Good afternoon, and welcome to session two of Current Concepts in Pediatric Critical Care. My name is Sharon Irving, and I'm the chair of Current Concepts in Pediatrics. I am an associate professor at University of Pennsylvania School of Nursing, and I'm a pediatric critical care nurse practitioner maintaining practice at the Children's Hospital of Philadelphia. So, welcome to all of you. I have with me an esteemed panel, and my two colleagues that share in the leadership of Current Concepts are Dr. Kyle Ryder and Dr. Nick Ettinger, and I'll turn it over to you, Kyle. Yeah. So, again, thank you all for being here, particularly thank you to our faculty for joining in to field questions on their excellent presentations. So, my name is Kyle Ryder. I am a pediatric intensivist at Duke Children's Hospital and the vice chair of education here, and I am the vice chair of the Current Concepts Committee, and I'll turn it over to Dr. Ettinger. Hi, everybody. I'm Nick Ettinger. I'm a pediatric intensivist at Texas Children's Hospital, and I'm the past chair of Current Concepts. Again, I also want to say thank you very much to all of our speakers for their excellent slides and I'm sure what will be excellent discussion this afternoon. So, welcome, everybody. And we'll do quick introductions. We will have you all introduce yourself. We'll start off in order of presentation, so Dr. Fitzgerald. Hi. Thanks for having me here today. My name is Julie Fitzgerald, and I am an assistant professor of critical care at the Children's Hospital at the University of Pennsylvania, and I work clinically in the Pediatric Intensive Care Unit as a pediatric intensivist at the Children's Hospital of Philadelphia. Thank you. Dr. Randolph. Hi. I'm Adrienne Randolph. I am a professor of anesthesia and pediatrics at Harvard Medical School, and I am a intensivist at Boston Children's Hospital in the Medical Surgical Intensive Care Unit. Dr. Watson. Hi. Welcome, everyone. It's great to see you all and have you virtually with us today. My name is Chris Watson. I am a pediatric intensivist at the Children's Hospital of Georgia, professor of pediatrics at the Medical College of Georgia, and the fellowship program director here, as well as a member of the current concepts committee. I'm excited to be here and have this discussion with our panel today. And finally, Dr. Madden. Hi. Welcome, everybody. It's my pleasure to be here. I'm Maureen Madden. I am a professor of pediatrics at Rutgers Robert Wood Johnson Medical School, and my clinical practice is as a nurse practitioner in the Pediatric ICU at Robert Wood Johnson. Great. Again, thank you, all of you, for joining us today. So I'm going to start us off with some questions, a question specifically to you, Dr. Fitzgerald. You had the sepsis-induced organ dysfunction, and sepsis is something that we're all constantly dealing with. It's one of the most prevalent disease disorders that we deal with in the ICU. You did a lot of work and a lot of talking about the phenoms, and really trying to bring this into precision medicine as we look at that. And so my question surrounding that is, how long do you think, or what do you think it will really take to take it from what you have described in terms of the various phenoms and phenotyping to truly at the bedside working with these children? That's a terrific question. Dr. Irving, thank you for it. I think that the work that has gone into the sepsis phenotypes is really tremendous. There's been a lot of, like over a decade of work in defining these phenotypes and the associated mortality profiles. And this has translated into a set of nested, if you will, randomized controlled trials that are about to start enrolling sometime in the next month at multiple sites across the United States using this precision medicine technique where the goal is to define patients up front who meet these different phenotypes, and then to enroll them into randomized trials that will either test anakinra or GM-CSF, depending on their phenotype, to treat their severe sepsis and MODS. So I think that those are slated to enroll over a period of about five years at multiple sites. So I think that that's really the next step. There's some good preliminary data in like phase one, two trials for GM-CSF. So this will be kind of the next step in moving that to the bedside. And then the anakinra data, this will be kind of the initial trial of that in this specific subpopulation of children. But I think that these are well-designed trials that should really provide us with the ability to move this to the next step of using this clinically. So maybe in the next decade, we'll be able to really put this into practice. And along those lines, Dr. Fitzgerald, thanks much, because I think certainly we've already experienced some of these and seen potential benefits of some of these therapies. With these randomized trials, do you worry about equipoise as people become more familiar with these different phenotypes and start to jump on some of the therapies? Another great question. I think that equipoise is always a concern when there's trials going on, especially if the trials are not blinded. I think we didn't have enough patients probably enrolled at our institution in the preliminary trials of the GM-CSF for our group to particularly feel like we don't have equipoise any longer. Hopefully, I think that these are going to be well-designed trials. And my hope is that the data will not be seen outside of the trial, the DSMB and whatnot. So I think there's always a risk that you could lose your equipoise if there's rumors or rumorings of what the results are early on before the entire data has been reviewed. So I think there's a risk, hopefully there's enough safeguards in place to mitigate that risk. I don't know if others have... I know that's a tough question to think about, especially during trial design, it can be so problematic. I appreciate you feeling that. Yeah. I don't know if others have institutional experience where there's concerns about equipoise for these treatments, but I haven't gotten the sense that we have those concerns at our institution currently. I have kind of a practical question. When you have that undifferentiated pediatric sepsis patient who rolls up into the ICU, Dr. Fitzgerald, what's your practice in terms of when you're starting to think about these different phenotypes of sepsis? At what point are you starting to send to ADAMS-TS13 and try to differentiate what kind of sepsis this is? What are the signals that you're looking for, practically speaking? So I think when you look at the slides in the handout, some of these phenotypes take a few days really to become evident. And I think that the median time for some of the phenotypes to really be defined was three or four days, which is nice from a trial design standpoint, because you have a little bit of time then to think about how the patient is evolving and whether they need immunomodulatory therapies, if you will, so you're not kind of having to just give it to everyone. So I think that that's a nice aspect of the fact that some of these phenotypes takes a few days. I think it's always best practice to be vigilant for things that might indicate the patient might be going in the direction of a specific phenotype and to screen for things early. So I think when I have a patient that presents with thrombocytopenia and shock on multiple basal active agents, I will be sending the ADAMS-TS13 sooner rather than later. I think the data on plasma exchange in that population really shows that if you're going to institute that therapy, it's best done as soon as possible, within the first 24 hours. And that test, depending on where you are, can take a little bit of time to come back. So I think sending something like that, or ferritin early on, and maybe even testing ferritin serially if the patient is not getting better, is really helpful. So I think as we do with checking creatinine and liver function tests and things like that, checking these other inflammatory markers serially over the course of days while the patient's evolving, if they're not getting better, will be helpful in identifying these patients that might meet these phenotypes. So I have another question for you, Julie. And I open this up to anybody to answer, based on Julie's information and such, is with this work and looking at phenotypes and such, and with what people are using in terms of pathways and protocols to follow at the bedside for medicine, how do you see those two things blending? Because we're all, you know, there's so many times that you put them on the sepsis pathway, or you put them on the bronchiolytic pathway, or you put them on, you know, the pancreatitis pathway, or whatever the case may be. And then how will these, that blend when you have the septic patient that you're looking for phenomes and phenotypes? Because it's true, right? It's like one size does not fit all. Absolutely. Because I think pathways try to push it in that direction. Yeah. And I think pathways or protocols or guidelines are really helpful in, like you said, kind of standardizing management for, you know, 80% of the population that comes in with a particular disease. But there needs to be that ability to personalize the approach, you know, based on the patient's situation and their evolution. I think at least speaking from a sepsis pathway standpoint, which I've been involved in a lot of work at CHOP in terms of the sepsis pathway development and the iterative process of refining that pathway over the years, a lot of what is addressed in that pathway is kind of those initial 6 to 12 hours of treatment, which I think really needs to be a little bit more general and have a kind of standardized approach to how you handle the patient in the first 12 hours of stabilization. And so I think a lot of, you know, finding these phenotypes in this ongoing care and this precision medicine comes up in not in the first 12 hours at this point anyway, but is more emerging in like the first few days of being in the ICU. But what I think we could work into our pathways is kind of what we talked about in the last question is that early screening for the different phenotypes of sepsis induced mods. So building in, you know, in addition to checking all of your markers of end organ function as the patient arrives and, you know, iteratively over their hospital course, looking for those other markers that you might not traditionally check in the sicker patients to help define their phenotypes so that then they can move down that road of the precision approach within immunomodulatory therapy. Yeah. I love where you went there. I had that same thought about building in triggers into protocols, which allow you to then pick up earlier and particularly for those where it's so key for early diagnosis. Chris or Adrian or Maureen, what do you, any additional comments to any of that? Well, I was just thinking as well, as we think about kind of extrapolation on some of these pathways and newer updated approaches, some of the evidence-based that we've used historically and thinking about more resource limited settings and some of the updated guidelines that have been shared, what kind of thoughts do we have about how do we carry that forward into those settings and what this means in those particular healthcare settings is something that I'm wondering about as well. I think we always have to think about, we are in a unique situation in that we are in a very resource place being in the U.S., but what about, Chris, to your point, what about some of the more under-resourced places and how do they utilize some of this very sophisticated and very fancy, for lack of a better term, fancy medicine that we all practice and use and how do we help those colleagues? Because I'm sure every single one of us has received the email or the phone call or something saying, this is what presented, what thoughts might you have? So, other thoughts on how we would do that? I think it goes to what Julie was speaking about. So, this is a clinical trial space and that it's going to take two years or so to try and differentiate out this population and actually see which markers are going to be the most helpful in determining which part of the algorithm, because these pathways are going to change and move with this. And I think we've seen a little bit with COVID also that a lot of the things that we were testing for have now become more available to many other people. And I think over time, as medicine evolves, so will hopefully the cost and the availability as well. So, maybe everybody can have a little bit of benefit. It's not a lot larger benefit from it. Agreed. Agreed. Go ahead. I'm sorry. We can shorten that decade that you mentioned, Maureen, about that we know that it classically takes from time of when we realized best practice until it's truly practiced. My hope is that we can continue to shorten that, but maybe I'm being Pollyannish. Dr. Randolph, one of the things that's really been unique about the whole COVID-19 pandemic, and you've been very intimately involved in this, was how rapidly people were able to do multi-center descriptive studies of the patients. And since you were very much involved with that, I was wondering if you could talk a little bit about how was that able to happen so fast for this disease, and we haven't been able to do that for other things. Was it just because it was so unique and everybody was focused on it? Or were there changes that happened that facilitated people sharing patient data across centers so quickly? Yeah, so that's a good question. So the Pediatric Acute Lung Injury and Substance Investigators Network, which was started in 2000 by starting off with the trial that we did on weaning and mechanical ventilation management and excavation readiness testing. So that grew into a bigger network, and then we spun off this pick flu network subgroup that was on influenza, which a lot of people participated in. And we did some influenza studies, including the 2009 pandemic, an observational study. And then we got some funding in 2013 to set up a pandemic preparedness network of just observational data and get everybody IRB approved. And then we basically sat there till 2020, waiting for the pandemic that we thought would be flu. But it turned out to be COVID. But we had made all the, you know, red cap case report forms modular. So we just changed things because COVID is so multi-system, you know, and wasn't always severe respiratory disease in the children and adolescents. And then, and then MIS-T emerged. And so in like one month, we were able to get, we got funding April 20th. And then in, in the end of May, we had submitted our paper on MIS-T to New England Journal. And everybody just really pitched in and worked together. And a lot of these people were already in the network, and then we added some more sites. So that's how to get better representation across the United States. So that's how we had sort of a leg up, because we already had the red cap forms, we had the IRB approvals, we had a whole bunch of sites that were representative. And, and, and we were waiting really for this to happen. So, you know, I think though, that the one thing that was didn't work is, you know, we were hoping that by having all this, we would be able to jump in and participate in some of the trials, which there was a lot more COVID trials than there were flu from in 2009, H1N1 in adults, there weren't a ton of trials, but there was antivirals trials. And then we didn't get involved in those until later with the kids, it was more dosing. So we were trying to, you know, set ourselves up to be able like, okay, the adults are doing a trial, we'll jump in and do a trial with them. But there was quite a few barriers, we wanted to be part of remdesivir trial. But the pediatric mortality and illness severity was a lot lower. And it's just hard, harder to set up, you know, that across all these sites to get enough patients and also, we didn't have the best, we didn't have validated outcome measure that was non mortality, where in the adults, there was high mortality. So they had, they could do mortality trials. So, so that was an issue. So we've been working on that now, like what outcome measure to use for less sick patients for a spectrum of severity. So that's sort of how, where, where that's at, at the moment for the next pandemic, which will probably this time be flu, since we haven't had flu for a while, but now we're prepared to even more. So, Are you setting us up to do this again? Oh, my goodness. So, Dr. Randolph, you talk a lot, like the MS, the MIS-C The MIS-C has been really a phenomena that I think initially people were, as you said, we were poised, right, to see this influx of COVID-19 in children. And then we didn't really see that. And then like little by little, and, you know, as on your one slide, you point out when this started and how it kind of progressed. Where do you think we are now in terms of MIS-C with all of these variations of COVID that's coming? Where do you think we are now? And what do we need to be watching for, for our kids that didn't have COVID, but then they're sick now? Well, for MIS-C, I mean, it seems like the numbers are going down, whether it's because of, like, patients have been exposed already from natural infection or vaccination. We did an association study showing vaccination decreases, is associated with the decrease in MIS-C as well, that we published in MMWR. And we've done a follow up of that. That's, that's that we're finishing up. But, but with MIS-C, it does seem like the numbers have gone down. And the second thing is, it's really hard to tell now what's MIS-C, because early in the pandemic, as soon as we got the antibody testing, somebody came in in shock, or, you know, look like Kawasaki's was antibody positive, and PCR negative, especially. It was like, okay, well, this is MIS-C. But now a lot of patients are antibody positive from a prior infection, if it's nucleocapsid antibody, because the nucleocapsid is from a prior infection, but the spike is from the vaccine, right? So if you're a centers only testing for spike, you can't tell whether the patient had had a prior infection, or was it just from the vaccine. But if they're testing for nucleocapsid, you know, then you can say that's probably from a prior infection, but then when was that infection? It was a long time ago, it's just really hard to tell. So it's hard now to distinguish MIS-C, you kind of have to have a history of an infection in the family or exposure or something, or a positive test a month ago, like, surprisingly, a high proportion of these patients had a positive test that they knew of a month before, approximately, you know, three to six weeks before. And that kind of gives you a hint. But it does overlap with a lot of things, including, you know, rolling out other infections often, you know, now there's other viruses circulating. Back then, there was no other circulating viruses hardly except for a little bit of rhinovirus. And then, you know, RSV broke out in the summer. So it so now there's all these other circulating viruses, adenovirus, which can, you know, all kinds of things that make it really difficult to confirm, you know, is this what's going on? So it's a different, it's hard now. All of our kids are sick with rhinovirus right now. Keep it down there. So Dr. Watson, we've talked a lot about disease states, and you are a pediatric trauma person. And so what impact has the sepsis or the COVID-19 had on what you've seen in terms of trauma? Thank you, Sharon. I think it's been really interesting as we talk a little bit about the evolution of COVID and children, also to survey the landscape of how that's impacted trauma. And I think there's a lot of important findings that came out of that. And the idea, as we've talked about, and kind of experienced over the last several years, that COVID has an unequal impact across society and communities, and particularly affecting marginalized communities and those with poor or limited access to healthcare in unequal ways. And looking at that through the lens of trauma, we've also continued to see that. And the idea that there are regional and even local differences in how that's experienced has been something that has been looked at. And with the long course of COVID, I think, given us a lot of information about that and recognizing unintentional injury and the role and the significant impact of injury and trauma in children and morbidity and mortality associated with that. There's been many questions that I think have come out of the COVID experience. And we think about children and potentially looking more kind of locally, as I think what we've seen is that there's been discordance in how that's been experienced. And the idea that trauma, in some regards, is approached from a regional standpoint has been one of the take homes, I think, one of areas that we've continued to look at. Also, the impact of child maltreatment, I think, has been an open question too. And how, if COVID has affected access to care or delayed presentation to care for children, the idea that there's perhaps a silent epidemic of child maltreatment that has occurred, I think, has been unanswered. And there's definitely great suspicion that that may have been the case. And again, I think probably a more regional focus would perhaps show that. Certainly, as the volumes, as we all experienced during the initial shutdown of COVID, kind of led to diminished numbers in our ICUs, the overall trauma volumes, the raw numbers were down. But the patterns that I think we see locally and what type of patients and children presented does speak to perhaps the idea that there was a secondary crisis in the background and that child maltreatment, secondary to mental health and stress factors related to family, may have perhaps exacerbated that. I think it's one of the things that I've taken from this and that I think is worth a continued research and investigation into that. Obviously, in the setting of this horrific week in America as well, I think the importance of talking about firearm related injuries in children is something that is extremely important in recognizing that our role as well as clinicians perhaps also extends beyond the bedside and that there's a role for advocacy is something that I think is very important for us to continue to reflect on as a community at this point in recognizing that we do have other obligations as well to the community. So those are, I think, a few of the things that from the trauma lens have been interesting to me and I think are extremely relevant at this point in time. And especially as we continue to figure out COVID as it goes forward and becomes more endemic and trying to address healthcare disparities and structural inequities as they exist in our current healthcare system to try and really minimize the disparity and the effects of trauma on those marginalized populations, I think is extremely important. I would agree with you. I think that one of the things, and Dr. Fitzgerald, since we're both in the same center, please jump in here. I think one of the things that we saw, as you said, was a lower overall number, but then the ones that did come in were more from the marginalized communities and the trauma seemed to be more severe. Julie, what do you think? That's what I experienced in our ICU during that time and immediately following. I think looking back, I recall the same. I think there's always an issue with our recollections and anecdotal thoughts, but I think what you're saying is accurate. Yeah, I think it's always tough because it's the bad cases that really stick out, but I would say we had discussions in our own center expecting that wave of non-accidental trauma and abusive trauma that didn't come right away. It felt like it came later than we thought, but it yet did come. I do really worry and I appreciate Chris's comments about the amount that was missed and are we going to see long-term effects from that that may or may not show up in our ICU, but that still is a significant pediatric health issue. I also very much appreciate your comments around the importance of advocating not only for things like gun safety in the setting of the school shooting this week, but also advocating in the terms of equitable care because we can't say that we provide good care unless we provide equitable care. Absolutely. Absolutely. Dr. Madden, so all of these can end up as the chronically, critically ill. I wonder if you can speak to those patients that end up the repeaters sometimes that have had sepsis or have been the victims of trauma and or have, I don't know that we'll see and maybe Dr. Randolph, you can jump in this too, that we'll see that whole phenomena of long COVID or long missee in pediatrics, but if you can give some thoughts to what do we do now with this chronically, critically ill population of children that is growing by leaps and bounds? Yeah, that's a really broad and big question that I think everybody who works in pediatric critical care can acknowledge that we've seen a rise in our chronically, critically ill children as we've had the capabilities of providing more technology for the patients and whether they stay in your ICU for extended periods of time, or as you said, have recurring admissions or they're at home. And it had already come to my mind of long COVID, in terms of, you know, starting to study that and what that phenomenon may look like. And many of our children that, in my own experience, they had underlying comorbidities when they came in either with COVID or MISD that contributed to that. And those are the individuals who now have fallen into the category of chronically ill children if they weren't there before. So it's very interesting, and it's these recurrent admissions and trying to, in the context of a pandemic, also work with the population of patients. Each individual facility did different things about visitation, and I think most of us, at least for caring for children, were a little bit more open to having their families versus their parents, and for getting pregnant. During the last few years, we still had COVID, but it created a very challenging dynamic of how we engaged with parents, just on rounds, and that really, then we would notice a well-repeating participant on our daily rounds, come back to you. On that extent that our visits could be held and verify the care of just the medications, if they're regular regimens, because they're on a ventilator and they're pulmonary toilet regimens that we list, or we were not accurate in terms of their care, and so, in fact, they're like, okay, did they now have to stay longer? And then, I think every single person here can also attest to the fact that our healthcare systems were so challenged with these COVID pandemics that the population of children that we have that are technology-dependent and rely upon nursing care at home has been significantly impacted. So, that also has impacted their length of stay, or they've come in a little bit sicker than we anticipated, and their parents are exhausted. So, they're overwhelmed with this concept. So, I've been working in pediatric critical care for a long period of time, and I'm not gonna tell you how long, but I really have seen over the years that that population of patients has grown significantly. And as we now have improved our care with sepsis, with COVID, with trauma, we're continuing to add to that population of patients. Yeah, I really appreciate the call-out about the COVID patients that we did see in the ICU. That was certainly our experience as well, is that they were largely these patients who had chronic comorbidities who were ending up in the ICU. And once again, the families that may not have had the resources that were necessary to be able to really support these children and came in exhausted with the challenges of visitation. Dr. Madden, can you talk a little bit about, and I don't know if there's a process at your hospital about who decides whether a child gets a trach or not? You know, is there a work group that comes to a consensus about it? Is the individual clinician responsible, you know, who's on service that week, responsible for making that decision? And what do you know about what are the trends across the country at other institutions? Wow, you just really wanted to do that, right? So clearly I could speak much more to my own environment and my own system. I've worked in a couple other places, so I think I can assess to that as well, but I don't know how accurately I can speak to the trends in the country, but other people here can certainly chime in. So it is definitely not just the individual clinicians who's on service that week. As a nurse practitioner, I'm an integral part of that team and part of what we have ensured is that every member of the healthcare team has a voice and the nurses are in the room far more frequently oftentimes with this population who potentially require a trach and they can bring some insight to the family's thought processes. We have, you know, and it's a struggle, I think oftentimes depending upon what the nature of the child's illness or clinical condition is, if this is somebody over time because they've had other underlying comorbidities and it's now just gotten to the point that they are no longer handling their respiratory status or their respirations or their neurologic status and we're seeing them being admitted to the critical state and what time between those admissions and other patients to be admitted because it was trauma or that the patient is at the CID center that is considered more temporary and allowing them the recovery phase versus others that have that chronic underlying illness and there isn't really an expectation for them to no longer need this. We need to envision our population of patients and weigh in on this conversation and oftentimes there's some really fierce conversations and very strong opinions that are found. You really have, we have a valued peer team that may not be the best title to that. Maureen, you're breaking up just a little bit. Can you talk a little closer to your phone? There you go. Is that better? I apologize. No worries. So I was just saying we have a palliative care team that we engage so they have much more of a different level of engagement with the families but they provide invaluable insight into their environment, to their resources, potentially to their understanding about what this may mean for the care of their child. So it really is a team dynamic. We come together, we have numerous conversations and we engage our surgical teams pretty early on so they can help make an assessment to see if there are other things that we could potentially do in the interim before we go onto that step of a surgical approach. That actually segues really nicely into, I was hoping, Dr. Madden, to hear from you but also from, really I'd love to hear from everyone about the role of those complex care teams, palliative care teams. So you've got your palliative care, we call ours our quality of life team but we also have a separate complex care team that provides a continuity of care. And so what is the role of the intensivist and how does that partner with this more complex care teams? Are you all, and so I'm looking now at the entire panel, are you all using complex care teams in that way? Do they function in the ICU as well or are they primarily outside of the ICU? We really try to partner with them in the ICU even though the intensivist may be the primary doctor in the ICU. So I'd love to hear from others. So in our institution, I'll jump in here first. We do have, we actually have three complex care teams. Of course you do. And the one that I think we interact with and interface with the most are the ones that we call them, the ones that it's our goal team. And they have the kids that have multiple devices. So trachs, vents, those kinds of things. And we tend to let them know that those kids have been admitted because what they bring is like that historical perspective. We don't have them, they can give us a lot of good information about what the family can and can't manage. As we're getting closer to those kids improving from the need of ICU level care, that's when they really, we have a lot of more interaction with them. So they can tell us like, you can send this child home on some oxygen because the family has been used to weaning or for feeds or something like that. So we utilize them. We let them know that their kids have been admitted to the ICU and what for. And then we will touch base with them as those kids are improving from needing ICU level care and helping us with decision-making as to how to include the family or what kind of care they will need following that. Thank you. Yeah, we have a, one of our group, his name's Rob Graham. He, a long time ago, took an interest in the patients who required home mechanical ventilation, whether it was non-invasive or through a tracheostomy. And so their team includes more than like two physicians and then a respiratory therapist. And they go out on home visits and they really get to know these families. They know their whole home setup. And so when the patient comes in, then what can happen is we can discharge them on higher settings and then they'll wean them or they'll tell us, you know, this is what they wanna do. And then because they don't usually go to the floor, they go directly home and then they come from home here to the ICU, because we don't have a, we don't allow mechanical ventilation through a tracheostomy on the ward here. So that's been really helpful for continuity purposes for the respiratory management part of it, of those patients. Yeah. I think it's just really interesting to kind of hear the differences in the way that we approach this because absolutely, as we talk about the long-term care of chronically ill children, there's such a kind of a rainbow of approaches to that and learning from each other is really the key part. Our experience here at the Children's Hospital of Georgia is slightly different from those that have already mentioned that. But I think kind of speaking to what several of the panelists said earlier is really a multi-professional multidisciplinary approach is the key part to all of those that are successful. And so involving families and all the different aspects of the care team, I think is really kind of the most important part of that. For us, we do have a new palliative care team and that's a very important part, especially reaching out in our region to areas that are more rural and have the later poor access to healthcare. I think that's been one of the ways we've tried to leverage that, but I just really enjoy hearing about other people's services as well too, because there are absolutely always opportunities for improvement. And for us, it's a bit more of getting all of the different teams involved and not necessarily a continuity team that follows these patients from the inpatient to the outpatient side as such. But I really just enjoy hearing about this from others as well. So Chris, you just brought up a good point that just triggered a question for me. When you talk about patients that are in some of the rural areas and their access to care, how does any of you, how do you deal with or how do you assess what resources a family may or may not need who has had not even, it doesn't have to be severe trauma, but any trauma, like sending a child home just on crutches because they broke their leg can be totally different if you are in rural Georgia or rural Texas for that matter. So how do we assess, how do any of you assess what resources may be that a family needs, whether they've had sepsis, whether they've been the victim of a traumatic injury, any of those kinds of things? I would just love to hear from the panel on that. I can say here in Texas, I rely for sure very heavily on my social work colleagues and case management colleagues who are exceptionally experienced and know different regions of Texas and know that, okay, down there, that the pulmonologist down there only does these kinds of events and not these kinds of events and oh yeah, there's rehab services available in this part of the state, but not available in this part of the state and just have really unparalleled knowledge to help us figure out how to support the families when they're closer to home. That's really impressive. I'd flounder without them, for sure. Yeah, that was my same response. I mean, the value that every professional team, again, the case managers and social workers are invaluable for that particular aspect in addition to many other things. But the rehab facilities you brought up as well, which is problematic. We really only have two viable rehab centers in North Carolina that we can send kids to. That for most of our types of kids after say severe traumatic brain injury and such, and not surprisingly, it's hard to get kids in those spaces. So that having those spaces to get kids to rehab, to transition to home environments, it can be a real challenge. Yeah, the nursing shortage has exacerbated it for COVID especially because there was such a shortage of nurses at the adult facilities that they took some of the respiratory therapists and nurses from some of the rehab centers, which then made us at our hospital have a huge backup because there's only one rehab hospital that takes trach and vented pediatric younger patients. And they didn't have enough staff because they had lost so many nurses and respiratory therapists. So we had like 30 or 40 kids just waiting for a bed there with a really long list. And we still have that because it hasn't improved because I think there's still a nationwide shortage of respiratory therapists and nurses because of all the impact of the pandemic on the staffing. Yeah. I've seen the same thing with not just the rehab facilities, but the long-term care facilities that our children go to or need placement in, just waiting in the hospital for months for a placement. And then some of the facilities are no longer taking ventilators when they used to take ventilator. So having to find a new placement for patients that live in certain facilities, it's created a big backlog in the hospital. It's real challenge. So I'm in a little bit of a different environment where I'm very fortunate. There's five rehab centers that I can reach out to, but we still have the same issues. As you said, in terms of the staffing issues, some of them have to do oftentimes because they're putting them in isolation now because of COVID. So that takes up beds for an extended period of time. But the other piece that I really wanna touch upon is the uninsured population as well. So we've been incredibly fortunate, as Kyle had said, we rely upon, and it's all our social workers and our complex teams and institutional memories about some things and leveraging for state funds, as well as federal funds to get insurance to allow particularly our dramatically injured population who now has sustained significant injuries and are now technology dependent and need to progress to rehab. But we've been able to leverage it because of our institutional memory saying, we know X kid that we were able to achieve getting insurance through our child and family services. So we mentioned by name, and now we have Y child who needs the same things and we hold them to it. And we've been fortunate probably 50% of the time that we get them insured and the other ones are still visiting on the other floors. In addition to that, so that's really good to hear. But when I think about resources, I also think about the family unit, right? And so how are we screening and how are we thinking about those families that have those children that have long-term care needs, but the family may be facing a need. There may be food deserts, there may be lack of transportation and that kind of thing. And I don't know that anybody has an answer. I do think, however, with the growing population that we have of the chronically critically ill, that this is gonna be something that we all have to think a little bit more about in terms of family needs, where are they living? There is a shortage of nurses and respiratory therapists to go to those homes and help them. And so sometimes those are the people that can see that, did you know the family's living there and their home is powered by a generator because they can't afford the electricity and the food and that kind of thing. So I just think all, if COVID did anything, it helped us to really begin to think about all of these processes that our families are dealing with. Sepsis is the same way. You had this child that was healthy, and MST, you had this child that was healthy, and now because of this horrific injury or illness or whatever, now they become a chronically critically ill child and how does that impact your family? And how does that impact the resources that you had before? I think those are some of the things that we have to think about from a system standpoint that all of us are gonna face because we're gonna have those backups in the hospital. So I would, and any other comments, thoughts on that, I would be very interested to hear as well. Well, I was just gonna add to that, Sharon. That's an amazing and super insightful observation. And I really appreciate that in the context of kind of the PICS or post-intensive care framework, especially as it's been adopted for children, that the categorization of social health is being important to that, I think is exactly what you're speaking to in the family unit and how that adaptation for the pediatric patient goes much beyond the adult framework for this and for trauma and for sepsis and for all of the other pathology and diseases that we take care of. The idea that long-term outcomes are something that we're becoming much more in tune with and getting further research and further data on and trying to optimize that is really the challenge and the opportunity for us. And it's not an easy goal to aspire to, but it is something that we as a community are obligated to do for our patients and for their families. And it does require sometimes going above and beyond to find those answers that kind of are outside of the guidebook as has been described by some of the others and figuring out ingenuity solutions to problems, I think is something that we have to tackle as a community to make sure that those that perhaps are marginalized for other reasons aren't in the ICUs and that we ensure that they get the standard of care and the best opportunity to recover as a patient and as a family from their critical illness. Agreed, thank you. Thanks, Chris. Other thoughts about any of that? I think just one thought that I had about some of our patients is they often go, especially if they were previously healthy, they could be super, super sick with sepsis or acute respiratory distress syndrome or after trauma, but then they have a period of time on the ward and then the ward will often discharge them home. And often, they go to the general pediatrics team or the general surgery team, even though they might've had neurologic trauma as well as other system trauma. And when they get discharged, these kids with very, very severe lung infections often don't get followed up with a pulmonologist or if they have status asthmaticus triggered by flu or COVID, they don't get followed up by an asthma allergy or asthma specialist pulmonary person because they're thought to be kind of a one-off, that it just, oh, it's just bad luck that this patient got sick. But in my research with the flu follow-up, we are just now starting to do follow-up. We did follow-up of MIS-T and COVID and then flu. Up to like even 90 days, we found that a lot of these patients, about a quarter had ongoing symptoms and activity limitations of the, especially of the acute COVID and the MIS-T patients. And it was, some of it was associated with their underlying pre-illness diagnoses, like the ones who had activity limitations tended to be more obese and they have more higher percent of obesity and those with respiratory symptoms tended to have an underlying diagnosis of asthma. And so, but they weren't getting seen, followed up by the specialists and they weren't getting ongoing prevention, right? Interventions. And then because they had MIS-C, the ones with MIS-C who were obese, because there was a quite a high percentage of obesity, but a lot of MIS-C patients also have myocarditis. So they're told to limit activity for three months and they're on steroids. So, you know, the worst combination. So we're, and you know, we don't know why we're telling them to do certain things because we didn't know the, what was the disease really doing to their heart? You know, we made a lot of assumptions, but it made things worse on the outcomes. So I think that, you know, it's really, and in the ICU, we don't see what goes on afterwards and very few of us do outcome studies. So I think we have to develop more protocols that we get pulmonary involved quick, you know, in the ICU and they know that when the, and they follow the patient discharge and then latch onto them, you know, and we have outcome studies that show the pulmonary and allergy asthma people that they need to follow this group because they're at high risk of relapse. Although Adrienne, that even brings up another large problem that we're not going to solve in the next few minutes, which is the overall workforce. So, you know, the ability to find outpatient pediatric pulmonologists and even the pipeline. And as I've moved into new roles, looking largely at how do we recruit, you know, fortunately we have lots of folks who want to do ICU because why wouldn't you? But specialties is sometimes difficult. And then as we go back to those rural settings and those underserved populations, it's hard to find those specialists. And so that's a different challenge. Can I ask- In addition to that, go ahead, Nick. Sorry, go ahead, Nick. I was going to ask you a speculative question that kind of primarily is aimed at Dr. Fitzgerald and Dr. Randolph, but also applies for Dr. Watson, Dr. Madden, but what do you see the role of more routine or do you see the role of more routine whole exome sequencing in the, for PICU populations? What are your thoughts? Yes, I mean, and as Julie knows, you know, we've been doing, she's been part of a big study we did on COVID and MIS-C and flu. And so there are certain patients that, especially those that present, you know, early on who have an underlying, you know, immune deficiency that was undiagnosed. And so, you know, these kids that come in with really, really supposedly previously healthy or might've had like some baseline reactive airways disease or something, but now all of a sudden they're on the ventilator intubated. It's actually an uncommon, you know, complication for previously healthy children to get that sick. And so a decent number of them do have underlying variants that might explain why they got so ill. And some of them need to be treated and followed up by immunology. So I've been working with a pediatric immunologist here and Julie can comment at her institution, but they, you know, we work up all the MIS-C patients and about 10% we've identified different variants that could be triggering hyper-inflammation. Some of the acute COVID patients who are previously healthy but then got really, really sick, which is very rare. Also, we found some things. So, and I'll let Julie comment because she has a even more organized system where she is. Sure. So I think Adrian's alluding to something called our immune dysregulation team that we now pretty much consult on anyone who gets very critically ill out of the norm for kind of their underlying past medical history. You know, so those previously healthy kids who come in, you know, in really bad mods and very hyper-inflamed and we don't know what's wrong with them. And they're generally doing whole exome sequencing on nearly all of those patients. And a lot of times they're sending rapid exomes and a variety of other tests for them. And then there's several research projects that I know kind of going on in the US and Europe that were recently funded to look at genomics, proteomics, immunophenotyping of children to see if we can pick up on that who have sepsis to see if we can pick up on underlying genetic variants that could be contributing to these phenotypes that we see. And if we can get kids with recurrent infections into immunology, follow up sooner, those sorts of things. So areas of active investigation. I think the question when we start sending lots and lots of whole exome sequencing on these patients is then what do you do with the results? Who looks out for them six weeks later when they come back? And when you have all these variants of unknown clinical significance, you know, what do you do with that? And how do you report that to the family? And our immune dysregulation team now has every couple weeks or monthly meeting where we review the whole exome sequencing and everyone kind of puzzles over it and tries to decide what to do with the results. And we're starting to see some stewardship of the genetic testing where if we send things as an inpatient, the genetics consult team has to get involved and approve the exomes being sent to make sure that there's appropriate followup and someone that's knowledgeable about what to do with the results that can help with the interpretation once it comes back. That was a nice cycle back to where we started about the unique phenotypes of critical illness and personalized treatments. Yes, and with that, I thank each and every one of you. This has been a lively discussion and we've touched on so many things, but all things very pertinent to our populations and it's critical care. So I will say Julie and Adrian, we look to you to see what's happening next in terms of phenotyping and exome sequencing. And what do we bring back to the bedside? Chris, we're gonna see what you tell us about these trauma patients and what do we do with them, Maureen, as they end up as our chronically, critically ill patients and what do we need to expand to in terms of how we care for them and their families as we think about resources that any of these patients with even the exome patients, the sequencing patients that you talk about, if we find something and there's something long-term, then how do we help this family? How do we resource this family to deal with whatever it is that they now need to deal with? So lots to come. So we all have long careers if we want them in PEACH Critical Care because I think there's lots happening and lots going on. So I thank each and every one of you and of course my co-chairs for this session and the time that you have spent to do the recording and be here with us today. Thank you so much, everyone. Thanks very much. Thank you. Great to have you. Thank you so much. Thank you. Thank you. And then tomorrow, please join us. We have some more sessions lined up and you can see those at the bottom. So starting tomorrow morning and then tomorrow afternoon as well. Thank you.

pediatric critical care

precision medicine

pediatric sepsis

COVID-19 impact

chronically critically ill

interdisciplinary teams

resource disparities

whole exome sequencing

social determinants of health

patient-centered care