Good afternoon. I don't know if any of you are like me, but after lunch, I tend to get the itis. So there will be some movement included in my presentation, mostly for you because I'm up here moving already. But I also have my co-authors on the chapter referenced on the slide as well. I have no disclosures except that I'm probably recovering from RSV. So if I lose my voice, please be patient with me. It will come back. It has all day today. So I'm hoping to talk to you about resource-limited settings and pediatric critical care practice. I'm not going to focus a lot on the history of pediatric critical care medicine, but we'll focus mostly on the current, well, not even mostly on the current state of PCCM and resource-limited settings, but more so on the opportunities for growth and some of the successful programs. And we'll talk through that in a multi-step fashion. Before we start, how many people practice in resource-limited settings? Do you mind rising? Yeah, let's stretch those legs. You can do it. You can do hard things. Come on. Let everyone see you because you're doing some amazing work. Thank you. How many people think that they service resource-limited settings? You can also rise. Should be everybody else in the room. Because really, people who practice in resource-limited settings are referring to you who do not practice in resource-limited settings. So we're all involved in this. I will not focus much on the history, as I mentioned. What I do want to emphasize is that pediatric critical care medicine got to develop in the milieu that was very appropriate, mostly in high-income countries. There was stability. There was governance. There was the desire for improving life, and the countries, for the most part, could do that. Not so for the majority of resource-limited settings, and we'll talk about why. So like I mentioned, the focus is going to be mostly on opportunities. This will be the theme, the opportunities for growth, but also some of the success stories in some of those growth patterns. I figure we should probably define what a resource-limited setting is. So this is a couple authors have put together multiple definitions that we kind of pulled together in the writing of this chapter, but we defined a resource-limited setting as an area where the capability to provide care for life-threatening illness is limited to basic healthcare resources. So when you think basic healthcare resources, some of you are thinking, oh, yeah, there's a bunch of monitors. There's a bunch of ventilators. There's different modalities of ventilators, even. That's basic. That's not entirely true in all of these areas. For instance, ventilators may exist, but they're not connected to oxygen, or the anesthesiologists are who man the ventilators. There are no respiratory therapists who can do that. So what are some of the other things that define it? While they have limited human resources, there's poor infrastructure. There's limited equipment, including the maintenance of the equipment. There's issues with proximity to the healthcare infrastructure. So practicing in North Dakota, I probably provide care to about a five-hour radius north of me and almost to the eastern border of Montana, and there are sometimes patients that are traveling six hours to get to a community PICU, and a lot of the time, it's a lot more than that. So what about public health catastrophes and how that affects the infrastructure of providing healthcare? And then research capabilities. I've been awed by all I've been hearing about what's happening in the research arena on this side of the world, but we're talking phenotypes, and we don't even think that way in resource-limited settings for the most part, right? We're just thinking, how do we stabilize you and get you better? So these are some of the things to think about as you think through that. This is not the best slide, but I thought this was very interesting. MIT has developed a global intensive care unit risk score. It's based on about 205 hospitals in the United States, and then Argentina is represented, Brazil, India, Nepal, Sri Lanka, Australia, and New Zealand. Those are all the areas in blue. What you will notice is this map shows you that the majority areas in gray actually globally are the ones that are heavily resource-limited. So this global score doesn't really account for low middle income slash resource-limited areas. We all know what an ICU is, but I thought I should define it in the way that is multinational, and the World Federation of Societies of Critical Care came together in a task force. This has been about a decade, and defined an ICU using this multinational approach. I highlighted things that I thought were very important. So they say, yes, we provide care for critically ill patients. We are providing intensive and specialized medical and nursing care, and it needs to be in an environment that has enhanced capacity for monitoring, and a multiple modality of physiologic organ support to sustain life during a period that's a life-threatening issue that's going on. ICU is not defined by geographic area. Most of you know that yes, we have ICUs, but then the ER can be a place where ICUs, where critical care is practiced, or even in a hospital ward, a step-down unit, and a follow-up clinic. The other thing that they did was that they categorized the ICUs based on 12 criteria into a four-level ICU, and these were based on what resources were available, and then depending on the country or the region, what the AAP and the Society for Critical Care Medicine has done for pediatric ICU anyways, that they took that a step further, and now we have what we call the three categories, right? Community PICU, tertiary PICU, or quaternary PICU. And that's also based on resources and what's available for practice, but actually the key thing that they emphasize is that you need to have the expertise of a pediatric critically trained individual or individuals to practice in those environments. How do we quantify then what the burden of critical illness is in resource-limited settings? And it might not be quite as easy as simply saying you're a sick kid, you go to the PICU. It's a lot more complex in resource-limited settings. So the same way the AAP and the SCCM, when they created this guideline to distinguish who should go to a community hospital PICU, who should go to a tertiary, and who should go to quaternary, is how I want us to kind of think through how to quantify the burden of critical illness. So first of all, how are you going to define critical illness in a resource-limited setting? For us, so I'll use Bismarck again as an example, in moving there to help grow the PICU program, as we're thinking through our policy, our admission policy, and who we can keep and who we can't keep, we're thinking hemodynamic parameters, right? As you think through your policy of how to define who gets to stay, you're thinking maybe some lab values can help guide who should go where, what specialists are involved, is there multi-organ involvement that's going to need an ID doc, a rheumatologist, and those kinds of things, while in resource-limited settings, something as simple as diarrhea could be a death sentence to a child, depending on how long they've had it. So then what are we really using to define critical illness in those kinds of settings? And then how do you count an ICU? We understand that every hospital should have an ICU, but what about a country that just had Ebola? They may have Ebola makeshift units that are set up. Are those also counted as ICUs? Will those help us then categorize what the burden of critical illness is, or are those like a temporary thing, and how do we factor that in? In the United States, for instance, we use mortality data and cause-specific data. The CDC spits out this 10 top 10 causes of mortality in the pediatric population. And in most resource-limited settings, sepsis is still number one, some respiratory failure of some kind, and then we start to think about the things like diarrhea, malnutrition, and malaria. However, within these regions, there might be variability in what their leading causes of mortality are. And so these are some of the things that make it complex. We'll talk a little bit in depth about the critical illness scoring and how that may or may not be able to help us with categorizing the burden of critical illness. I especially like this paper. It was published a couple years ago now, we're in 2025, by Chanda et al. in the PCCM Journal. This was based in Cambodia, and they looked at the different scoring systems that are available in high-income countries. And when I use the terminology of high-income countries, it's really very tied to the designation of GDP, if you can think of it that way, the same with low-middle-income countries. It's almost interchangeable if you're thinking about resource-limited and GDP. It's very much in that arena. I'll use South Africa as an example. South Africa is more of a middle-income country, but it has many pockets of low-income, so we just lump it into that low-middle-income country. India is the same, high resource, but because of the share population is considered sometimes low-middle-income country, not always fits that category. So this paper, they looked at 49 scoring systems. Think of all the scoring systems in critical illness that you know, and they wanted to see if those were applicable in a resource-limited setting. And what they found was of those 49, only nine of them could they use because they either used really advanced tools to measure their predictors, or they just couldn't apply them in their settings. And then of those nine, they had to eliminate, they did this model and found that only three of the nine scoring tools were able to be used in their setting. So these are the nine that they looked at and thought, okay, we have all the predictors that are all the elements that are useful to make these scores. And of those nine, the ones with the red stars, so the pediatric, the PAWS, the PLOD, and the QSOFA were the three that could be used, but their utility was limited to ranking a high-acuity PICU patient versus a low-acuity PICU patient. Their primary outcome was death on PICU admission. So these scores were not actually helpful for that. They were just helpful for ranking high versus low acuity, which is helpful in a resource-limited setting where you have to decide which patient am I going to pour my resources into. Then based on that, they went further and they developed their own scoring system, which I thought was remarkable. What I like about what they used is they actually factored in estimated time of travel, things that we don't think about when we think about predicting illness. But they used these five clinical domains, and then in those five clinical domains then had predictors that they then factored into getting this formula. And what they found was actually this new model that they created actually was really good at predicting PICU mortality. They broke it up into a tiered system of 2.5% prediction, 5% prediction, 10% prediction, and so on. And what they were finding was, yes, they would have a high false positive value for patients, but then at about a 10% cutoff, it was like a five-to-one ratio where you had five patients that probably would not die in the PICU, but for that one patient. So it's almost like a number-needed-to-treat type of situation, if you want to think of it that way. They then took it a step further, and they compared those three scoring models, so the PAWS, the QSOFA, and the PILOD2 to their new model to then determine how well does it do with predicting the acuity. Do you go to a high-acuity level part of the PICU, or do you go to a low-acuity part of the PICU? And you can see on the y-axis that they have a net benefit that kind of tells you how well, is it actually worth it for these patients to be going to these designated areas? And then there's a threshold of probability where about 7.5% is kind of the cutoff that they used, but if you look at the graphs, you can tell that the straight line treat all, and then the dashed line treat none. Of course, we don't want to treat no patients, but to the far right, everybody's net benefits is getting lower. They didn't continue it past the 25% probability. And then on the net benefit, to the top of that, treat all, like everybody's net benefit is going to be great if they all go to the PICU, but they can't all go to the PICU because of limited resources. The new model outperformed the three scoring predictors that they had used, which I think is actually remarkable given that they created this with the environment in mind. And it's, I think, encouraging for other models. So this study was done in Cambodia, but in other regions to think about what predictive model then can be used for them to allocate PICU resources, but also to perform outcome analysis on who's going to the PICU and who's surviving PICU. So what are some of the other strategies that have been used to quantify burden of critical illness in resource-limited settings, or that have worked in high-income settings that we can see whether or not they translate to resource-limited settings. What we found as we did research for this paper is actually the majority of guidelines that we use every day in high-income countries actually do not apply in resource-limited settings. So for instance, the Surviving Sepsis Campaign guidelines, there was a group of anesthesiologists at a Pan-African anesthesiology conference five years ago that were given a survey based on the things that are required for the surviving sepsis process, like think of the moment the patient shows up and that one-hour rule and what you're doing, and what they reported was that the majority of the things that were required could not be used because they did not have them available. So yes, they had access to fluids, but storage of pressers was an issue for them, for instance. Another example is in transfusion medicine. So the WHO had published guidelines saying severely anemic kids need to get blood right now, and you should give them 20 per kilo. The TRACT study was a randomized trial that was performed in severely anemic children in the sub-Saharan African context. And what they found was actually severely anemic patients, so hemoglobin of four to six grams per deciliter, would not benefit from immediate transfusion and would not benefit from the 20 per kilo if they didn't have a fever. So it was better to give them 30 per kilo if they were afebrile, but if they were febrile, definitely give them 20 per kilo. And that needs to be teased out further, but that was an example to show those guidelines don't apply across the board. They also found in that TRACT study that regardless of malnutrition, malaria, all the other factors that we typically think affect the comorbidities, that that did not affect the patients. It was just that fever threshold. Pediatric early warning scores have shown wonderful benefits in resource-limited settings in the oncology population. It has not yet shown to be translated across the general PICU. So studies are needed for that as well. And then we talked about the prognostic scoring models, and there were a few papers that went into further detail about that, but that Chadna et al study I thought was the best one to kind of show some of the limitations of using that. So as if you haven't heard enough of the challenges of PICU in resource-limited settings, I thought I'd go into a little more detail about it. So we've heard so much about some of the wonderful studies that are going on in our scenario on this side of the world but we have only about 20% of randomized controlled trials or randomized studies are happening in resource-limited settings, even though they carry the burden of critical illness. So high-impact research, definitely important there. I mentioned ventilator use, and in a lot of these settings, so they may have ventilators but may not be able to use them. A lot of them are using non-invasive support or even high-flow support or bubble CPAP. While there haven't been, because we know respiratory failure is, again, a leading cause of pediatric mortality in resource-limited settings, but there haven't been studies to actually evaluate how effective those tools are. There was one study coming out of Seattle that was starting a few years ago, Seattle Children's, where there was a bubble CPAP non-invasive device that had been designed specifically for the resource-limited settings. So think electricity shortage, oxygen issues, can the compressor work or not, and they're starting to look into it as to whether or not this is a good modality to use. What about poor staffing and brain drain? So we think about our nursing shortages on this side of the world. Well, nursing shortages here actually worsen nursing shortages in resource-limited settings because guess where countries like the US are recruiting their nurses from when they can't staff their units? They are going to the Philippines and to Nigeria and to Kenya, and they're pulling resources from there as well. And we haven't even started talking about physicians. About a quarter of us in this room probably were born and raised in resource-limited settings and have transitioned to this side of the world for the opportunities that it offers, but also pediatric critical care in resource-limited settings has not existed in the same way as it has here. So it has kept us on this side of the world with the hope of improving it in resource-limited settings. Mentorship and continuing medical education opportunities are almost non-existent unless there's partnership with high-income countries, and that is happening. I'll talk about that a little bit as we go on. We talked about some of the equipment issues, maintenance issues with that, and limitations of advanced therapy. So ECMO is not even something to discuss in majority of resource-limited settings because of something as simple as the blood supply. And maybe blood is not a simple thing because we have shortages here, but who's giving blood? Who's, is it a family member that's donating, which is actually usually what ends up happening, is that a family member is who's told, well, if you go and you give blood, then your child can get blood. Who's checking the blood? All of those things are some of the things to think about. And then limited space and infrastructure. One of the organizations that I'll mention has consulted in the past on creating PICU spaces. Dr. Nwakwo, who talked earlier, was part of actually a lot of the brainchild behind developing a pediatric ICU in Nigeria and thinking about where should this go and how do we feed into it? Where does the ER go in proximity to where the PICU is? How about the theater, the operating rooms? Budgetary and financial challenges also exist because unlike the US, a lot of resource-limited countries do not necessarily build in healthcare budgets into their fiscal planning. And so that sometimes is coming out of the patient's pockets and communal offerings, if you will, to support the care of the children in ICUs. So I don't mean to be all gloom and doomsday. I'm getting to the part where we have some successful organizations and partnerships to talk about. There is a proverb, I don't know who to give credit, who gets the credit because I've seen multiple versions of it, but it says, how do you eat an elephant? And we know that you eat it one bite at a time. And so let's talk about some of that one-bite scenarios. I wanted to highlight this study as well that was published also within the last two years that looked over their own investigator-led randomized clinical trials that were conducted specifically in low and middle-income countries. And what they found as they looked over their process, and this was kind of a commentary actually on their studies and their experience, was they wanted to emphasize some contextual factors for things like informed consent that we don't necessarily have to think about here. So if you think about the disclosure by the investigative team, if there's limited infrastructure for research, then that can vary from site to site, and that was one of the things that they found. So they had to standardize their disclosure process regardless of where they were going within the low-middle-income countries. Comprehension and literacy rates was another issue that they needed to streamline and figure out how to overcome that hurdle. The voluntary choice and the authorization, I thought, was interesting and very relevant that they mentioned the community consultation because in a lot of these settings, the community's voice plays as heavy as a role as the individual's voice, and that sometimes we don't think about on this side of the world, high-income countries, as we talk through that. But also, for those of us who serve Native American communities, that also might be part of your experience where you think, well, I'm just going to present it to this family, while the family may need to take it back to whoever the head of the family is, whether it's the matriarch that's back on the reservation and have a conversation. And so these are some of the cultural contexts that we experience. So I have highlighted the successful programs that have come to mind, especially in the last five years, but this is not a comprehensive list by any chance. There are actually a lot more that I haven't specifically paid attention to. One, or haven't highlighted in this talk, one study that I will highlight was a study that was performed in Kenya where they looked at the pediatric mortality just simply from the presence of a pediatric intensivist moving to that region, and what they found was there was more than a 40% decrease in pediatric mortality just by there being a pediatric intensivist. So some of the successful programs that I'm aware of or that we were able to find in our review was a pediatric and critical care training program based in Nairobi. It's a partnership between Seattle Children's and the university there, and they are now, I think, in their fourth or fifth cycle of training, actually took three years, so second cycle of training intensivists to practice both emergency and critical care medicine, and my understanding of the program is to hands-off eventually when they have enough of a presence of pediatric intensivists there. They also provide nurse training, which I think is great as well. There's a certificate in critical care that is provided in South Africa as well, and this is open to Pan-African countries, and so it's not just specific to South Africans. There's a program in Malawi that has a global fellowship that's supported by the University of, I think it's SLU and University of Washington in St. Louis. I'm not sure exactly. I think they have a partnership to do that. I did not mention that in this slide. With the advent of the pandemic, a lot of virtual education was pushed in many ways for a lot of these partnerships that were already in existence, and the Pediatric Critical Care and Resource-Limited Settings, that's the PICIRLS, is one of the online platforms that provides education to Sub-Saharan Africa, parts of the Middle East, and I believe some parts of Southeast Asia as well, where they weekly have didactics where the residents or registrars are presenting cases, and then experts at Yale in particular and other universities or programs in the United States are providing lectures, teaching ventilator management, teaching how to intubate, trying to do as much from a virtual perspective as they can. Another organization is the Pediatric Universal Life Support Effort that goes in-person and provides free educational and hands-on critical care education. They use PFCCS, which is a program through the Society of Critical Care Medicine as their vehicle to provide education. The nice thing about that is it's almost using the austere model where they take what is present in high-income countries and make it applicable. Tell us what you have, and let's incorporate it. So if you don't have a ventilator, yes, the course requires that we show you how to put a patient on the ventilator, but let's start at the basic as to this is the tubing that you use, and these are the tube sizes, and so taking it down to the very basic level of understanding. I cannot not mention PALISI and the wonderful research partnerships that exist that they've created a subgroup now with a global focus that is now putting a lot of emphasis on research in research-limited settings. I didn't find, there's a respiratory study that's happening or that's currently being recruited, and so I'm just keeping an eye on that so that we can update this chapter in the future, hopefully. Some special considerations that I will highlight that we don't think about in resource-limited settings, something like post-ICU care. So for patients who went to the ICU who are suffering from whatever, sequelae of their admission to the ICU, that's not something that's heavily emphasized. I know that there's some post-ICU clinics that are happening. The NICU is very good at the follow-up from discharge from the NICU, but in resource-limited settings, that is not happening quite as much or is not being published. The emphasis on pediatric palliative and end-of-life care is also something that really isn't focused on. Yes, it's happening in the context of oncology, but not in the general pediatric population. And the community and cultural factors that tie into that would be a really awesome way of supporting that, but also learning for the pediatric critical care community. And then just the other cultural and communal considerations that need to be taken into effect as we talk about supporting our counterparts in resource-limited settings. So just to conclude, the goal is not for the critical care of children in resource-limited settings to look exactly like high-income settings, right? It actually never will because the financial and the expertise is light years in advance, but it is so that these kids can thrive and the practitioners who are supporting them can actually feel supported, but like they are actually making a difference. So that Kenya study is one that's highlighted again, where the presence of the intensivists in building the team cut the mortality by 40%. And that is where I will stop. Thank you.

pediatric critical care

resource-limited settings

training programs

infrastructure challenges

collaboration

context-specific guidelines