Pediatrica intensiva: Art & Science of Pediatric Critical Care

Airway management remains the single highest risk time for our patients in pediatric ICU.  Different studies of pediatric airway management report first pass success as low as 50%. Rates of severe desaturation as high as 20%, and significant rates of cardiac arrest ranging from two to 15% in the 30 minute peri intubation window alone. A difficult airway might be anticipated or unanticipated and is not just difficult endotracheal intubation, but also difficulties with mask ventilation. supraglottic airway devices, difficult rescue techniques including front of neck access and physiologically difficult airways, which we covered in previous episodes.  The good news is that the attention our community has been paying to these issues has reduced the rates of endo tracheal intubation (ETI) associated adverse events significantly, but there's still a long way to go. We are joined by Akira Nishisaki from NEAR 4 Kids & CHOP which has been one of the main drivers of improvements in this space for almost 20 years and who has an incredible knowledge of the literature and Doug Atkinson a pediatric anesthesiologist and cardiac intensivist from Boston Children's Hospital. As always, we focus on how our expert panel do things in practice at their institutions whilst being aware of the evidence.

This season is  about airway management or airways that scare me and this episode, we discuss the respiratory unstable patient or the patient who's a "physiologically difficult airway" because they have bad lungs. We were incredibly lucky to have the amazing Robi Khemani from CHLA, a world expert on respiratory disorders in #pedsICU, join us and be able to share his thoughts. It's not just about putting the tube in, it's about that whole high risk period of peri intubation. And with better drugs and devices we've opened a big space between low flow oxygen and invasive ventilation which makes decision making trickier. Here we focus on that difficult decision making and the patients that really scare us. If you haven't heard it yet, our previous episode on team, environment, and equipment is very relevant here. Featuring special guest Robinder Khemani from Children's Hospital LA and regular hosts @drpetaalexander @BostonChildrens @drgregkelly @SCHNkids and @Karen_Choong @MCH_childrens No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter @pedsintensiva and our website here https://pedsintensiva.com

Children with complex airway surgery are airways that truly scare us. Though a small number of patients in pedsICU, they can stay a long time and are at risk of death and morbidity from their underlying conditions, co-existing conditions, their treatment and ICU acquired problems. Managing these patients requires a high level of understanding, communication and teamwork between ENT/ORL, ICU, anesthesia, cardiothoracic surgery and numerous other teams. We're going to cover the working up and investigation of patients transfers. The kind of conditions that are treated ranging from severe stenoses to severe malacias.  What the surgeons actually do what they want us to know and how it can best work together between ICU and surgical team.  We're also going to cover how we maintain these patients in the ICU, how we progress them, forwards, how we investigate problems and how we get the next debated and keep them safe. Featuring special guests ORL surgeon and innovator David Zopf and Ryan Barbaro from University of Michigan and regular hosts @drpetaalexander @BostonChildrens  @drgregkelly @SCHNkids and Mike Clifford @RCH No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter @pedsintensiva and our website here https://pedsintensiva.com  

Airway Management remains the single highest risk time for our patients in pedsICU & pedsCICU. We've known about problems for long time, but finally gaining attention, new ways of thinking & new ways to use drugs & devices- there's a lot more gray then there used to be. We'll discuss resuscitation and airway management in child with cardiac disease or hemodynamic instability, introduce the concept of the resus spiral staircase and talk about how you can optimize your team, respiratory support and hemodynamics. We cover delayed sequence intubation and that not every patient needs a tube and not every patient needs a tube right now. With better drugs and devices like dexmedetomidine and non-invasive, we've actually opened up a big zone between no support and invasive ventilation. We'll discuss ECMO standby when, how, who, and then finally de-resuscitation and extubation or separation from support. This was a really big episode, so we've split it into two. The first half covered the resus spiral, team management, equipment & environment. In this second episode, we will go into respiratory and hemodynamic support, rescue strategies, including ECMO and finally extubation. Featuring regular hosts @drpetaalexander @BostonChildrens @karen_choong @MCH-childrens @drgregkelly @SCHNkids No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter @pedsintensiva and our website here https://pedsintensiva.com

What are the pediatric #ECMO scenarios that even experts struggle with? "Challenging Pediatric ECMO Scenarios" Special Collaboration w @PCICS @ECMOPedi and @PedsIntensiva 3 cases covering what our expert hosts and panelists all decided were three of the HARDEST scenarios to deal with: 1. VA ECMO for respiratory support; 2. L heart decompression on VA ECMO &; 3. "Inadequate" VV ECMO support Feat. international experts @drpetaalexander @deanna_md @ETEmrath @DrGregKelly @JFurlongDillard @ozmen001 and Dr Ariane Willems As usual, the audio content will be released as a tweet thread that you can find and comment on - here is the link Pedsintensiva.com      

Airway management remains the single highest risk time for our patients in pediatric ICU. We've known about these problems for a long time, but they're finally gaining the attention they deserve with registry projects and multicenter studies, new ways of thinking that move away from old dogmas and new ways to use our drugs and devices. One of the groups with the highest rates of peri intubation cardiac arrest is the child with cardiac disease or hemodynamic instability. Recent studies show extraordinary rates of peri intubation cardiac arrest as high as four to 15% in the 30 minute peri-intubation window. We'll discuss resuscitation and airway management in child with cardiac disease or hemodynamic instability, introduce the concept of the resus spiral staircase and talk about how you can optimize your team, respiratory support and hemodynamics. We cover delayed sequence intubation and that not every patient needs a tube and not every patient needs a tube right now. With better drugs and devices like dexmedetomidine and non-invasive, we've actually opened up a big zone between no support and invasive ventilation. We'll discuss ECMO standby when, how, who, and then finally de-resuscitation and extubation or separation from support. This is a really big episode, so we've split it into two. This first half covers the resus spiral, team management and monitoring. And in the second episode, we will go into respiratory and hemodynamic support, rescue strategies, including ECMO and finally extubation. Featuring regular hosts @drpetaalexander @BostonChildrens @karen_choong @MCH-childrens @drgregkelly @SCHNkidsNo time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter @pedsintensiva and our website here https://pedsintensiva.com

Culture and Practice Change are a vital element to implement ICU based rehabilitation in the pediatric ICU - because even when we know what to do it can be really hard to get our large and diverse teams on board and manage resource limitations, change fatigue and differing views. Here, experts from around the world discuss how they implemented change in their units - using everything from quality science to gossip and merchandise! Invited guests are Dr Brianna McKelvie from @CHEO, an intensivist with a masters degree in quality science, Dr Matteo DiNardo from Bambino Gesu, who has implemented QI projects in Italy and in low resource settings and Dr Mirjana Cvetkovic @mirjanaxxx @GreatOrmondStreet a cardiac intensivist and anesthetist who has driven change at GOS. Featuring regular hosts @drpetaalexander @BostonChildrens @karen_choong @MCH-childrens @drgregkelly @SCHNkids No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter @pedsintensiva and our website here https://pedsintensiva.com/culture-practice-change-in-picu-based-rehabilitation/

Long term & technology dependent aka "chronic critically ill" #pedsICU patients with Dr Rob Graham @BostonChildrens @karen_choong @drgregkelly @drpetaalexander Our #ICUrehab season focussed on preventing PICU morbidities & improving recovery. Our successes in #pedsICU mean that most kids survive & we increasingly see survivors with chronic complex conditions, either in ICU or frequently readmitted. They are still a relatively small population but use a huge proportion of our bed days and are a population with unique risks & needs. Dr Rob Graham established the home ventilation program at Boston Children's and has deep expertise on these patients. #ICUrehab #ICUSurvivorship No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter @pedsintensiva and our website here https://pedsintensiva.com/long-term-technology-dependent-aka-chronic-critically-ill-pedsicu-patients-feat-dr-rob-graham/  

There is a growing awareness of the broad range of problems that patients and their families can face after a stay in the #pedsICU which is now known as Post Intensive Care Syndrome - pediatrics Nurse researcher and clinician Joseph Manning developed the PICS-p framework and has deep experience in following up these patients and families after they leave the ICU Pediatrica Intensiva season 3 is guest edited by Professor Karen Choong from McMaster University in Hamilton, Canada and co hosted by Drs Greg Kelly (Sydney Children's Hospital Network), Peta Alexander (Boston Children's Hospital) and Mike Clifford (Royal Children's Hospital Melbourne) No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/post-intensive-care-syndrome-in-pedsicu-pics-p-with-nurse-researcher-joseph-manning-mbe-rn/

Analgesia and/or Sedation is provided to almost all the patients in the #pedsICU but it is something that often lacks precision. In this episode we speak to intensivist Prof Jayashree Muralidharan, #pedsICU nurse Sharon Prior and pharmacist Jonathon Wong Pediatrica Intensiva season 3 is guest edited by Professor Karen Choong from McMaster University in Hamilton, Canada and co hosted by Drs Greg Kelly (Sydney Children's Hospital Network), Peta Alexander (Boston Children's Hospital) and Mike Clifford (Royal Children's Hospital Melbourne) No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/analgesia-sedation-in-pedsicu-feat-jayashree-muralidharan/

Delirium is a hugely important topic in the #pedsICU with up to 90% of some patient populations being affected and impacts on disease severity, length of stay and quality of life, even months after discharge. It is related to underlying disease, but also to the drugs and abnormal environment that we expose our patients to. Chani Traube and Deb Long are two of the foremost experts on pediatric delirium and offer countless pearls in this practice-changing conversation. Pediatrica Intensiva season 3 is guest edited by Professor Karen Choong from McMaster University in Hamilton, Canada and co hosted by Drs Greg Kelly (Sydney Children's Hospital Network), Peta Alexander (Boston Children's Hospital) and Mike Clifford (Royal Children's Hospital Melbourne) No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/delirium-in-pedsicu-feat-chani-traube-deb-long/

Survival in PICU continues to increase around the world. The hidden cost of this is ever increasing numbers of children with severe, sometimes lifelong, problems from their critical illness and intensive care stay. Joining us as a guest editor for this season is one of the world experts on this topic - Professor Karen Choong from McMaster University in Hamilton, Canada. The episodes for this season cover the breadth of rehabilitation in the peds ICU. No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/picu-based-rehabilitation-season-trailer/  

6th regular episode of Pediatrica Intensiva with Aparna Hoskote, consultant in cardiac ICU at Great Ormond St Hospital London. The time around the stage 1 procedure is the time of the highest mortality for single ventricle patients, up to 15%. What we do in the #pedsICU really matters for these patients but there is very little high quality evidence to inform our practice. Consequently, practice varies greatly around the world with things to learn from many great centers. No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/110-2/  

5th regular episode of Pediatrica Intensiva with Peta Alexander from Boston Children's, Mike Clifford from Royal Children's Melbourne & Greg Kelly from Westmead Children's Sydney. The interstage is a time of incredibly high mortality despite the fact it only lasts a few months. These patients can get sick for a variety of reasons between the mundane and the catastrophic - management is tricky and varies between centers. Hosts: Dr Greg Kelly (Westmead Children's Hospital, Sydney, Australia), Peta Alexander (Boston Children's Hospital), Mike Clifford (Royal Children's Hospital, Melbourne). Produced & edited by Caitlin Gibson, special thanks to Maya Newell. No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/the-sick-interstage-single-ventricle-patient/

4th regular episode of Pediatrica Intensiva with Liz Crowe - Senior PICU Social Worker Having a child with single ventricle disease is an extraordinarily stressful time for the child, the family, and the staff who are involved. Liz Crowe is a world expert on these matters with over 20 years experience clinical work and a recently completed PhD on grief, resilience and wellbeing. Hosts: Dr Greg Kelly (Westmead Children's Hospital, Sydney, Australia), Peta Alexander (Boston Children's Hospital), Mike Clifford (Royal Children's Hospital, Melbourne). Produced & edited by Caitlin Gibson, special thanks to Maya Newell. No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/supporting-the-child-family-in-single-ventricle-disease-feat-liz-crowe/

3rd regular episode of Pediatrica Intensiva with Dr Ravi Thiagarajan - Division Chief of Cardiovascular Critical Care at Boston Children's Hospital Patients with single ventricle heart disease are a very high risk group for cardiopulmonary arrest and requirement for ECMO support. Arrest and CPR is not inevitable and we are increasingly finding ways to prevent it, as well as manage the CPR and ECMO period with more nuance and better outcomes. Hosts: Dr Greg Kelly (Westmead Children's Hospital, Sydney, Australia), Peta Alexander (Boston Children's Hospital), Mike Clifford (Royal Children's Hospital, Melbourne). Produced & edited by Caitlin Gibson, special thanks to Maya Newell. No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/cpr-ecmo-in-single-ventricle-patients-feat-ravi-thiagarajan/

2nd regular episode of Pediatrica Intensiva with Dr Mike Seed, division head of cardiology from Sick Kids and also a fully qualified cardiac radiologist. Patients with otherwise normal hearts can tolerate single residual lesions fairly well, but in single ventricle patients they are often associated with major adverse outcomes. Modern management involves aggressive monitoring for and intervention on residual lesions, though interventions must be seen in the context of the whole patient. No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/residual-lesions-in-single-ventricle-patients-feat-mike-seed/   Hosts: Dr Greg Kelly (Westmead Children's Hospital, Sydney, Australia), Peta Alexander (Boston Children's Hospital), Mike Clifford (Royal Children's Hospital, Melbourne). Produced & edited by Caitlin Gibson, special thanks to Maya Newell.

1st regular episode of Pediatrica Intensiva with Dr Peter Laussen, cardiac intensivist & anaesthesiologist from Boston Children's Hospital who is one of the world's most experienced people at dealing with borderline left heart patients, one of the toughest groups of critical congenital heart patients. These patients are tricky because of issues with terminology, testing, management and differences in institutional approach. A whole-of-program understanding is vital to ensuring best outcomes. No time to listen or want to participate in the discusion? You can find a full Tweetorial of this episode on Twitter https://twitter.com/PedsIntensiva and our website here https://pedsintensiva.com/borderline-left-hearts-pedsicu-feat-peter-laussen/   Hosts: Dr Greg Kelly (Westmead Children's Hospital, Sydney, Australia), Peta Alexander (Boston Children's Hospital), Mike Clifford (Royal Children's Hospital, Melbourne). Produced & edited by Caitlin Gibson, special thanks to Maya Newell.

A podcast that aims to bridge the gap between literature and practice for pediatric critical care clinicians. Hosted by Drs Peta Alexander, cardiologist & intensivist at Boston Children’s Hospital; Mike Clifford, intensivist & anaesthetist at Royal Children’s Melbourne and Greg Kelly, intensivist at Westmead Children’s Hospital, Sydney, Australia Second season on Single Ventricle Patients featuring borderline left hearts with Peter Laussen, pre and post stage 1 management with Aparna Hoskote, CPR and ECMO in single ventricle patients with Ravi Thiagarajan, supporting the family and staff with Liz Crowe and residual lesions with Mike Seed. https://twitter.com/PedsIntensiva

Surviving COVID19 in NYC feat. Sam Parnia (intensivist at NYC Langone) & Liz Crowe (social worker & world-leading resilience expert). At the time of recording in April 2020, only Wuhan, Italy and NYC had sizeable COVID-19 epidemics. We knew it was going to be bad, but we weren't sure how we were going to cope. In this conversation we focussed on the personal characteristics that enable us to find meaning, draw on our resilience and to care for our patients and loved ones in such trying times.