PICU Doc On Call

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.I'm Pradip Kamatand I'm Rahul Damania and we are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine.Welcome to our PICU Mini-Series Episode a 10 month old who is intubated for acute respiratory failure secondary to RSV bronchiolitis.Here's the case:A 10-month-old full-term infant girl old is intubated for acute respiratory failure secondary to RSV bronchiolitis. Patient was brought to the ED by parents on day 3 of her illness with h/o cough, congestion and worsening respiratory distress. She has had increasing WOB and grunting. After assessment in the ED where the patient had a brief trial of HFNC, she was intubated with a 4.0 ETT due to persistent hypoxemia. Pertinently, her viral panel was positive for RSV, and the patient was transferred to the PICU. In the PICU, patient was ventilated using PRVC: Set TV of 90cc (patient is 11KG), PEEP 6, PS 10, and FIO2 40%. Throughout her course, she was mechanically ventilated and sedated for about a week. She required a continuous infusion of rocuronium due to decreased lung compliance and high peak pressures. Patient weaned on her ventilator settings by ICU day 7 and the decision to move towards extubation was made.To summarize key elements from this case, this patient has:10 month old with acute respiratory failure secondary to RSV infection and with a secondary bacterial infection due to H.Influenza.Had about a six day course on the ventilator requiring sedation and NMBand now we are at the discussion of extubation readiness.Rahul, do you mind summarizing the patient's peri-extubation course?Sure Pradip, so on day 6 of hospitalization our patient was weaned to low mechanical ventilator settings. The chest radiograph, which initially showed evidence of interstitial pneumonitis and atelectasis now improved and the patient had improved secretion burden. The patient was on ceftriaxone throughout the hospital course as her ETT cx with which grew Hemophilus Influenzae.What about the patient's neurological status?The patient was initially on fentanyl, dexmedetomidine and a rocuronium infusion — a day prior to considering extubation, the patient was off of the continuous rocuronium infusion oxygenating and ventilating well. The patient prior to extubation was wide awake and appropriate during the morning sedation holiday.Any other important clinical markers?Yes, the patient's clinical exam including lung exam was reassuring. The patient underwent a pressure support trial PEEP 5, CPAP 10 and had a normal respiratory effort with exhaled of about 5 mL/kg. The RT, however mentioned that the patient did not have a "leak" when performing the leak test. The finally the patient was given a few doses of furosemide for diuresis prior to extubation.Awesome, today's episode we really want to focus on extubation readiness however prior to this discussion, can we take a step back and talk about some red-flag symptoms which led to intubation for this patient?This patient had severe respiratory distress which progressed to failure.The tachypnea, decreased mentation, and grunting were key signs that the patient was progressing to endotracheal intubation.Grunting is important to highlight as this refers to the child generating auto-PEEP to combat the atelectasis present in bronchiolitis.Remember that a child's chest wall has a high compliance and a decreased propensity for outward elastic recoil — this in essence reduces FRC and thus there is a more balance towards the inward recoil of the long (closing capacity). The highly compliant chest wall and the natural inward recoil of the infant lung creates a propensity towards atelectasis and subsequent impairments in breathing. Low FRC can also create increase PVR which can thus imbalance optimal cardiopulmonary interactions.OK let's transition to our topic of discussion by a quick summary:A 10 month old after 6 days of MV is now ready for extubation.Let's start with a short multiple choice question:In children deemed ready for extubation by clinicians, which of the following is most likely to be associated with reintubation?A) High breath by breath variabilityB) Failed Pressure Support trialC) Duration of mechanical ventilationD) No leak around the ETT prior to extubationCorrect answer is A. Pediatric extubation failure rate ranges from 2-20%. Although extubation failure is usually multifactorial, High respiratory variability during spontaneous breathing trials is independently associated with extubation failure in children.A recent paper by Kelby et al in CCM 2020-found that after controlling for confounding variables such as age and neurologic diagnosis, reported that both coefficient of variation of respiratory rate and decreased maximal change in airway pressure generated during airway occlusion had almost 3-fold higher risk of extubation failure. When this subset of children developed post-extubation upper airway obstruction, reintubation rates were greater than 30%.What about the other factors we had in our answer choices like the Pressure Support Trial?Children fail PS trial for variety of reasons including ETT size, sedation, to name a few. Khemani and colleagues (Intensive Care Med. 2016 Aug; 42(8):1214-22)reported that regardless of endotracheal tube size, pressure support during extubation readiness tests significantly underestimates post-extubation effort of breathing.Further, A 2009 paper by Newth et al (Pediatr Crit Care Med. 2009 Jan;10(1):1-11.) reported in systematic review of weaning and extubation for pediatric patients on mechanical ventilation, that extubation failure bore little relationship to the duration of MV.I think it is important to highlight that though we frequently perform PS trials, we should assess other factors such as primary reason for extubation being reversed, secretions, and even neuromuscular components - extubation does not just refer to lungs being ready to have less support!Yes Rahul, absolutely agree — I do want to mention A controversial topic has always been the utility of measuring a leak pressure around the ETT to predict upper airway obstruction. A study by Khemani et al (Am J Respir Crit care 2016 Jan 15;193(2):198-209) reported the risk factors independently associated with subglottic UAO, included low cuff leak volume or high preextubation leak pressure, poor sedation, and preexisting UAO (P < 0.04) for cuffed ETTs; and age (range, 1 mo to 5 yr) for uncuffed ETTs (P < 0.04). For uncuffed ETTs, the presence or absence of preextubation leak was not associated with subglottic UAO.Lets summarize - upper airway obstruction involves checking if there is flow (in the form of pressure) surrounding the ETT — key point younger patients (1 mo to 5 yr old) with uncuffed tubes have risk to develop UAO peri-extubation.An older study by Wratney et al (Pediatr Crit Care Med. 2008 Sep;9(5):490-6) had previously reported that an endotracheal tube air leak pressure >/=30 cm H2O measured in the non-nparalyzed patient before extubation or for the duration of mechanical ventilation was common and did not predict an increased risk for extubation failure. The authors in that study concluded that- Pediatric patients who are clinically identified as candidates for an extubation trial but do not have an endotracheal tube air leak may successfully tolerate removal of the endotracheal tube.This suggests that having a leak may not be necessary for a patient to successfully extubate.So Rahul for our listeners What are factors associated with extubation failure?Thats an excellent question. Factors correlated with an increased risk of extubation failure include a longer duration of sedative use, younger age, higher complexity of medical conditions, and diaphragmatic dysfunction. The most common reported cause of extubation failure in pediatric patients is upper-airway obstruction, with other causes that include respiratory insufficiency, muscular weakness, cardiac dysfunction, and neurologic impairment. Duration of MV, PRISM III score did not predict extubation in a multivariable analysis reported by Krasinkiewicz et al (Respiratory Care April 2021 Vol 66 No 4).Pradip, What are the main barriers to extubation in pediatrics?Thats an excellent question Rahul. One study published in Respiratory Care in` 2021 Vol 66 No 4) reported that in patients who had their passed the extubation readiness test, most common reason for holding off extubation was a planned procedure, neurologic diagnosis/status of the patient, and no leak around the ETT, other factors included high ventilator rates and over sedation, hemodynamic instability, fluid status etc.I think it is important for us to truly consider procedures or imaging which are planned to play a factor in our timeline for extubation readiness - this mitigates the risk for re-intubation - which is especially important in children with difficult airways! Rahul: how do majority of children's hospitals perform extubation readiness test prior to extubation?I think Pradip there is considerable variation in the methodology of ERT. Some common practices which I have noted as a fellow include: A daily spontaneous breathing trial performed probably early in the am (~4am) by the RTs. As long as patient didn't require any procedure (imaging or surgery), hemodynamically stable, patient spontaneously breathing, FIO2 < 50% (some use 40%), PEEP ≤ 6cm H2O, SPO2 > 92% and TV exhaled ~ 6-8cc/kg on PIP ≤25 cm H2O. These are the patients who we deem on minimal vent settings. The sedation is decreased or a propofol bridge is added followed by a switch to PS CPAP trial (PS 8-10cm H2O and CPAP of 5cm H2O) for at least 2 hours. It is also important to correlate PO status with timing of extubation especially if the patient does well with the SBT.After switching to PS/CPAP If patient has no hemodynamic issues, hypoxia, increased WOB and a normal blood gas, the patient's secretions are manageable, upper air reflexes are intact and neuromuscular function is sufficiently good to achieve an adequate vital capacity and maximum inspiratory pressure, GCS > 8—patient is considered a likely candidate for extubation. Most institutions will also check a leak around the ETT the night before. Some may decide to use a dose of decadron prior to extubation (although this is not supported by pediatric studies). Some extubate patient directly to room air, whereas others may use NIPPV such as CPAP or HFNC.Pradip, what are the signs of failure of ERT and what should be done in patients who fail their spontaneous breathing trial?Rahul, Signs of failure during ERT: include apnea, Exhaled TV < 5ml/kg, tachypnea for age, increased respiratory effort, desaturation below target SpO2 and unstable hemodynamics. Patients SBT can be repeated later in the day, sedation, fluid balance etc may require modification of optimization. The concept of sprinting -where the patient is subjected to SBT and allowed to remain on PS/CPAP for few hours everyday and which is subsequently increased is useful in those who are slow to wean off their ventilatory support.In essence this may optimize their neuromuscular strength.Can you comment on any objective indices used in pediatrics as predictors of successful extubation?Rahul two indices used to objectively predict success of extubation were the rapid shallow breathing index (RSBI) and the compliance, resistance, oxygenation, and pressure index (CROP index).A paper by Thiagarajan et al (Am J Respir Crit Care Med. 1999 Nov; 160(5 Pt 1):1562-6.) reported on 227 mechanically ventilated children.Extubation failures had higher RSBIs and lower CROP index values. A RSBI value of </= 8 breaths/ml/kg had a sensitivity of 74% and specificity of 74%, whereas a CROP value of >/= 0.15 ml/kg/breaths/min had a sensitivity of 83% and specificity of 53% for extubation success. IN contrast adult studies have shown that a CROP ≥ 13.5 ml/breat/min had a specificity of 91.9% and sensitivity of 87.9% in predicting extubation success.OK to summarize - high rapid shallow breathing index and poor compliance, resistance, oxygenation indices indicate negative predictors for successful extubationThats correct — for more detail, The RSBI is a ratio of spontaneous TV to RR (adjusted for age). the CROP index is the compliance, respiratory rate, oxygenation and pressure index. The CROP index (ml/ kg/breaths/min) was calculated using the formula: Cdyn × NIF × (PaO2 /PAO2 )/RR.Let's break this down:Cdyn - is a function of plateau - peep / TV.NIF measures conducting zone resistanceand the OI index involves patient gas as well as alveolar gas which brings into the FiO2 the patient is receiving.Rahul what is the role of respiratory muscle weakness in extubation outcomes?Khemani et al (Crit Care Med. 2017 Aug; 45(8):e798-e805.) used respiratory measurements using esophageal manometry and respiratory inductance plethysmography to assess respiratory muscle strength and predict respiratory extubation failure.The authors reported in their study that 35% of children had diminished respiratory muscle strength (aPiMax ≤ 30 cm H2O) at the time of extubation, and were nearly three times more likely to be reintubated than those with preserved strength (aPiMax > 30 cm H2O; 14% vs 5.5%; p = 0.006). aPiMax = maximum airway pressure during airway occlusion (aPiMax). the authors concluded that Neuromuscular weakness at the time of extubation was common in children and was independently associated with reintubation, particularly when post-extubation effort was high.To summarize Neuromuscular status is essential to assess peri extubation - this is especially true in patients with myopathies either stress, paralytic or steroid related or primary muscular dystrophies.Correct, also, More recently Glau et al (Pediatr Crit Care Med. 2020 Sep;21(9):e672-e678) reported Diaphragm atrophy is associated with prolonged post extubation noninvasive positive pressure ventilation in children with acute respiratory failure.Serial bedside diaphragm ultrasound may identify children at risk for prolonged noninvasive positive pressure ventilation use after extubation. However There was no difference in diaphragmatic parameters (atrophy rate, and peri-extubation diaphragmatic thickness in expiration and inspiration) in extubation success versus failure (Mistri S. et al. Pediatr Pulmonol. 2020 Dec;55(12):3457-3464).So Rahul to look at our case again, what about her metabolic alkalosis prior to extubation ?I generally correct metabolic alkalosis (when Sr HCO3 ≥30) using acetazolamide or chloride in form of K chloride. I also optimize Mag, Phos and Ca in any patient prior to extubation. I also optimize the nurtitional status with help of our PICU dietician as soon as a patient is intubated.To wrap up, Rahul, why should we extubate patients early?Great question: There is increased morbidity from prolonged mechanical ventilation: To name a few— VAP, pneumothorax, muscle weakness, atrophy of diaphragm, pressure sores, subglottic stenosis (can happen in less than a week of MV), unplanned extubation with cardiac arrest, and prolonged ICU length of stay. Additionally delirium and need for abstinence medications and rehabilitation.The SCCM's ICU liberation ABCDEF bundle recommends use of spontaneous breathing trials and spontaneous awakening trials to improve patients outcomes. PCCM providers should strive for early mobility, minimal sedation, focus on analgesia as well as push to liberate patient from MV as soon as safely possible.To highlight a key concept from today - extubation readiness is a coordinated effort in the PICU - it involves asessments from RTs nurses and as well as physicians and advanced care providers. Understand the primary etiology why the patient was intubated and whether or not that cause was reversed. Plan to complete imaging Or procedures within reason prior to activating the patient. Understand components such as sedation, neuromuscular weakness, and secretions to provide a holistic assessment on extubation readiness!Pradip - Are there any recent publications related to extubation success?Furhman and Zimmermans latest edition of the textbook of Pediatric Critical Care chapter 54 page 642A recent article by Krasinkiewicz et al in respiratory Care April 2021 Vol 66 no 4 has done a great job on extubation readiness practices and barriers to extubation in pediatric patients.This concludes our episode on Extubation Readiness We hope you found value in our short, case-based podcast. We welcome you to share your feedback, subscribe & place a review on our podcast! Please visit our website picudoconcall.org which showcases our episodes as well as our Doc on Call management cards. PICU Doc on Call is co-hosted by myself Dr. Rahul Damania and my cohost Dr Pradip Kamat. Stay tuned for our next episode! Thank you!

Welcome to PICU Doc On Call, a podcast dedicated to current and aspiring intensivists. My name is Pradip Kamatand my name is Rahul Damania and we come to you from Children's Healthcare of Atlanta Emory University School of Medicine. Today's episode is dedicated to optimizing your Pediatric Critical Care Knowledge and study skills by utilizing your medical librarian.We are delighted to be joined by Ms. Carrie Price a health Professions librarian. Carrie was formerly at the Welch Medical Library, serving the faculty, students and staff of Johns Hopkins Medical Institutions. Ms Price is currently at the Albert S. Cook Library of Towson University in Towson, Maryland.Ms Price is an expert searcher with a strong interest in user-centered and instructional design, evidence-based medicine, and inter-professional education.Ms Price also maintains and updates a YouTube Channel with videos about citation management, searching, and evidence-based medicine. Carrie is on twitter @carrieprice78Q1. Carrie welcome to PICU DOC on Call Podcast. Our topic today— Value of the librarian in PedsICU education and it is one of the first in our series of how learners can organize their study habits while rotating in the PEDS ICU.Carrie: Thanks Rahul and Pradip for having me on PICU DOC on Call podcast. I have no conflicts of interest or financial disclosures.Q2. Carrie tell us your story and how you came to be an expert medical librarian ?Carrie: I came into librarianship as a second career, after a first career in nonprofit development. I was fortunate to start my work in libraries at Johns Hopkins University, where I worked as a library assistant in access services while getting my masters degree in library science. During this time my mom was diagnosed with appendix cancer, a rare cancer, (she's okay now), and through the time we spent together in the hospital, I noticed there was a medical library in the building. I had this epiphany that librarians weren't limited by traditional career paths. From then I started focusing on health and consumer health classes. Later, at a work all-staff meeting, I literally bumped into the former director of the Welch Medical Library, and the rest is history! I applied for an open position, was hired, and started working at the Welch Medical Library in 2012. It has been an incredible experience. I am fortunate to work extensively with a number of departments and divisions at Johns Hopkins and now at Towson University, so my experiences have been really multidisciplinary. In the past I worked as a physical therapy technician, which was awesome and helped inform the knowledge I brought to the profession. I've taken a lot of professional development in the field. I just never stop learning, and I love sharing information on Twitter, YouTube, and on my website, which is carrieprice78.github.io.This is such an amazing story!Q3: Carrie the practice of critical care medicine requires that learners in the Peds ICU remain current in their knowledge of the literature. Given an overwhelming amount of information out there how should these learners drink from that fire hydrant without being blown away?Carrie: I think that's an excellent question. Prior to the arrival of internet, most additional knowledge was acquired from physically going to a library and perusing through peer reviewed journals and textbooks. Now, things are digital and even "born-digital" — and there is so much information available online and on your phone.... I understand that given how much information is out there, a learner can feel overwhelmed and have difficulty trusting the information they see. That's why critical appraisal is a key part of evidence-based practice. Studies have shown the value of readily-available information in patient care and have highlighted the role of the library and librarian in support of clinical practice.In 1996 Sackett et al (BMJ 1996). defined evidence based medicine (EBM) as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient." It's come to be seen as a combination of sound research evidence, clinical expertise, and patient preference. While the Accreditation Council for Graduate Medical Education (ACGME) requires peds residents to have formal training in EBM, there is considerable variation in what constitutes EBM training. This is where learners can pull from the expertise of medical librarians, who are experts in searching and evaluating literature. I suggest reaching out to your medical librarian right away. They can help you set up search alerts for topics of interest and journal tables of contents from PubMed and other resources. There are also apps, there is an app called QxMD that can help you be more aware of current literature in fields you follow. There's another app called Browzine, which you may have access to through your institution, where you can subscribe to journal table of contents. You can also find clinical, evidence-based, frequently-updated summaries with tools like UpToDate and DynaMed, depending on what you have through your institution.Having comprehensive resources such as UpToDate and Dynamed can help you curtail individual studies into a concise review!Q4. Carrie: now that you brought out the concept of Evidence-Based Medicine, what are some of the appropriate venues for teaching evidence based prospects in the Peds ICU environment?Almost all pediatric critical care medicine fellowships have a fellow conferences where learners have "protected time" for their education. Fellows conferences can have journal clubs, lectures, chapter reviews and case reports. Fellows conference could be one of the best venues for teaching EBM, where faculty and learners can interact. I think EBM practices should be a part of the peer-peer sign out after a call or service, or morning report. Programs can invite librarians to attend meetings, or seek help of a librarian while preparing for presentations. I also want to emphasize that with daily patient care rounds in the PICU — most fellows should question practices on rounds, which are handed down from previous trainees but don't always have sound evidence behind the practice, or some new research may have changed practice or knowledge. You can reach out to your librarian with these kinds of queries. Librarians can also help with PICO question formulation, searching for and appraising the evidence, and translating evidence into practice—all critical aspects of EBM.As trainees we are always wanting to optimize our clinical skills and understanding by asking the Why, the How, and the Why Not behind certain clinical scenarios in children! Asking these PICO questions, which stands for isolating the Population, Intervention, Comparison, and Outcome can help us ascertain key clinical questions which come up in our training!Q5. Carrie: How are librarians utilized by the pediatric residency programs ?There is an excellent study by Boykan and Jacobson (2017) which evaluated this exact question by surveying ~ 91 Program Directors of Pediatric Residency Programs in the US.In their study, Boykan and Jacobson reported that 80% of programs utilized medical librarians. Most of these librarians assisted with scholarly or research projects (74%), addressed clinical questions (62%), and taught on any topic — not necessarily EBM (58%) — it might be something like citation management or workflow tools. Only 17% of program directors stated that librarians were involved in teaching EBM on a regular basis. Size of the program mattered the most when it came to the use of librarians. Smaller programs (≤29 residents) were more likely to utilize librarians (100%) than were medium (30-59 residents) (71%) or large programs (>60 residents) (75%). The authors concluded that while most pediatric residency programs have an EBM curriculum and engage medical librarians in various ways, librarians’ expertise in teaching EBM is underutilized. It is important to stress that regardless of the program size, the cost of utilizing librarians did not appear to be a barrier.Q6. Carrie: How can librarians help the Peds ICU fellow and other learners in the PICU with respect to clinical practice?In the clinical practice arena with the PICU: As librarians, understand the Peds ICU fellow and other learners, especially in their first year of training, will be very busy from the get go. The peds ICU fellow and other learners, such as the advance practice nurses, serve the role of team leaders within the picu: managing residents, medical students, and the clinical care team, and report to their PICU attending. Some programs are very busy and leave very little time to adequately prepare for gathering the evidence necessary for making informed clinical decisions. Research has shown that when clinical librarians are involved in providing information in the patient care setting, answers to clinical questions can be obtained more quickly and efficiently. (McGowan et al Plos One 2008; Oliver et al. J Med Libr Ass 2011). The Value Study by Marshall et al. noted that clinicians who had used their librarian had changed patient care based on the information they received. This was spread across patient education, diagnosis and differential diagnosis, choice of medication, and... overall they felt that they had made more informed clinical decisions because they were able to receive timely, high-quality information. Your librarian can efficiently and effectively search for evidence, which can be quickly appraised and put to use by busy Peds ICU fellows or others. Librarians can provide information for fellows/faculty during morning reports, grand rounds, committees, morbidity and mortality conferences, and more. One case controlled study has (Banks DE, Shi R, Timm DF, et al. J Med Libr Assoc. 2007;95(4):381-387) demonstrated that librarian support was associated with saved resources and reduced costs beyond a health practitioner’s time savings; a librarian’s presence at morning report correlated positively with shorter length of stays and lower hospital charges in 55 cases with 136 matched comparisons.This is such a key point, leveraging your instutitions libarian can serve to be a bimodal learning process! As both trainee and librarian collaborate learning can be optimized and this can ultimately affect patient outcome!Q7. Carrie: How can librarians help the Peds ICU fellow and other learners in the PICU with respect to research and their scholarly activities?At most institutions, Librarians and library professionals choose what resources and databases to buy: they negotiate prices; ensure that electronic resource vendors have the information they need to provide access; ensure remote access through proxy servers; organize the information on digital portals and guides; build interfaces and education to facilitate searching; and collect and analyze usage data to validate use of institutional resources.Most PedsICU fellows require some scholarly activity (research/publication) during their fellowship. Besides talking early on with the statistician, Peds ICU fellows and learners could really benefit talking to a librarian about their research question prior to initiation of the research project. Medical librarians are your research partner! A 2015 publication by Rethlefsen et al. showed that librarian involvement on systematic reviews in general internal medicine correlated with higher quality reported searches. Additionally,y our librarian can update you with new references from your literature search, and over time, help you understand your research impact. And like I said, they can help you set up alerts and understand what's out there and how the literature is trending in your areas of interest. The librarians can help with organizing references needed for the project. If a full text article is not available, the librarians can help you obtain it through inter-library loan. Librarians are invaluable to decreasing the stress of fellow/learner embarding on a research project.Q8. Carrie: Do you see a role for the healthcare librarian in patient safety and quality initiatives?Yes! Many institutions will also have fellows on a committee or two within the PICU based on their interests such as the airway safety committee, vascular access committee etc. Librarians have an increasing role in providing patient- and family-centered information and can help the fellows acquire the latest information and evidence, which may be necessary to update protocol or guidelines commonly used in the PICU. Fellows and learners should approach librarians when faced with the task of updating a previous protocol, guidelines, standard of care, algorithm or best practice documents used in their PICUs to get the best and the latest available evidence.Q9 Ms Price: whats your advice to the fellows with respect to online databases use to access medical information:I think fellowship programs should invite their librarian to speak to the fellows and the PICU team to inform the learners of what resources their institutional library provides. Most libraries, especially in the healthcare setting, have a number of resources free and easily accessible, with access to content that you wouldn't have otherwise. The most commonly utilized is the free resource PubMed, from the U.S. National Library of Medicine. It's considered one of the premier databases for health and biomedical literature, containing over 32 million records. It does not include full text journal articles; however, links to the full text are often present when available from other sources, either through your university or institution, or through the publisher's website or PubMed Central. Your institutional library will have its own collections of journals and databases provided to you free of charge. Even Google Scholar can be helpful for finding hard-to-locate articles and interfacing with citation management tools. I should also mention that good collection of the latest articles from the Peds ICU literature is provided by Dr. Hari Krishnan at picujournalwatch.com.Q10. Carrie what are some good resources to store articles, citations for future use? (Carrie please add/delete stuff as you want)..There are a lot of good resources for storing references collectively called reference or citation management software: there are Zotero, Mendeley, EndNote, and actually a lot more. They all kind of compete with each other so they're all pretty good, and the ones I just mentioned are either completely free or have free versions. Most reference management software programs have the same functions: importing references, organizing, storing, and creating citations and bibliographies in a manuscript. These can be a huge time saver for the busy pedsICU fellow — and your librarian can help you get set up and get started with the tool you select. Personal preferences, type of operating software used, and pricing may factor in choice of reference management software. I cant stress enough to save your work, hopefully to the cloud, for ready access anywhere, but also in case there is a malfunction or loss of your device. Another great tool — not a citation management tool, but one that everyone who has published or hopes to publish should sign up for is ORCID. ORCID is open researcher and contributor ID. It's a free researcher profile system that is increasingly being used and even required for grant applications and article submissions. This researcher profile system can help you save all your research products in one place, update your CV, speed up the process of creating your Biosketch or applying for grants, and help disambiguate you from other researchers. You can check it out at orcid.org.OK to summarize, have a reference manager which can quickly capture and organize key articles — as you delve into your research project utilize this reference manager and their respective integrations to streamline your manuscript process!Q11 Carrie we appreciate your insights on today's podcasts, as we wrap up, would you mind highlighting your personal clinical pearls?I think I would say that the medical librarian is your friend. Set up a meeting with them early on in your fellowship. Make use of this invaluable resource for not only to improve on your clinical work, patient outcomes, and decreasing costs but also for research, systematic and scoping reviews, quality and safety initiatives within the PICU. We can save you time doing literature searches, getting you the latest and best evidence, helping you organize citations, requesting the reference/article you need for that case report or lecture presentation, even finding Creative Commons medical images for use in posters and presentations. We can be there at the point of need, at morning report, journal clubs, department meetings, and we can help faculty with creation of medical education and EBM instructional materials. Librarians should be included in development of educational curriculums, written into grants, considered co-authors as a part of an author research team, and included in-class teaching for PICU fellow conferences. Faculty can and should coordinate with medical librarians for optimal training of the peds ICU fellows and other learners.To summarize today's episode...We learnt today the immense value, which the medical librarians bring to the learning environment of the Peds ICU. Medical librarian Carrie Prices would like to see more involvement of medical librarians in the development and maintenance of PedsICU learning curriculum. A collaborative approach between the librarians, faculty, fellows and other allied health personnel my be a win win for all including the patients and their families.This concludes our episode today on Value of the Librarian in PedsICU Education. We hope you found value in this short podcast. We welcome you to share your feedback & place a review on our podcast. PICU Doc on Call is co-hosted by me Pradip Kamat and my cohost Dr. Rahul Damania. Please visit our website picudoconcall.orgStay tuned for our next episode! Thank youReferences:Quesenberry, A. C., Oelschlegel, S., Earl, M., Leonard, K., & Vaughn, C. J. (2016). The impact of library resources and services on the scholarly activity of medical faculty and residents. Medical Reference Services Quarterly, 35(3), 259-265.Rethlefsen, M. L., Farrell, A. M., Osterhaus Trzasko, L. C., & Brigham, T. J. (2015). Librarian co-authors correlated with higher quality reported search strategies in general internal medicine systematic reviews. Journal of clinical epidemiology, 68(6), 617–626. https://doi.org/10.1016/j.jclinepi.2014.11.025Sollenberger, J. F., & Holloway, R. G. (2013). The evolving role and value of libraries and librarians in health care. JAMA, 310(12), 1231-1232.Boykan, R., & Jacobson, R. M. (2017). The role of librarians in teaching evidence-based medicine to pediatric residents: a survey of pediatric residency program directors. Journal of the Medical Library Association : JMLA, 105(4), 355–360. https://doi.org/10.5195/jmla.2017.178Ullah, M., & Ameen, K. (2019). Teaching information literacy skills to medical...

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A 12-year-old girl presents to the PICU with symptoms like chest discomfort, tremor, and fever, leading to a diagnosis of thyroid storm. Key history features include high fevers and altered mental status. The podcast delves into the diagnostic process, red flag symptoms, and management strategies for thyroid storm, emphasizing the importance of thorough assessment and collaboration with medical specialists.

We've got an exciting new series for the show and we can't wait to share with you our PICU Doc On Call Mini Case Series. Coming this weekend!

Today's episode is dedicated to Critical Illness In Children With Hematopoietic Stem Cell Transplants.We are delighted to be joined by Dr. Muna Qayed, Associate Professor of Pediatrics Emory University School of Medicine , Atlanta, GA. She is also the Director of the Blood and Marrow Transplant Program at the Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta.Our Case: A 10 year old female with refractory high-risk ALL s/p mismatched unrelated donor transplantation T+13 days presents as a transfer to the PICU with abdominal distention, worsening jaundice, and escalating nasal cannula requirements. The patient's post-transplant course was complicated by gram-negative bacteremia requiring fluid resuscitation. A CXR upon transfer to the PICU is notable for bilateral airspace disease, a right sided pleural effusion, and hypoexpanded lung fields. The patient is promptly intubated, sedated and started on renal replacement therapy. Echo labs, and further imaging are pending.What are the classic pediatric indications for BMT?Autologous BMT (where donor cells are from the patient/recipient) is used as consolidation in some solid tumors such as High risk neuroblastoma, brain tumors like medulloblastoma, and germ cell tumors, and are a standard treatment approach in relapsed Hodgkin lymphomaAllogeneic BMT-where in the donor cells are derived from another individual are typically used for hematologic malignancies. ALL and AML are most common pediatric indications.Also allogeneic BMT are used for wide spectrum of nonmalignant hematology conditions such as hemoglobinopathies ( Sickle cell disease, Thalassemia), and severe aplastic anemia, and inherited bone marrow failure syndromes, as well as some metabolic disorders and immune-deficiency disorders such as SCID, HLH and other primary immune regulatory disorders.The sources of graft in BMT?Stem cells (which give rise to different types of blood cells - red cells, white cells and platelets are derived from the bone marrow. Thus the overall process is known as Bone Marrow Transplantation.Stem cells can be also derived from peripheral blood - when the donor is treated with granulocyte colony stimulating factor or G-CSF.There are some key advantages here, which include the ability to collect a much higher stem cell dose, with faster hematopoietic recovery.However the downside is a higher T cell content of the graft with subsequent increased risk of graft versus host disease.Umbilical cord blood is also used as a source of stem cells.Mega doses of stem cells are used to overcome histocompatibility barriers of mismatched transplantation. Majority of T cells have to be removed from donor pool to prevent severe GVHD., Increase risk of infection and relapse of patients original disease.Explain the human leucocyte antigen (HLA) and its role in BMT?The Major Histocompatibility complex (MHC) system known as the human leukocyte antigen (HLA) in humans is located on the short arm of chromosome 6 and contains the most polymorphic gene cluster of the entire human genome.The HLA consists of regions designated as "classes". Class I and class II are relevant to stem cell transplant.The main function of HLA class I gene products (HLA-A, -B, and -C) is to present endogenous peptides to responding CD8+ T Cells, HLA class I antigens are expressed on all nucleated cells and platelets.While the class II coded molecules HLA-DR, -DP, and –DQ have restricted expression and process exogenous peptides for presentation to CD4+ helper T Cells, and are expressed on antigen presenting cells. HLA-A, HLA-B, HLA-C and HLA-DR are traditionally the loci critical for matching for stem cell donor.In addition to deciding on the source of the graft, we have to make decisions on who the donor will be. If a matched sibling donor is not available (or in some inherited conditions that may not be an option as a donor), then matched unrelated donors or matched cord blood units of appropriate size can provide a good option to proceed.Then come considerations of mismatched unrelated donors, and haplo-identical related donors.The type of donor and degree of match dictates the type of GVHD prophylaxis we will use and further immunosuppression.

Dr. Michael Wolf, PICU specialist, discusses an unstable neonate case. Highlights include diagnosing an acutely ill newborn, managing neonatal shock, assessing congenital heart disease, and stabilizing neonates in the PICU. Topics cover initial investigations, considerations for neonatal airway dynamics, and prostaglandin use in duct-dependent heart conditions.

Today’s episode is dedicated to venous/arterial thrombi, also known as catheter directed thrombolysis.We are delighted to be joined by Dr. Anne E. Gill, Assistant Professor of Radiology and Imaging Sciences at Emory University School of Medicine. She is a pediatric interventional radiologist at Children’s Healthcare of Atlanta. Her areas of expertise include pediatric thromboembolic disease, vascular malformations, enteric feeding tube access, and interventional oncology. Dr. Gill is on Twitter @AnneGillMD. Show Highlights:Our case, symptoms, and diagnosis: A 17-year old girl with antithrombin III deficiency presented with bilateral leg pain to an outside ED. Duplex ultrasound of the bilateral lower extremities revealed extensive acute bilateral deep vein thrombosis. A CT scan of the abdomen and pelvis showed an extensive occlusive clot in the inferior vena cava involving the infrarenal and suprarenal IVC. She was transferred to our hospital and admitted to the ICU for thrombolysis and initiation of catheter-directed TPA infusion. In interventional radiology, an IVC filter was placed in the suprarenal IVC; additionally, the venogram in IR showed complete thrombosis of the right upper femoral, external iliac, common iliac, and IVC, with collateral veins in the right lower extremity draining into the thrombosed upper femoral vein. Interventional radiology performed pharmacomechanical thrombolysis and balloon angioplasty of right external iliac, common iliac, and IVC and placed infusion catheter to drip tPA from right femoral vein to the IVC filter. The patient was also placed on continuous heparin drip for systemic anticoagulation management. Morphine and Dexmedetomidine were used for pain management.The overall prevalence of systemic venous occlusion in children is difficult to ascertain due to their asymptomatic quality.Congenital SVOs in children can be due to developmental hypoplasia or agenesis of major conducting veins; they can happen in utero or manifest as neonatal thrombosis. Acquired causes of SVOs can include catheter acquired obstruction, hypercoagulability/thrombophilia, mechanical obstruction, and trauma.A careful history is necessary to determine whether the occlusion was a congenital or acquired SVO.This is challenging because symptoms of venous obstruction in children may not present until later in life.This distinction is important as it affects the procedures that can be done.Better outcomes are possible if a native pathway is present, even if it’s diminished from chronic obstruction and scarring. Clinical presentations of systemic venous occlusions in children include head and neck swelling coupled with shortness of breath. In patients with acute DVT, venous congestion can manifest as prolonged capillary refill, coolness of extremities, and bluish discoloration to frank venous ischemia with loss of pulses. Chronic DVT in extremities can present with a sense of heaviness, aching pain, and fatigue with activity; these symptoms are collectively described as post-thrombotic syndrome.Remember that obstruction to flow can compromise oxygen delivery!Common causes of venous occlusions are mal-positioned or wrongly sized central venous catheters, May-Turner syndrome, and long-standing central venous access lines in dialysis patients. CDT is not recommended for DVTs below the inguinal ligament, based on the ATTRACT trial in 2017 that showed that CDT is most beneficial in veins above the inguinal ligament.Contraindications for CDT in children include allergy to tPA, active bleeding, surgery within the last 14 days, any invasive procedures in the last three days, recent seizures, recent trauma, or coagulopathy which can’t be easily corrected. Caution is needed with premature infants and those with HTN or other risk factors for bleeding. Diagnostics needed prior to consulting on a patient with venous occlusion include Doppler US, CT or MRI to visualize central vessels, cone-beam CT (CBCT), and hematology consult.General principles of venous recanalization for acute venous occlusion:Acute venous occlusions are typically related to acute thromboembolism.Intravascular ultrasound (IVUS) is a valuable tool.CDT with a catheter dripping tPA overnight.Balloon angioplasty followed by systemic anticoagulation.Treatment options for chronic venous occlusions range from endovascular angioplasty and stenting to surgical bypass grafts or prosthetic graft reconstruction. Endovascular techniques are more widely accepted in pediatrics.Post-procedure patients in the PICU should have neurological monitoring and pain management, along with careful monitoring of the heparin infusion and tPA management. Worsening conditions may point to surgical interventions. Dr. Gill explains the protocol developed for heparin and tPA dosage and monitoring.Precautions needed by the PICU doctor for patients getting tPA and heparin include no arterial sticks, intramuscular injections, rectal temperatures, catheters, NSAIDs, or other platelet drugs. The key is a collaborative approach between interventional radiology, anesthesia, and hematology.Once the IR physician is satisfied with clot removal and blood flow in the previously occluded vessel, a decision is made to stop the tPA infusion.IR also provides other services like chest tube, PICC line, and GT placements, lumbar punctures, biopsies of liver/kidneys, and thermal ablation of solid tumors or painful bony metastases.Takeaway clinical pearls include the collaborative team of anesthesia, hematology, PICU, and IR for optimal outcomes. IR should be called early and often. Labs should be followed closely, especially Fibrinogen, platelets, and hemoglobin/hematocrit. 

Today’s episode is dedicated to the differentiation and management of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)We are delighted to be joined by Dr. Eric Felner. Dr. Felner is a Professor of Pediatrics/Pediatric Endocrinology at the Emory University School of Medicine and is an Adjunct Professor of Chemical and Biomedical Engineering at Georgia Tech.Show Highlights:Our case, symptoms, and diagnosis: A 15-year-old male presents with a one-week history of increased urination. He is otherwise healthy except for a viral URI last week. He is found to be disoriented and tachycardic, with an exam notable for delayed peripheral capillary refill and cool extremities. The patient has deep, labored respirations upon examination, and labs confirm hyperglycemia with a serum glucose of 850, mild acidosis, and 2+ ketones. His CPK level is elevated, and a crystalloid fluid bolus is started. Hyperosmolar hyperglycemic state is defined as a serum glucose greater than 600 mg/dL, serum osmolality of 330 mOsm/kg, and the absence of ketosis and acidosis.The key difference between HHS and DKA is that DKA is characterized by the presence of ketones in the blood and acidosis, but HHS means these are completely absent.Even though DKA and HHS are similar, their management strategies have their own nuances.In DKA, the lack of insulin leads to management strategies, while HHS is marked by complete dehydration and excessive urination. Factors that point to HHS will be a very overweight child, family history, and ethnicity; Type-2 diabetes is much more common in African-American, Latin-American, and Native-American children, while Type-1 is more common in Caucasians. Specific labs for patients with suspected DKA or HHS include a comprehensive metabolic panel (CMP), blood gas, and CPK for HHS.For both conditions, management strategies focus on insulin and fluid administration, but there are key differentiations:DKA is managed using the triple bag therapy that was pioneered by Dr. Felner.There is a risk for cerebral edema with administering fluid.The most important data relating to fluid administration with regard to neurological outcomes is what we have learned in calculating fluids with the “2x maintenance formula” to guard against mistakes that could result in cerebral edema.Key considerations regarding low-dose vs. standard-dose insulin therapy revolve around the weight and age of the pediatric patient.For HHS, the key is to manage fluids and give insulin; for Type-1 diabetics, the key is to eliminate acidosis.Key PICU management pearls in minimizing cerebral edema risks are to determine the level of sickness by the PCO2 level, high BUN, and by not giving bicarbonate. Remember that children under age 5 have a higher risk for cerebral edema.In the management of both DKA and HHS, remember that it comes down to how sick a patient is and not necessarily following the numbers. In general pediatrics, managing a sick DKA patient means giving an IV, administer fluids, and call a specialist management team right away.Dr. Felner discusses the association between COVID-19 and Type 1 diabetes based on his experience. As intensivists and endocrinology teams work together to transition patients to an intermittent insulin regimen, it’s important to remember how to convert from IV insulin to subQ insulin. Takeaway clinical pearls include the key diagnostic elements between DKA and HHS. In HHS, patients will have higher glucose levels, milder acidosis, mild ketosis, and increased dehydration. Both conditions will have insulin and fluid management, and HHS patients may require increased fluid resuscitation.  

Today, we welcome Dr. Stella Shin, Assistant Professor of Pediatrics-Pediatric Nephrology at The Emory University School of Medicine. Dr Shin is also the Director of General Pediatric Nephrology and the Director of Acute Kidney Replacement Therapy at The Children's Healthcare of Atlanta in Atlanta, GA. Her interests include nephrotoxic medication stewardship, health informatics and healthcare quality improvement. She is on twitter @BabyBeanDocA 17 year old previously healthy thinly built male teenager is brought to the emergency department for sudden development of blurred vision. Patient has a h/o headaches for the last few months accompanied by abdominal pain and relieved by vomiting. He has also felt his heart racing during such episodes and accompanied by profuse sweating. Patient had tried various over the counter pain medications without much improvement in his headaches or abdominal pain. An initial CT scan of the head reveled no intracranial pathology. ED physician noted a a blood pressure of 200/120 mm HG and a pulse of 132beats/minute. He is started on nicardipine in the ICU.Definitions for normal and high blood pressure come from the AAP clinical practice guidelines for screening and management of high blood pressure. According to these guidelines:Normal BP is a blood pressure reading that is < 90%ile for children 1-12 yrs of age: A normal BP for teenagers 13 years and older = <120/<80.High blood pressure is divided into three categories: Elevated BP, Stage 1 HTN, and Stage 2 HTN. This is further delineated into categories for children 1-12 yo and 13 or older.For children 1-12 yo:Elevated BP is a BP that is >/= 90%ile but <95%ile, or a BP of 120/80 up to <95%ile, whichever is lower.Stage 1 HTN is a BP that is ≥95%ile to <95%ile+12 mmHg, or a BP of 130/80 to 139/89, whichever is lower.Stage 2 HTN is a BP that is ≥95%ile+12 mmHg, or a BP that is ≥140/90, whichever is lower.It's much more simple for children 13 and older:Elevated BP is 120/<80 to 129/<80Stage 1 HTN is 130/80 to 139/89Stage 2 HTN is >/= 140/90That's a lot of numbers and cut offs to remember. To make it easy, in general, hypertension in children and adolescents is defined as a sustained systolic and/or diastolic blood pressure elevation ≥ 95%ile for age, gender, and height. And adult BP cut offs are used for teenagers 13 years or older.Acute severe hypertension is defined as significant blood pressure elevation with or without of acute target-organ damage from the hypertension.This is further classified based on target organ involvement into hypertensive urgency and hypertensive emergency. The key difference between the two is whether target organ injury is present.Hypertensive Urgency is acute severe hypertension WITHOUT acute target-organ damage. Hypertensive urgency is not associated with adverse short-term outcomes and can be managed in the ambulatory setting.Hypertensive Emergency is acute severe hypertension that is accompanied by acute target-organ injury. It is a medical emergency with substantial morbidity and mortality requiring immediate treatment in an ICU.It is important to note for our listeners that acute sever hypertension is on a spectrum with hypertensive urgency and emergency, and these diagnoses exist on a spectrum!Our discussion focused on acute severe hypertension, which is a medical emergency especially when there is target organ injury. A titratable infusion of an antihypertensive such as nicardipine should be the first line to lower the BP by 25% in first 8 hours as precipitous drop may cause cerebral ischemia. While there are multiple IV antihypertensives, the pediatric critical care team should be should be aware of the pharmacology and relevant side effects of these agents in efforts to choose the best drug for the patients condition. Early consultation with nephrology is warranted in these patients along with monitoring of end organ function.