The PicPod

ECMO: The ultimate end point of Paediatric Intensive Care. We discussed all things ECMO with Chris Harvey, who leads the UK’s only mobile ECMO service. He will cannulate a patient in the referring hospital, and transport back to his ECMO centre in Leicester.

What are the survival rates from ECMO? What are the survival rates of patients not accepted, either because they are too sick, or too well? What about E-CPR: which patients are eligible, and how common are they?

What are the thresholds for ECMO referral? How has the type of patients referred changed over time? What are the limits of ECMO acceptance? What is the survival from oncological ECMO?

Ethics is coming to ECMO: when can we say no, and to which patients? When is ECMO indicated in sepsis?

How can we compare ECMO statistics between units and countries? Can we do a randomised trial in ECMO? What are the main complications, and how are they mitigated?

What are the unanswered questions in ECMO? Is OI, or PIM scoring used in ECMO prioritisation? How do you stop ECMO? What is the longest ECMO run seen worldwide, and in the UK?

What about ECCO2R? Is it ECMO-lite, or does it not really solve the problems which these patients have?

Finally, from a standing start, how long would it take Chris to crash someone on to ECMO?

The PIVOTAL trial is the world’s first PIC specific Platform trial. It comes hot on the heels of some brilliant UK PIC research, like OxyPICU (PicPod77), and GASTRIC (not published yet, but will definitely have a PicPod soon!).

It’s a platform which aims to reduce the life cycle of PIC research from about 10 years from idea to publication, down towards one half, or one third. All UK PICUs have signed up to this.

We discuss the ethics, methodology, and statistics (spoiler alert: PicPod65 will help). We go through the aims, and hoped for end points. We discuss each of the three starting arms, (restrictive vs standard fluids, midazolam vs dexmedetomidine or clonidine, and various transfusion thresholds).

It’s a study of ambition and huge scope, with an aim of recruiting as many PIC admissions as possible.

For UK listeners it’s a must: for those in other countries it’s an example of how PICUs can work together to build a platform like this.

Enjoy!

We were able to have a short conversation with Dr Mohammed Abed, director of the only functioning PICU in Gaza, at the Al Nasser hospital in Khan Younis.

His dignity, pride, and incredible efforts in the face of a humanitarian catastrophe was incredibly humbling. He describes three cohorts of patients: a large amount of trauma, especially shrapnel injuries from bombs, patients admitted, and dying, of malnutrition, and recently a surge of flaccid paralysis patients, whose aetiology is unclear (but may be due to enterovirus D68 due to poor sanitation).

He is working without a blood gas machine, ultrasound, central lines, paediatric milk feeds, and even bandages.

His team is running 9 beds at the moment, for a population where about 50% is paediatric.

This was a very difficult conversation, hearing first hand about a situation which he described as catastrophic. Our thoughts are with everyone affected.

He has sent a list of equipment, supplies, and medications which are urgently needed. If you can help, please get in touch via our bluesky (@picpod.bsky.social) and X (@picpod_podcast) accounts.

The top urgent list is:

PicPod 88 is all about Pertussis in Paediatric Critical Care. Malignant Pertussis is, for intensivists, one of the most terrible conditions to treat, with a dearth of evidence, and but plenty of evidence of death.

For PicPod 88 we have spoken to James Cherry from UCLA. James Cherry is a medical institution. At 94 years old he is still going strong with an encyclopaedic knowledge of Paediatric Infectious Diseases, and is author of the seminal Feigin and Cherry’s Textbook of Pediatric Infectious Diseases.

First we hear of the history of pertussis vaccine, and the debate and controversy of “vaccine encephalopathy” in the 70s and 80s. We then discuss the pathophysiology of malignant pertussis: is the problem the white cells themselves, or is there another mechanism? What is the role of coinfection, either bacterial or viral?

We compare two papers: James Cherry’s paper from 2018, and the newly published 2025 UK paper from the 2024 outbreak in Archives of Disease in Childhood (conflict of interest alert ).

What is the role of exchange transfusion? What is a reasonable threshold to do this? Does it work? Can we say it works, or is it a correlation only? When should we do an exchange transfusion: is it a number, a clinical state, a trajectory, or all three?

Does vaccination work? What do the studies show on PICU admission, and PICU survival? Has Pertussis changed its phenotype in the past decades? Which antibodies are important, and in which ratio?

How do we address vaccine conspiracy theories, or can we actually get past them? What’s the future for Pertussis vaccines?

Pertussis comes around once every 3-10 years depending on vaccination rates. Be ready for the next one.

Links to sources:

Cherry et al: An Observational Study of Severe Pertussis in 100 Infants ≤120 Days of Age – PubMed

Calley et al: Characteristics and outcomes of children admitted to paediatric intensive care units with life-threatening pertussis infection in Great Britain 2023–2024 | Archives of Disease in Childhood

MAHA report: whitehouse.gov/wp-content/uploads/2025/05/MAHA-Report-The-White-House.pdf

We spoke to Juan Valle Ortiz from Newcastle, Consultant in Paediatric Intensive Care. He is involved in the PaNGEa project (www. pangeacambridge.co.uk), and is an ESPNIC ventilation instructor. He’s also a singer!

What is non invasive ventilation? Does it work? What are the thresholds for starting NIV? S/F ratios: are they useful in clinical practice? How do we know that NIV has been effective? How long do we have to assess benefit before mortality starts to rise? What are the reasons for NIV failure?

When can we deliver “extreme” NIV? Should we use NIV in sepsis or multi organ failure? What about asthma? What pressures are deliverable, and safe, through NIV? What are the highest pressures we have given non invasively?

Which ventilators do we use and which are our favourites? What is the most critical part of the non invasive ventilation apparatus? (hint: it’s the usual answer )

Why is invasive ventilation still prioritised over non invasive, culturally?

Finally, what courses are available in the UK?

And of course, the DO2 equation makes an appearance.

Major traumatic brain injury is a huge issue for Paediatric Intensive Care. We have machines for almost every organ: but the brain is on its own.

Shruti Agrawal, consultant in paediatric intensive care in Addenbrookes Hospital, Cambridge, is first author on the Starship study, recently published in the Lancet eClinical medicine.

We discussed this study with her. 135 children with severe traumatic brain injury were studied with over 17,000 hours of data analysed.

PRx: what is it, what does it mean, how do we derive it, and what implications does it have? What is the optimal cerebral perfusion pressure (CPPopt), what intracranial pressure should we be targeting, and how do we know what is best for the individual patient?

Does NIRS, or TCD have a role? Which of these are proxy measures, and at how many degrees of separation?

This is a really difficult area to treat, but high quality studies like this are really important to improve our knowledge.

And just for the record, the alpha is 0.05, not 0.5. Phew.

“Saving lives” is what we do. But at what cost? Are we threatening the survival of the world by our PIC practices? What’s the point of healthcare, if we are destroying the world’s future for those same children?

We talked to Heather Baid, an ICU nurse and lead for sustainability special interest group at the University of Brighton and Imogen Stringer, Head of Sustainability at Great Ormond St Hospital.

How much waste do we create on PIC? How much of this is necessary, and how much is actually excessive? How do we balance the demands of, for instance, infection control vs the use of plastic gloves?

Are solutions local, or global? This is a global issue, but are we just moving the problem away from us? Do parents actually care about the environment, when their child’s life is on the line?

What are the top tips to improve sustainability on your unit, tomorrow?

And, importantly, is a T Rex an SI unit? (weight, of course).

Nudge nudge…. a favourite of politicians and social commentators, but how can nudge technology help us in ventilation weaning? Lisa McIlmurray has been working on a pilot study of nudge technology attached to a ventilator. How does this help to move patients on?

What are the algorithms used in this technology? Are there unintended consequences? What is the user acceptability? How was the tool developed, and how was it improved to be worthwhile?

Alarms are annoyances which can distract from the patient, and therefore are often switched off. How is this different to an alarm, and how do we harness the interplay between machines and humans?

The future is coming. Listen about it now.

Change is hard….isn’t it? We spoke to Rebecca Lawton, a professor of Psychology from the University of Leeds, who is an expert in patient safety; behaviour change; improvement science; workforce engagement and wellbeing.

Why is change so difficult? Who is it most difficult for? And how do we convince individuals, and teams, to make changes? How do hierarchies interact with team changes?

The psychology of change is challenging, but we cannot progress with our practice without this. Is it harder to adopt a practice, or to remove them? And why does this matter?

And what do prehistoric cave dwellers have to do with this?

First, do no harm… How much of the things we do every day are worthwhile? We all do so many interventions, but are they actually worthwhile?

Some may be ineffective, some inefficient, and some may be harmful. But which is which? How do we find out whether we should, or shouldn’t do something?

What is an acceptable miss rate? What are the implications of getting this trending towards zero? Who will have our backs if something goes wrong, and how defensive should we be?

Benficience, and non malifience. Not two sides of the same coin: they are two ends of a seesaw.