The PicPod

It’s one of the miracles of medicine that we are able to help patients in need of new organs, and it’s one of the miracles of humanity that about to be bereaved parents have the generosity to donate their child’s organs.

But the process only works if we can keep the patient stable and physiologically functional until the organ retrieval operation.

So how do we do this? How do we maintain blood pressure? Which inotrope should we use? What about other interventions? Thyroid axis? Steroids? Insulin? Temperature? Anything else? And is the practice in this field based on dogma, history, or (shock!) actual hard evidence?

And what interventions are acceptable for these patients?

It is our duty to do our best for these patients so that the parents’ wishes are fulfilled. Enjoy!

The seriously low-tone baby is a heartsink diagnosis for intensivists. Knowing that this perfect looking baby is looking at a lifetime of severe disability, with full consciousness, is such a difficult journey for the patient, the parents, and the whole team around them.

However, in the past few years some treatments have been launched for Spinal Muscular Atrophy. Here we discuss the pathophysiology and the history of treatment for SMA, and the evidence behind Nusinersan and Zolgensma, the two primary candidates for treatment.

Both are phenomenally expensive. The evidence behind them is not overly strong. But what are the effects of the treatments, and how much of an effect is useful for the patient?

Is long term ventilation suitable for patients with SMA? Where are the limits of support in such complex lifelong conditions? Why do these drugs cost so much? Should we give them?

Lots to chew over. Life is analogue, decisions are digital.

During the COVID-19 pandemic, many PICUs took adult patients. Although initially taking “older adolescents” was planned, it rapidly became clear that patients of any age would need to come to PICU.

For PicPod 42 we discuss these issues with the King’s Hospital, London team. Starring are Richard Long, a 78 year old Paediatric Intensive Care survivor, and Lesley Lingen, his partner who supported him throughout. From the clinical team we have Kerry Murphy, matron for Paediatric Critical Care, Tom Best, clinical director of Adult Intensive Care, and Akash Deep, clinical director of Paediatric Intensive Care.

What did it feel like to wake up after a prolonged illness in the middle of COVID times? How was it for the partner? What were the differences between AICU and PICU care from the patient perspective?

How was the planning done? What changes were made to facilitate this? Was this “adults on PICU”, or “AICU outliers on PICU”? What aspects of paediatric care could be translated to adult care, and vice versa? How did death impact on the team, and how did the team look after themselves? How would it have been different if it had been the other way around?

Are we all ready for the next surge? Keep listening, keep talking, keep thinking.

Were you surprised by the COVID-19 pandemic? If you were (and I was), you haven’t been paying attention. Pandemics are constantly threatening: in the past few decades we have had HIV, MERS, SARS, H1N1, Zika, and Ebola.

Mike Osterholm is the Regents Professor, McKnight Presidential Endowed Chair in Public Health, and the director of the Center for Infectious Disease Research and Policy (CIDRAP) in Minneapolis, Minnesota. He has advised the past 5 US government administrations and has written a truly fascinating book “Deadliest Enemy”, available at all good bookshops which pay their taxes (that one’s aimed at you, Amazon).

Ruchi Sinha is a consultant Paediatric Intensivist at St Mary’s Hospital, London, and a member of the UK High Consequence Infectious Disease panel. She is also a friend of this podcast having been interviewed what seems like an unimaginably long time ago (last November) in PicPod 33.

Is this pandemic the Big One? How should we react to it now? What is going to happen in the future with this pandemic, or the next one? What are the solutions we can put in place now, to keep us safe(r) for the next time?

How would it have been different if it had been a disease of children instead of adults? Does it help to have a joined up healthcare system? What does Ruchi think of what she said 7 months ago?

And much, much more.

We have experienced an amazing development in Paediatric Intensive care over the past few months. Out of nowhere, a raft of patients with similar but highly unusual presentations started appearing in PICs across Europe and parts of the US, lagging behind the COVID-19 curve by around 4-6 weeks, but not seen in many countries who had experienced high levels of COVID infection.

For this podcast we have two expert guests: Prof Mike Levin and Dr Liz Whittaker, both from Imperial College London, who were the key authors on the recent paper in JAMA entitled “Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2“.

In this podcast we discuss:

Is PIMS-TS/MIS-C a new condition, or is it a variant of Kawasaki’s / Toxic Shock?

What is the potential pathophysiology of this condition?

What are the outcomes in the medium term for PIMS-TS?

What are suitable treatments, and what should we be giving? What are others giving, and is this based on any evidence, or just a herd reaction?

Will immunisation work, and what are the risks? Is there a potential Dengue type reaction?

What research is happening? How do you get involved? Please get your unit involved in the Best Available Treatments Study (BATS) here.

Which definition is best? PIMS-TS vs MIS-C vs the WHO criteria?

And much more .

So much of the conversation around Covid-19 has been from the well resourced, high income countries. A pandemic is bad enough when a country has almost unlimited funds to throw at the problem: but what is it like in areas where this is not the case?

For this podcast we have spread our wings yet further: our guests today are:

Cleopatra Patterson, anaesthetist and paediatric intensivist from the Bustamante Children’s Hospital in Kingston, Jamaica

Tariq Davidson, head of Paediatric Critical Care at the National Referral Hospital in Guyana

Fenny Shidhika, Paediatric cardiologist and critical care from Windhoek Central Hospital, Namibia

Bala, Ramachandran, Intensivist from Kanchi Kamakoti Childs Trust Hospital, Paediatric Chennai, India

Sumant Patil, Paediatric Intensivist from Deenanath Mangeshkar Hospital, Pune, India

How has it been so far? What effect has Covid-19 had on your practice, department, hospital, and country? What kind of patients have been seen? What are PPE stocks like, and what are people using for PPE? Can you reuse it?

This is a global problem, which needs global thought and team working.

We are all under Covid stress at the moment: patients, parents, and staff. To discuss the ethics of the situation we have two more special guests:

Erin Talati Paquette, Assistant Professor of Paediatric Critical Care at Lurie Children’s Hospital in Chicago, Associate chair of the ethics advisory board , associate director for ethics advocacy, and with a background in Law

Joe Brierley, consultant on the PICU at Great Ormond St Hospital, lead for GOSH and ESPNIC bioethics.

How does this situation affect us? How does it affect our patients? What implications are there for our treatment choices, and for how we deal with situations like cardiac arrest? Does joining up with adult units change how we deal with our children, both clinically and ethically? How do we maintain the mental health of children and staff?

In a time where the correct treatment of Covid patients is unknown, we must be extremely careful to do the right thing. The dust will settle, and when we will look back on the situation how will we be assessed?

PicPod 37 continues our theme of international interviews on the theme of Covid.

Martin Kneyber is a paediatric intensivist from Groningen in the Netherlands, Chair of scientific affairs of ESPNIC, and lead author of the just published guidelines on mechanical ventilation in Covid children.

Jimena del Castillo is a paediatric intensivist from Madrid, and chair of the ESPNIC resuscitation section. Or should I say “used to be a paediatric intensivist”? She has been treating adults for the past few weeks.

In PicPod 37 we discuss how to treat these children on intensive care. Should we use NIV, and when should we intubate? What PEEP should we use? What fluid balance should we aim for? Why does proning work? What about nitric or anticoagulation? What fluid status should we aim for? What are the resuscitation protocols?

And what can we learn from treating adults, and what could AICU learn from us?

Back soon with another Covid PicPod.

Covid-19 is everything at the moment. Much of the world has been affected: the parts which have not are about to be. But what about seriously ill children?

For PicPod 36 we have a discussion between your regular PicPod-ers and three guests from around the world who have all been significantly affected by Covid19:

From Genova, Italy, Dr Andrea Moscatelli, clinical director of the PIC at the Gaslini Children’s Hospital

From Paris, France, Dr Laurent Dupic , consultant in PIC at the Necker-Enfants Malades Hospital

From Conneticut, USA, Dr Josep Panisello, medical director of the PIC at the Yale School of Medicine

What kind of children are presenting with Covid-19 to PIC? What ages, which co-morbidities? How are they doing? What strategies, both organisational and clinical are needed? What are the major challenges? What treatment strategies are being used? What clinical pitfalls are being found? Why do children do so much better than adults? Should we be treating with anticoagulants, or looking at interleukins?

It’s a long one, but worth it. Back very soon with more Covid-19 themed podcasts.

It’s a difficult time for all of PICU with coronavirus causing international devastation. Stay safe everyone, work hard, do your best.

At the 2019 PICS/PCICS conference in London, Simon Nadel gave a talk on the use of ECMO in very severe sepsis.

There is little which is more frightening in our practice than trying to arrest the unstoppable beast of a runaway sepsis. When we are throwing the kitchen sink: should we be doing ECMO? It *kind of* makes sense…. surely if we offload that sick heart and those struggling lungs then that’s a win?

Not so fast: ECMO is a serious intervention which has risks and cost. What is the evidence base? How often is it used? What is the survival? Is VA or VV ECMO better in these situations? At what predicted mortality does it become, on balance, better to go for ECMO? Is it the same if you have in house ECMO or need transferring?

And what on earth is a Bootstrap procedure?

Reference list for this podcast:

Use of extracorporeal membrane oxygenation and associated outcomes in children hospitalized for sepsis in the United States: A large population-based study. Robb et al, PLOS ONE

Improved survival in venovenous vs venoarterial extracorporeal membrane oxygenation for pediatric noncardiac sepsis patients: a study of the Extracorporeal Life Support Organization registry. Skinner et al, Journal of Pediatric Surgery Extracorporeal therapies in pediatric severe sepsis: findings from the pediatric health-care information system . Ruth et al., Critical Care BMC

Defining benefit threshold for extracorporeal membrane oxygenation in children with sepsis-a binational multicenter cohort study. LJ Shlapbach et al, Crit Care 2019

Venoarterial Extracorporeal Membrane Oxygenation Versus Conventional Therapy in Severe Pediatric Septic Shock. Oberender et al, PCCM