilation-Perfusion (V/Q) Mismatch: Impaired gas exchange leads to hypoxia and tachypnea.
Etiology by Age Group
The causative pathogens of pneumonia vary by age group:
Neonates: Group B Streptococcus, E. coli, Listeria, Klebsiella
Children Under 5: Viral causes (50% of cases) such as RSV, human metapneumovirus, and influenza, with bacterial causes like Streptococcus pneumoniae and Haemophilus influenzae
Older Children and Teens: Mycoplasma pneumonia, Chlamydia pneumonia, and Streptococcus pneumoniae
Classification of Pneumonia
Pneumonia can be classified based on the acquisition setting:
Community-Acquired Pneumonia (CAP): Occurs in patients not hospitalized in the past month
Hospital-Acquired Pneumonia (HAP): Develops after 48 hours of hospitalization
Ventilator-Associated Pneumonia (VAP): Occurs within 48 hours of intubation
Aspiration Pneumonia: Results from inhaling gastric or oral contents
Necrotizing Pneumonia: Caused by aggressive bacteria, often requiring CT imaging for diagnosis
Clinical Presentation
When a child presents with suspected pneumonia, clinicians should look for:
Systemic Symptoms: Fever, lethargy, poor appetite
Respiratory Symptoms: Tachypnea, hypoxia, and classic findings like crackles
The diagnostic workup for bacterial pneumonia typically includes:
Basic Labs: CBC, inflammatory markers (CRP, procalcitonin), and a comprehensive metabolic panel
Cultures: Blood cultures have low yield; pleural fluid cultures are more definitive
Imaging: Chest X-rays can overestimate pneumonia; point-of-care ultrasound may help identify effusions
Management Framework
Management begins with assessing whether the child can be treated at home or requires hospitalization. Key considerations for admission include:
Hypoxemia: SpO2 < 92%
Rapid Respiratory Rates: Indicative of severe respiratory distress
Toxic Appearance or Poor Oral Intake: Suggests a need for closer monitoring and supportive care
In the PICU, management involves:
Respiratory Support
Nasal Cannula: For mild cases
High-Flow Nasal Cannula (HFNC): For moderate cases
Mechanical Ventilation: For severe cases of respiratory failure
Antibiotic Therapy
Empiric Therapy: Based on age, severity, and local resistance patterns
Targeted Therapy: Adjusted based on culture results and clinical response
Supportive Care
Fluid Management: To maintain hydration and electrolyte balance
Nutrition: Ensuring adequate caloric intake
Fever Control: Using antipyretics to manage fever
Complications of Pneumonia
Complications occur in about 3% of pneumonia cases and include:
Pleural Effusion: Managed with chest tube placement and fibrinolytic therapy
Necrotizing Pneumonia: May require drainage if abscesses develop
Systemic Complications: Such as ARDS, sepsis, and multi-organ dysfunction
Conclusion
Early diagnosis and management of bacterial pneumonia are crucial to prevent complications and mortality. Key indicators include moderate hypoxemia and increased work of breathing. Diagnostic imaging findings such as large pleural effusions and cavitation strongly suggest bacterial infection.
Inhalation Injury in the PICU
22 Dec 2024
00:22:44
In today’s episode, we explore a tragic but educational case involving a 15-year-old girl who suffered severe inhalation injury following a house fire. While heroically rescuing her brother and his friend, she endured prolonged cardiac arrest and severe multi-organ dysfunction. We’ll focus on the pathophysiology, investigation, and management of inhalation injuries, including the critical role of recognizing carbon monoxide and cyanide poisoning in these complex cases.
Exposure to house fire and prolonged cardiac arrest
Signs of inhalation injury and airway compromise
Pathophysiology of inhalation injuries and their impact on multiple organ systems
Management strategies for inhalation injury, including airway protection and ventilation
Differentiating carbon monoxide and cyanide poisoning in pediatric fire victims
Case Presentation
A 15-year-old previously healthy girl is brought to the Pediatric Intensive Care Unit (PICU) after experiencing cardiac arrest during a house fire. She was found unconscious by firefighters after a heroic rescue attempt where she saved her brother and his friend. Upon arrival at the hospital, she was unresponsive, intubated, and in severe cardiovascular distress with signs of multi-organ dysfunction.
Key findings include:
Soot deposits and superficial burns on extremities
Prolonged resuscitation (45 minutes of field CPR and 47 minutes of in-hospital CPR)
Cardiovascular compromise with PVCs, cool extremities, and delayed capillary refill
These findings raise immediate concern for inhalation injury, which is the primary focus of today's discussion.
Pathophysiology of Inhalation Injury
When a patient is exposed to smoke and hot gases during a fire, inhalation injury results in significant damage to the respiratory system. Inhalation injury has three main components:
Upper airway involvement – Thermal injury can cause swelling and obstruction.
Chemical pneumonitis – Noxious chemicals like carbon monoxide and cyanide trigger inflammation in the lungs.
Systemic toxicity – Toxins such as carbon monoxide and cyanide can affect cellular oxygen utilization.
The primary damage occurs in the lower respiratory tract, leading to airway edema, mucosal damage, and bronchial cast formation. This process can result in bacterial pneumonia, respiratory failure, and the need for aggressive intervention.
Investigating Inhalation Injury
A thorough diagnostic approach is essential when assessing patients with suspected inhalation injury:
Basic Imaging: A chest X-ray (CXR) should be obtained, although a normal film doesn't rule out injury.
Gold Standard – Bronchoscopy: Direct visualization allows for assessment and removal of bronchial casts.
Laboratory Tests: Key labs include CBC, CMP, blood gas, lactate, co-oximetry (to assess CO levels), and toxicology screens.
CO and Cyanide Testing: Critical for identifying toxic exposure, especially when a patient presents with altered mental status or unexplained metabolic acidosis.
Managing Inhalation Injury: A Structured Approach
Management revolves around three key pillars:
Airway Protection: Intubation is essential for airway security. Signs such as progressive hoarseness, soot around the nose, or face burns should prompt early intervention.
Ventilation Strategies: Use low tidal volumes and optimized PEEP for lung protection. In severe cases, consider advanced modalities like APRV, HFOV, or ECMO.
Secretion Management: Aggressive pulmonary toilet and medications such as nebulized heparin, tPA, and N-acetylcysteine may help manage airway inflammation and obstructions.
Recognizing and Treating Carbon Monoxide (CO) Poisoning
In cases of suspected CO poisoning, the key is early recognition and treatment:
CO Blood Levels: Measure carboxyhemoglobin levels immediately.
Classic Symptoms: Look for the “cherry red” skin color and neurologic symptoms such as confusion or dizziness.
First-Line Therapy: Administer 100% oxygen via a non-rebreather mask or endotracheal tube.
Hyperbaric Oxygen: While 100% O2 works well, HBO therapy is crucial for preventing delayed neuropsychiatric complications.
Fun Fact: CO has a much higher affinity for hemoglobin than oxygen, which leads to a "tissue oxygen famine," even with normal PaO2 levels.
Identifying Cyanide Poisoning in Fire Victims
Cyanide poisoning can be particularly challenging to diagnose but is crucial in fire victims. Look for:
Late Signs: Cardiovascular collapse, hypotension, and bradycardia.
Treatment: Hydroxocobalamin is the first-line antidote (70 mg/kg IV), with the caveat that purple-red urine is a normal side effect.
Avoid Nitrites: In burn victims, nitrite-based cyanide kits can worsen CO poisoning by forming methemoglobin.
Clinical Tip: Unlike CO poisoning, cyanide poisoning presents with seizures and dilated pupils.
Clinical Course of Our Patient
The patient’s clinical course was marked by rapid deterioration despite aggressive treatment:
Initially managed with high-frequency oscillatory ventilation (HFOV) due to pulmonary hemorrhage
Developed severe PARDS, cardiac dysfunction, and multi-organ failure within 12 hours
Ultimately, neuroimaging revealed anoxic brain injury with cerebral edema and herniation, leading to brain death
This heartbreaking case highlights the importance of early intervention and recognition of inhalation...
Approach Toxic Alcohol Ingestion in the PICU
15 Dec 2024
00:30:06
Welcome and Episode Introduction
Hosts: Dr. Pradip Kamat (Children’s Healthcare of Atlanta/Emory University) and Dr. Rahul Damania (Cleveland Clinic Children’s Hospital)
Mission: A podcast dedicated to current and aspiring pediatric intensivists, exploring intriguing PICU cases and acute care pediatric management
Focus of the Episode: Managing toxic alcohol ingestion in the PICU with emphasis on ethanol, methanol, ethylene glycol, propylene glycol, and isopropyl alcohol
Case Presentation
Patient Details: A 7-month-old male presented with accidental ethanol ingestion after his formula was mixed with vodka
Key Symptoms: Lethargy, uncoordinated movements, decreased activity, and ethanol odor
Initial Labs & Findings:
EtOH level: 420 mg/dL.
Glucose: 50 mg/dL.
Normal CXR and EKG.
PICU Presentation: Tachycardic, normotensive, lethargic, with signs of CNS depression
Initial Management: Dextrose infusion, glucose monitoring, neurological observation, and ruling out complications
Key Learning Points from the Case
Toxic alcohol ingestion in pediatrics requires rapid stabilization and targeted interventions
Hypoglycemia and CNS depression are common features of ethanol toxicity in infants
Management prioritizes glucose correction, airway support, and close neurological monitoring
Deep Dive: Toxic Alcohols in the PICU
1. Ethanol
Typical Presentation in Infants/Toddlers: Hypotonia, ataxia, coma, hypoglycemia, hypotension, and hypothermia
Multisystem Organ Dysfunction Syndrome (MODS) in the PICU
24 Nov 2024
00:32:14
Did you know that Multi-Organ Dysfunction Syndrome (MODS) can result from both infectious and non-infectious causes? In our latest episode, we delve deep into the pathophysiology of MODS, exploring how different organs interact and fail in sequence. We discuss key concepts like organ functional reserve and the kinetics of organ injury, which aren’t as straightforward as they seem. Tune in to learn about the non-linear progression of organ damage and how it impacts management strategies in pediatric critical care.
We break down the case into key elements:
Patient Background: A 15-year-old girl with chronic TPN dependence and a PICC line presented with septic shock and respiratory failure.
Initial Presentation: Blood cultures confirmed Gram-negative rod bacteremia. She developed multi-system complications, including acute kidney injury (AKI), thrombocytopenia, and cardiac dysfunction.
Management: Broad-spectrum antibiotics, mechanical ventilation, vasoactive agents, and supportive care for MODS.
Key Case Highlights:
Clinical case of a 15-year-old girl with sepsis from a gram-negative rod
Dependence on total parenteral nutrition (TPN) and prolonged PICC line use
Discussion of septic shock, acute respiratory failure, and acute kidney injury
Overview of multiple organ dysfunction syndrome (MODS) and its definitions
Pathophysiology of MODS, including organ functional reserve and kinetics of organ injury
Molecular mechanisms involved in MODS, such as mitochondrial dysfunction and immune responses
Specific phenotypes of sepsis-induced MODS, including TAMOF and IPMOF
Management strategies for MODS, emphasizing multidisciplinary approaches
Role and complications of therapeutic plasma exchange (TPE) in treating MODS
Importance of recognizing signs of MODS and timely intervention in pediatric patients
Segment 1: MODS Definitions and Phenotypes
Key Definition: MODS is the progressive failure of two or more organ systems due to systemic insults (infectious or non-infectious).
Phenotypes:
TAMOF (Thrombocytopenia-Associated Multi-Organ Failure): Characterized by thrombocytopenia, hemolysis, and decreased ADAMTS13 activity.
Immunoparalysis: Persistent immunosuppression and risk of secondary infections.
Sequential Liver Failure: Often associated with viral triggers.
Segment 2: Pathophysiology of MODS
Molecular Insights:
Mitochondrial dysfunction and damage-associated molecular patterns (DAMPs)
Innate and adaptive immune dysregulation
Microcirculatory dysfunction and ischemia-reperfusion injury
Organ Interactions: MODS evolves through complex multi-organ interdependencies
Segment 3: Diagnosis and Evidence-Based Management
Key Diagnostic Pearls:
MODS is not solely infection-driven; it requires a shared mechanism and predictable outcomes.
Use biomarkers like ADAMTS13 and TNF-α response for phenotypic classification.
Management Highlights:
Supportive Care: Multisystem approach including lung-protective ventilation, renal replacement therapy, and hemodynamic support.
Therapeutic Plasma Exchange (TPE): Especially effective in TAMOF by restoring ADAMTS13 and removing inflammatory mediators.
Segment 4: Practical Tips for Intensivists
Early recognition of MODS phenotypes for targeted therapy
Importance of multidisciplinary teamwork in critical care settings
Monitoring for complications like TMA and immunoparalysis during prolonged ICU stays
In this episode, we discuss the case of a 15-year-old girl who presents with progressive headache, nausea, vomiting, and difficulty ambulating. Her condition rapidly evolves into altered mental status and severe hydrocephalus, leading to a compelling discussion about the evaluation, diagnosis, and management of hydrocephalus in pediatric patients.
We break down the case into key elements:
A comprehensive look at acute hydrocephalus, including its pathophysiology and causes
Epidemiological insights, clinical presentation, and diagnostic approaches
Management strategies, including temporary and permanent CSF diversion techniques
A review of complications related to shunts and endoscopic third ventriculostomy
Key Case Highlights:
Patient Presentation:
A 15-year-old girl with a 3-day history of worsening headaches, nausea, vomiting, and difficulty walking
Altered mental status and bradycardia upon PICU admission
CT scan revealed severe hydrocephalus without a clear mass lesion
Management Steps in the PICU:
Hypertonic saline bolus improved her mental status and pupillary reactions
Neurosurgery consultation recommended MRI and close neuro checks
Initial management included dexamethasone, keeping the patient NPO, and hourly neuro assessments
Differential Diagnosis:
Obstructive (non-communicating) vs. non-obstructive (communicating) hydrocephalus
Consideration of alternative diagnoses like intracranial hemorrhage and idiopathic intracranial hypertension
Episode Learning Points:
Hydrocephalus Overview:
Abnormal CSF buildup in the ventricles leading to increased intracranial pressure (ICP)
Key distinctions between obstructive and non-obstructive types
Epidemiology and Risk Factors:
Congenital causes include genetic syndromes, neural tube defects, and Chiari malformations
Acquired causes: post-hemorrhagic hydrocephalus (e.g., from IVH in preemies), infections like TB meningitis, and brain tumors
Older children: Headaches, vomiting, papilledema, and gait disturbances
Management Framework:
Temporary CSF diversion via external ventricular drains (EVD) or lumbar catheters
Permanent interventions include VP shunts and endoscopic third ventriculostomy (ETV)
Complications of Shunts and ETV:
Shunt infections, malfunctions, over-drainage, and migration
ETV-specific risks, including delayed failure years post-procedure
Clinical Pearl:
Communicating hydrocephalus involves symmetric ventricular enlargement and is often linked to inflammatory or post-treatment changes affecting CSF reabsorption.
Hosts’ Takeaway Points:
Dr. Pradip Kamat emphasizes the importance of timely recognition and intervention in hydrocephalus to prevent complications like brain herniation.
Dr. Rahul Damania highlights the need for meticulous neurological checks in PICU patients and an individualized approach to treatment.
Resources Mentioned:
Hydrocephalus Clinical Research Network guidelines.
Recent studies on ETV outcomes in pediatric populations.
Call to Action:
If you enjoyed this discussion, please subscribe to PICU Doc On Call and leave a review. Have a topic you’d like us to cover? Reach out to us via email or on social media!
Stay tuned for more cases that challenge and inspire us as PICU clinicians!
Approach Toxic Alcohol Ingestion in the PICU
15 Oct 2024
00:30:06
Introduction
Hosts: Dr. Pradip Kamat (Children’s Healthcare of Atlanta/Emory University) and Dr. Rahul Damania (Cleveland Clinic Children’s Hospital)
Mission: A podcast dedicated to current and aspiring pediatric intensivists, exploring intriguing PICU cases and acute care pediatric management
Focus of the Episode: Managing toxic alcohol ingestion in the PICU with emphasis on ethanol, methanol, ethylene glycol, propylene glycol, and isopropyl alcohol
Case Presentation
Patient Details: A 7-month-old male presented with accidental ethanol ingestion after his formula was mixed with vodka
Key Symptoms: Lethargy, uncoordinated movements, decreased activity, and ethanol odor
Initial Labs & Findings:
EtOH level: 420 mg/dL.
Glucose: 50 mg/dL.
Normal CXR and EKG.
PICU Presentation: Tachycardic, normotensive, lethargic, with signs of CNS depression
Initial Management: Dextrose infusion, glucose monitoring, neurological observation, and ruling out complications
Key Learning Points from the Case
Toxic alcohol ingestion in pediatrics requires rapid stabilization and targeted interventions
Hypoglycemia and CNS depression are common features of ethanol toxicity in infants
Management prioritizes glucose correction, airway support, and close neurological monitoring
Deep Dive: Toxic Alcohols in the PICU
1. Ethanol
Typical Presentation in Infants/Toddlers: Hypotonia, ataxia, coma, hypoglycemia, hypotension, and hypothermia
It’s Getting Hot in Here | Heat Stroke in the PICU
13 Oct 2024
00:29:35
Introduction:
Today, Dr. Rahul Damania, Dr. Pradip Kamat, and their guest, Dr. Jordan Dent, discuss a critical case involving a 15-year-old male who collapsed during football practice due to exertional heat stroke. The discussion emphasizes the clinical presentation, risk factors, pathophysiology, and evidence-based management of heat stroke and other heat-related illnesses in pediatric patients. The episode also delves into the role of rapid cooling interventions and long-term care to minimize mortality and morbidity.
Case Summary: A 15-year-old male with ADHD collapsed during football practice on a hot, humid day. He presented with:
After suffering cardiac arrest and undergoing resuscitation, the patient developed multiorgan dysfunction, including seizures, encephalopathy, and cerebral edema. Despite severe initial complications, the patient demonstrated neurological improvement with left-side hemiparesis before discharge.
Key Discussion Points:
Etiology and Pathophysiology of Heat Stroke:
Heat stroke occurs when the body’s thermoregulatory mechanisms fail, leading to dangerous elevations in core body temperature. Exertional heat stroke is common during strenuous physical activity in hot, humid environments.
Key physiological breakdowns include inadequate sweating, vasodilation dysfunction, and subsequent cellular damage due to hyperthermia.
Risk Factors for Exertional Heat Stroke:
Environmental factors: High temperature, humidity, lack of hydration, and breaks.
Athlete-related factors: Hypohidrosis, dehydration, medical conditions, and medications (e.g., Adderall).
Heat illness is the third leading cause of death in high school athletics, with American football players particularly at risk.
Spectrum of Heat-Related Illness:
Heat Cramps: Involuntary muscle contractions due to dehydration and electrolyte imbalance.
Heat Syncope: Transient loss of consciousness due to heat exposure.
Heat Exhaustion: Milder heat illness with core temperature < 104°F, potentially progressing to heat stroke if untreated.
Heat Stroke: Life-threatening with core temperature ≥ 104°F, CNS dysfunction, and risk of multiorgan failure.
Management of Heat Stroke:
Rapid Cooling: Immediate cooling to bring core temperature down to 39°C within 30 minutes is critical. Methods include ice packs, cold water immersion, and core cooling techniques (cold IV fluids, gastric lavage).
Supportive Care: Management of shock, electrolyte imbalances, rhabdomyolysis, DIC, and ARDS.
Monitoring and Long-Term Care: Continuous EEG, fluid management, and rehabilitation are key in managing neurological and systemic complications.
Differentiating Heat Stroke from Fever:
Fever results from a reset of the hypothalamic setpoint due to pyrogens, while heat stroke involves the failure of thermoregulation without a change in the hypothalamic setpoint.
Case Outcome:
The patient initially suffered significant neurological damage but improved with intensive care and rehabilitation. By discharge, the patient showed notable recovery, though with some lasting deficits.
Key Takeaways:
Heat stroke is a medical emergency with a high risk of mortality and long-term complications if not treated promptly.
Early recognition, rapid cooling, and a multidisciplinary approach are critical to improving outcomes.
Athletes and children engaging in strenuous activities in hot environments should be closely monitored for signs of heat-related illness.
References:
Fuhrman, B., & Zimmerman, J. J. (2020). Hyperthermic Injury. In Textbook of Pediatric Critical Care (pp. 1327-1331).
Rogers, M. C., et al. (2016). Thermoregulation. In Rogers' Textbook of Pediatric Intensive Care (pp. 546-552).
Jardine, D. S. (2007). Heat Illness and Heat Stroke. Pediatrics in Review, 28(7), 249–258. https://doi.org/10.1542/pir.28-7-249.
Patel, J., et al. (2023). Critical illness aspects of heatstroke: A hot topic. Journal of Intensive Care Society, 24(2), 206-214. https://doi.org/10.1177/17511437221148922.
Ramirez, O., Malyshev, Y., & Sahni, S. (2018). It’s Getting Hot in Here: A Rare Case of Heat Stroke in a Young Male. Cureus, 10(12), e3724. https://doi.org/10.7759/cureus.3724.
Hemostatis and Coagulation in the PICU
04 Aug 2024
00:50:04
Introduction
Welcome to PICU Doc On Call, a podcast dedicated to current and aspiring pediatric intensivists. I'm Dr. Pradip Kamat from Children’s Healthcare of Atlanta/Emory University School of Medicine, and I’m Dr. Rahul Damania from Cleveland Clinic Children’s Hospital. We are two Pediatric ICU physicians passionate about medical education in the PICU. This podcast focuses on interesting PICU cases and their management in the acute care pediatric setting.
Episode Overview
In today’s episode, we are excited to welcome Dr. Karen Zimowski, Assistant Professor of Pediatrics at Emory University School of Medicine and a practicing pediatric hematologist at Children’s Healthcare of Atlanta at the Aflac Blood & Cancer Center. Dr. Zimowski specializes in pediatric bleeding and clotting disorders.
Case Presentation
A 16-year-old female with a complex medical history, including autoimmune thyroiditis and prior cerebral infarcts, was admitted to the PICU with acute chest pain and difficulty breathing. Despite being on low-dose aspirin, her oxygen saturation was 86% on room air. A CT angiography revealed a pulmonary embolism (PE) in the left lower lobe and signs of right heart strain. The patient was hemodynamically stable, and thrombolytic therapy was deferred in favor of anticoagulation. She was placed on BiPAP to improve her respiratory status. Her social history was negative for smoking, illicit drug use, or oral contraceptive use.
Key Case Points
Diagnosis: Pulmonary embolism (PE)
Hemodynamics: Stable with no right ventricular (RV) strain on echocardiogram
Management Focus: Anticoagulation and consultation with the hematology/thrombosis team
Expert Discussion with Dr. Karen ZimowskiRisk Factors and Epidemiology of VTE in Pediatrics
Pathophysiology: Venous thromboembolism (VTE) in children involves components of Virchow’s triad: stasis of blood flow, endothelial injury, and hypercoagulability.
Incidence: VTE is rare in the general pediatric population but increases significantly in hospitalized children.
Age Distribution: Bimodal peaks in infants and adolescents aged 15-17 years.
Risk Factors: Central venous lines, infections, congenital heart disease, cancer, and autoimmune disorders.
Clinical Manifestations of DVT
Symptoms: Swelling, pain, warmth, and skin discoloration in the affected extremity.
Specific Presentations:
SVC syndrome from superior vena cava thrombosis
Abdominal pain from portal vein thrombosis
Hematuria from renal vein thrombosis
Neurological symptoms from cerebral sinus venous thrombosis
Diagnostic Approach for DVT
Imaging:
Compression Doppler Ultrasonography: Primary method for diagnosing DVT in pediatric patients.
MR Venography (MRV) and CT Venography (CTV): Used for abdominal and cerebral sinus thrombosis.
Laboratory Studies:
D-dimer: Useful in adults; limited specificity in children.
Other Labs: Renal and liver function tests, CBC with differential, DIC panel.
Management of DVTAnticoagulation Strategies
Unfractionated Heparin (UFH):
Targets factors IIa and Xa; requires frequent monitoring.
Adverse events: Bleeding and thrombocytopenia.
Low Molecular Weight Heparin (LMWH):
More predictable pharmacokinetics than UFH.
Advantages include ease of administration and lower risk of HIT.
Vitamin K Antagonists (VKAs):
Used for long-term anticoagulation.
Requires regular INR monitoring.
Direct Oral Anticoagulants (DOACs):
Dabigatran, Rivaroxaban, and Apixaban used in pediatric VTE.
Advantages: No routine monitoring required, predictable effects.
Conclusion
In this episode, we discussed the intricacies of VTE diagnosis and management in pediatric patients. We thank Dr. Karen Zimowski for sharing her expertise on anticoagulation and hemostasis in the PICU. For more episodes and our Doc on Call management cards, visit picudoconcall.org.
Stay tuned for our next episode, and thank you for listening!
References
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care: Thrombosis in Pediatric Critical Care.
American Society of Hematology 2018 Guidelines for Management of Venous Thromboembolism: Treatment of Pediatric Venous Thromboembolism.
Antithrombotic Therapy in Neonates and Children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
O’Brien, SH, Stanek JR, Witmer CM, Raffini L. The Continued Rise of Venous Thromboembolism Across US Children’s Hospitals. Pediatrics (2022).
PICU Doc on Call Shorts: Alveolar Gas Equation
28 Apr 2024
00:20:06
Welcome to PICU Doc On Call, where Dr. Pradip Kamat from Children’s Healthcare of Atlanta/Emory University School of Medicine and Dr. Rahul Damania from Cleveland Clinic Children’s Hospital delve into the intricacies of Pediatric Intensive Care Medicine. In this special episode of PICU Doc on Call shorts, we dissect the Alveolar Gas Equation—a fundamental concept in respiratory physiology with significant clinical relevance.
Key Concepts Covered:
Alveolar Gas Equation Demystified: Dr. Rahul explains the Alveolar Gas Equation, which calculates the partial pressure of oxygen in the alveoli (PAO2). This equation, PAO2 = FiO2 (Patm - PH2O) - (PaCO2/R), is essential in understanding hypoxemia and the dynamics of gas exchange in the lungs.
Calculating PAO2: Using the Alveolar Gas Equation, the hosts demonstrate how to calculate PAO2 at sea level, emphasizing the influence of atmospheric pressure, fraction of inspired oxygen (FiO2), water vapor pressure, arterial carbon dioxide pressure (PaCO2), and respiratory quotient (R) on oxygenation.
A-a Gradient and Hypoxemia: The A-a gradient, derived from the Alveolar Gas Equation, is discussed in the context of hypoxemia evaluation. Understanding the causes of hypoxemia, including ventilation/perfusion (V/Q) mismatch, anatomical shunt, diffusion defects, and hypoventilation, is crucial for clinical diagnosis and management.
Clinical Scenarios and A-a Gradient Interpretation: Through a clinical scenario, the hosts elucidate how different conditions affect the A-a gradient and oxygenation, providing insights into respiratory pathophysiology and differential diagnosis.
Clinical Implications and Management Strategies: The hosts highlight the clinical significance of the Alveolar Gas Equation in assessing oxygenation status, diagnosing gas exchange abnormalities, and tailoring respiratory management strategies in the pediatric intensive care setting.
Key Takeaways:
Utility of the Alveolar Gas Equation: Understanding and applying the Alveolar Gas Equation is essential for evaluating oxygenation and diagnosing respiratory abnormalities.
Interpreting A-a Gradient: A normal A-a gradient suggests alveolar hypoventilation as the likely cause of hypoxemia, whereas elevated gradients indicate other underlying pathologies.
Clinical Relevance: Recognizing the clinical implications of the Alveolar Gas Equation aids in accurate diagnosis and optimal management of respiratory conditions in pediatric intensive care patients.
Conclusion:
Join Dr. Kamat and Dr. Damania as they unravel the complexities of the Alveolar Gas Equation, providing valuable insights into respiratory physiology and its clinical applications. Don’t forget to subscribe, share your feedback, and visit picudoconcall.org for more educational content and resources.
References:
Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter: Physiology of the respiratory system. Chapter 42. Khemani et al. Pages 470-481
Rogers textbook of Pediatric intensive care: Chapter 44. Respiratory physiology. Akong K et al. Pages 691-721
Respiratory Physiology for the Anesthesiologist. Bigatello L and Pesenti A, Anesthesiology 2019; 130: 1064-77
PICU Management of Malignant Hyperthermia
14 Apr 2024
00:29:32
Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.
Hosts:
Dr. Pradip Kamat: Children’s Healthcare of Atlanta/Emory University School of Medicine
Dr. Rahul Damania: Cleveland Clinic Children’s Hospital
Introduction:
Pediatric Intensive Care Unit (PICU) physicians passionate about medical education in the acute care pediatric setting
Episode focus: A case of a 23-month-old ex-28 week premie presenting with sudden high fever and rapidly rising ETCO2 during surgery
Case Presentation:
Presented by Dr. Rahul Damania
23-month-old ex-28 week premie intubated during hernia repair surgery
Noticed rapidly rising ETCO2, unprovoked tachycardia, and elevated temperature
Transferred to PICU, exhibiting rigidity, clenched jaw, metabolic acidosis, and elevated lactate.
Consideration of Malignant Hyperthermia (MH) crisis
Key Points:
Elevated temperature, hypercapnia, metabolic acidosis, and unprovoked tachycardia raise concern for MH
Organized discussion on pathophysiology, clinical signs, symptoms, and management
Multiple Choice Question:
Diagnosis of MH crisis during scoliosis repair
Correct Answer: D) Sarcoplasmic reticulum
Dantrolene acts on the sarcoplasmic reticulum to inhibit calcium release, crucial in MH management
Clinical Presentation of MH Crisis:
Tachycardia, acidosis, muscle stiffness, and hyperthermia are hallmark features
Potential life-threatening complications underscore the urgency of recognition and treatment
Triggers and Pathophysiology of MH Crisis:
Triggered by inhalational agents and depolarizing neuromuscular blocking agents
Pathophysiology involves defective Ryanodine receptor leading to uncontrolled calcium release
Differential Diagnosis:
Includes sepsis, thyroid storm, pheochromocytoma, and neuroleptic malignant syndrome
Differentiation from similar conditions crucial for accurate management
Diagnostic Approach:
High clinical suspicion
Genetic testing (ryanodine receptor gene sequencing) and Caffeine Halothane Contracture Test (CHCT) for diagnosis
Immediate workup during crisis includes blood gas, lactate, CPK, CMP, and urine analysis
General Management Framework:
MH crisis is a medical emergency requiring rapid intervention
Dantrolene Na administration, supportive measures, and continuous monitoring in PICU
Utilization of Malignant Hyperthermia carts and involvement of specialized hotlines
Clinical Pearls and Pitfalls:
Early recognition is crucial.
Proper administration of Dantrolene Na without delay
Extended monitoring period in PICU to ensure stability
Today, we discuss the case of an 8-month-old infant with severe bronchospasm and abnormal blood gas. We'll delve into the epidemiology, pathophysiology, and evidence-based management of acute bronchiolitis.
Case Summary
An 8-month-old infant presented to the ER with decreased alertness following worsening work of breathing, preceded by URI symptoms. The infant was intubated and transferred to the PICU, testing positive for RSV. Initial blood gas showed 6.8/125/-4, and CXR revealed massive hyperinflation. Vitals: HR 180, BP 75/45, SPO2 92% on 100% FIO2, RR 12 (prior to intubation), now around 16 on the ventilator, afebrile.
Discussion Points
Etiology & Pathogenesis: Bronchiolitis is primarily caused by RSV, with other viruses and bacteria playing a role. RSV bronchiolitis is the most common cause of hospitalization in infants, particularly in winter months. Immuno-pathology involves an unbalanced immune response and can lead to various extra-pulmonary manifestations.
Diagnosis: Diagnosis is clinical, based on history and examination. Key signs include upper respiratory symptoms followed by lower respiratory distress. Blood gas, chest radiography, and viral testing are generally not recommended unless warranted by severe symptoms or clinical deterioration.
Management Framework: For patients requiring PICU admission, focus on oxygenation and hydration. High-flow therapy and nasal continuous positive airway pressure (CPAP) can be used. Hydration and feeding support are crucial. Antibiotics, steroids, and bronchodilators are generally not recommended. Mechanical ventilation and ECMO may be necessary in severe cases.
Immunoprophylaxis & Nosocomial Infection Prevention: Palivizumab and nirsevimab are used for RSV prevention in high-risk infants. Strict infection control measures, including hand hygiene and isolation, are essential to prevent nosocomial infections.
Conclusion
RSV bronchiolitis is a common and potentially severe respiratory illness in infants. Management focuses on supportive care, with a careful balance between oxygenation and hydration. Immunoprophylaxis and infection control are crucial in preventing the spread of the virus.
Thank you for listening to our episode on acute bronchiolitis. Please subscribe, share your feedback, and visit our website at picudoconcall.org for more resources. Stay tuned for our next episode!
References
Rogers - Textbook of Pediatric Critical Care Chapter 49: Pneumonia and Bronchiolitis. De Carvalho et al. page 797-823