PICU Doc On Call

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.

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 3. Chiew AL, Buckley NA. Acetaminophen Poisoning. Crit Care Clin. 2021 Jul;37(3):543-561.

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.

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.

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:

1. Overview of Mean Arterial Pressure (MAP) and its clinical significance in pediatric critical care.
2. Introduction of a clinical case involving a 6-year-old child in septic shock.
3. Explanation of the formula for calculating MAP and its application to the clinical case.
4. Discussion of normal reference values for MAP in children and their clinical implications.
5. Physiological determinants of MAP, including cardiac output and systemic vascular resistance.
6. Role of the autonomic nervous system in regulating MAP through baroreceptor reflexes.
7. Importance of maintaining adequate MAP for organ perfusion, particularly in critically ill patients.
8. Clinical applications of MAP monitoring and management strategies in the PICU.
9. Summary of key takeaways regarding MAP calculation, physiological determinants, and clinical relevance.
10. Mention of related topics, such as invasive versus non-invasive blood pressure monitoring.

References:

1. DeMers D, Wachs D. Physiology, Mean Arterial Pressure. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
2. 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)
3. Berlin DA, Bakker J. Starling curves and central venous pressure. Crit Care. 2015 Feb 16;19(1):55.
4. Magder S. Volume and its relationship to cardiac output and venous return. Crit Care. 2016 Sep 10;20(1):271

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:

1. Clinical case discussion of a 4-year-old girl with severe anemia and bleeding symptoms
2. Diagnosis of von Willebrand disease (VWD) and its significance in pediatric critical care
3. Etiology and pathogenesis of von Willebrand disease
4. Classification of von Willebrand disease into types (Type 1, Type 2 with subtypes, Type 3)
5. Clinical manifestations and symptoms associated with VWD
6. Diagnostic approach for identifying von Willebrand disease, including laboratory tests
7. Management strategies for VWD, including desmopressin and von Willebrand factor concentrates
8. Role of adjunctive therapies such as antifibrinolytics and hormonal treatments
9. Importance of multidisciplinary collaboration in managing complex bleeding disorders
10. Overview of the pathophysiology of von Willebrand factor and its role in hemostasis

References:

1. Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.
2. Reference 1: Leebeek FW, Eikenboom JC. Von Willebrand's Disease. N Engl J Med. 2016 Nov 24;375(21):2067-2080.
3. Reference 2: Ng C, Motto DG, Di Paola J. Diagnostic approach to von Willebrand disease. Blood. 2015 Mar 26;125(13):2029-37.
4. 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.
5. 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.

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:

1. Clinical case of a 14-year-old male with hypertension and rectal bleeding.
2. Diagnosis of inflammatory bowel disease (IBD) following significant blood loss.
3. Approach to pediatric rectal bleeding and its implications.
4. Diagnostic workup including laboratory tests and imaging modalities.
5. Management strategies for IBD in acute pediatric care.
6. Importance of early recognition and resuscitation in cases of shock.
7. Physiological principles related to blood loss and shock in children.
8. Differential diagnoses for lower gastrointestinal bleeding in pediatrics.
9. Initial evaluation and stabilization protocols for pediatric patients.
10. Nutritional support and multidisciplinary care in managing IBD.

References:

1. 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.
2. Pai AK, Fox VL. Gastrointestinal bleeding and management. Pediatr Clin North Am. 2017;64(3):543-561.
3. Padilla BE, Moses W. Lower gastrointestinal bleeding and intussusception. Surg Clin North Am. 2017;97(1):63-80.
4. 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.
5. Ashton JJ, Ennis S, Beattie RM. Early-onset paediatric inflammatory bowel disease. Lancet Child Adolesc Health. 2017;1(2):147-158.
6. Bouhuys M, Lexmond WS, van Rheenen PF. Pediatric inflammatory bowel disease. Pediatrics. 2022;150(6):e2022059341.
7. Rosen MJ, Dhawan A, Saeed SA. Inflammatory bowel disease in children and adolescents. JAMA Pediatr. 2015;169(11):1053-1060.
8. Conrad MA, Rosh JR. Pediatric Inflammatory Bowel Disease. Pediatr Clin North Am. 2017 Jun;64(3):577-591.
9. 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.

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:

1. Pediatric hypoglycemia and its implications in infants
2. Case study of a 9-month-old infant with hypoglycemia and seizures
3. Physiology of glucose metabolism and its regulation
4. Causes of hypoglycemia, categorized into primary and secondary etiologies
5. Diagnostic approaches for identifying the cause of hypoglycemia
6. Initial management strategies for acute hypoglycemia
7. Long-term treatment options based on underlying causes
8. Importance of timely diagnosis and intervention in the PICU setting
9. Pharmacologic management of hyperinsulinemic hypoglycemia, including the use of diazoxide
10. Multidisciplinary care and follow-up for pediatric patients with hypoglycemia

1. Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 84 Alder M et al. Pediatric Sepsis. Pages 1293-1309
2. 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.
3. 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.
4. 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.
5. 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/
6. 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.
7. 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.

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.

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 1: Brodsky RA. Paroxysmal nocturnal hemoglobinuria. Blood. 2014 Oct 30;124(18):2804-11.
• 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.

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.