The PicPod

Every day we go round the patients, making clear, robust plans so that the day works like clockwork. However, do you know how much of this information sticks with the team? It’s a shockingly low percentage (even JUST AFTER the plan has been made).

Listen to Lindsey who spoke at the 2023 PCCS conference in Edinburgh. She goes through the systems which are in place in her unit in Cincinnati, meaning that team knowledge has increased hugely. How does protocolising a ward round help? How do we listen (no, really, really listen) to our team? How are team members empowered to be a part of the process? Which metrics should we use to monitor ward rounds?

No ward round is perfect, but listen to Lindsey to hear how we can make them better.

She references two papers: links are here.

Improving Communication During Cardiac ICU Multidisciplinary Rounds Through Visual Display of Patient Daily Goals

Improvement in Multidisciplinary Provider Rounding (Surgical Rounds) in the Pediatric Cardiac ICU: An Application of Lean Methodology

In conjunction with the 2023 Paediatric Critical Care Society Conference in Edinburgh, we have interviewed Cathy MacDonald, one of the keynote speakers.

Cathy has had a long career as a police hostage and crisis negotiator. What can she teach us about crisis negotiation? What are the parallels between her world and ours? What are the strategies which can help us when conflict arises? What are the four dimensions of need?

Cathy’s a truly inspiring listen, honestly we could have listened to her for hours. Sadly we have cut it down to just under 44 minutes, but every one of those is worth listening to.

Enjoy: she’s the opening speaker to the conference, and worth listening to either on the way there, travelling back, or any other time.

This year’s Paediatric Critical Care Society conference in Edinburgh is a sell-out blockbuster.

We spoke to Chris Kidson, part of the organising committee, to go over some of the highlights.

These range from a hostage negotiator, talks about nutrition, debates on APRV, transfers to Norway, Scottish country dancing, and an early morning run.

Can’t wait!

In this episode of PicPod we speak to David Inwald, the Chief Investigator of the Pressure Study.

This landmark study is looking in to blood pressure targets, randomising critically ill children to normal care, or the 5th centile population blood pressure norm.

We discuss the study, its rationale, and what we might learn. Is a population blood pressure target reasonable, given the great variability in population norms? How do we choose a target? What are the comparators with other studies? What does the adult data show? How about cardiac output monitors, do they have a role?

Much to think about, and we await the results of this study with great interest.

How many times have we discussed fluid balance on a ward round? What is our fluid goal? And why?

Offloading fluid is a “good thing”, but why? And when?

What does the evidence say: what balance should we be aiming at, and when? Does the evidence actually give a message which can be summarised in one soundbite, or, surprise surprise, is it actually more complicated than that? Does the truism that more fluid = higher mortality actually hold up to scrutiny?

And what is fluid overload? Is this a definable metric, or does the evidence use an easy to calculate number, which isn’t what we should be talking about? What is the ROSE concept, and how can it help us?

How do haemodynamic monitors work, and what parameters are useful to us?

Again loads to think about, enjoy this episode!

Liz Whittaker, consultant in Infectious diseases at St Mary’s Hospital in London, talks to us about Group A Strep in children.

Over the past month or so the UK has had a huge surge in invasive Group A Streptococcal infection in children. Trainees up and down the country have rapidly been able to sign off their chest drain competencies, due to the huge amount of normally fit and well children presenting with empyema.

Is this year’s outbreak unusual? Why has it happened: is this a post COVID phenomenon, or something else? Which viruses are involved in making this infection more likely? Who should have flu vaccine, and why is there controversy about the nasal vaccine?

Why do patients react as they do, and how should we treat it? Which antibiotics? Should we give IVIG (here we go again….)? Should we give steroids, and in which situation?

Are there long term complications? Are we going to go back to the bad old days with rheumatic fever being a common condition, rather than something only suitable for textbooks and clinical exams?

What is the future for mask wearing: how much of this is rational, how much is cultural, and how much is simply polite?

And what is the frankly terrifying Zombie Bacteria Hypothesis?

Happy Christmas from the PicPod.

We all “know” of the clear respiratory support escalator: air, oxygen, CPAP, BiPAP, Invasive ventilation. But where does High Flow fit in? What parameters should we use to determine when and how to use it?

Ram from Imperial/St Mary’s in London led the two-armed First ABC trial, the largest and most robust trial in to High Flow vs CPAP. There were two arms: one for patients being admitted to PIC, and one for those post extubation.

Here Ram discusses the history of the trial, how it was designed, and how it worked. We discussed non inferiority designs, and the importance of displaying per protocol data as well as intention to treat. We dissect the results and debate what they actually mean.

Is CPAP about to be retired? Or is HFNC trying to do things it cannot?

Published simulatenously with his talk at the 2022 Leicester Paediatric Critical Care Society Conference.

Without statistics, studies are just words. We need some way of translating data in to messages. More and more we read about studies which are using the mysterious Bayesian approach.

How does this compare to the standard “frequentist” approach? What are the differences in data collection, analysis, messaging, and interpretation?

Bayesian studies allow a “head start” in data interpretation, and deliver a nuanced, complex message which allows us to be much better than the blunt and digital, arbitrary cut off of p<0.05 is true, p>0.05 is not true.

We discuss how it works, what it means, and how to deliver the results. With a little side helping of discussing the current publishing landscape.

Everyone has now heard of Cytokine Storms. It’s the thing with Covid: and why Covid was so severe in so many patients.

However, what is a cytokine storm? What are the “good” cytokines, and what are the “bad” ones? How do we differentiate, and what can we do about it?

And everyone’s favourite diagnosis of Haemophagocytic lymphohistiocytosis (HLH): how many forms are there, why are they different, and how do we treat this? Is HLH an independent diagnosis, or is it just super-sepsis? When should we use which treatment in what scenarios?

What about the Cytosorb modules: what is the evidence behind these therapies? What does the evidence show, and what are the caveats making adult ICU data difficult to interpret?

What are the most important numbers to track on your patients? What are the simple biomarkers we can use to prognosticate?

Our second podcast linked to the 2022 PCCS Conference in Leicester, September 2022, with Mike Farquhar, sleep consultant at Evelina Children’s Hospital, and Sapna Kudchadkar from Johns Hopkins.

This podcast went live at the time of Mike’s talk at the conference.

Take a walk around a paediatric intensive care unit. All the patients are lying, peacefully asleep. Except…. they are not asleep. They are sedated, experiencing fragmented and disturbed sleep.

We use this language all the time. We tell parents “we will keep your child asleep”, or “we will put them to sleep”. Neither of these are actually true.

What damage does prolonged fragmented sleep do? Which sedatives are worse than others for sleep? What can be done to improve sleep in our patients? What are the implications of prioritising sleep: and how do we get around the downsides?

What does the science say: is there research in to this, and are there proven benefits of improved sleep? And how much does Big Ben affect patients in Guy’s and St Thomas’s Hospital?