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.

Calum Semple is a respiratory and infectious disease professor in Liverpool. He has been part of the governmental advice team for pandemics since before COVID. We spoke to him in advance of his talk at the 2024 PCCS conference

What is the frequency of pandemics? Is the 1918 Spanish Flu pandemic the last “real” one, or do MARS, SERS, and H1N1 “count”?

What is a W shaped mortality, and why does this matter? Where will the next pandemic pathogen come from? What were the case fatality rates from previous pandemics?

We have heard of MPox: is this a problem?

How important are multi resistant bacteria, and of what relevance is chicken’s drinking water?

What can we do about all this? With novel vaccine technology (remember PicPod 52?), how long would it take to get a vaccine up and running? And then how do we convince the population to take the vaccine? Can we use social influencers and clinic patients?

How important are platform trials? How would digital NHS connectivity help? How useful is the COVID19 enquiry?

And when should we rebuild something which is broken?

Pandemics are not over. There will be more….

CORRECTION: At 12 minutes, Prof. Semple incorrectly refers to the film titled Children of God when he meant to refer to the film Children of Men ((Alfonso Cuarón, 2006).

Nicola Disma, an anaesthetist in Genoa, Italy, is lead author on the European Society of Anaesthesiology and Intensive Care guidelines on airway management in neonates and infants, published in full text here.

We discussed all things airway. Video laryngoscopes: useful, mandatory, or deskilling? “Normal” video blade or hyperangulated?

Oxygen during intubation: does it work, is it useful, how should this be done?

Nasal or oral tubes, what is the evidence, and what are the risks?

Cuffed or uncuffed tubes, what are the risks and benefits, and why would anyone choose an uncuffed tube?

What does it feel like to perform an emergency cricothyroidotomy, and exactly how many years has this aged Harish?

Is ECMO a viable option for airway emergencies?

How can we improve our team workings, and what is safety in these situations?

So many questions asked, some have answers, some don’t (yet). But great to share the knowledge and opinions of Nicola and his excellent research.