Good morning, everybody, and thank you for joining us for this session for current concepts in pediatric critical care. My name is Sharon Irving, I'm an associate professor at University of Pennsylvania School of Nursing, and I'm a Peds critical care nurse practitioner at the Children's Hospital of Philadelphia. And I welcome all of you and thank you for taking the time to join us today for this session. In addition, I have my two co-chairs with me here, past chair is Dr. Nicholas Ettinger and my co-chair is Dr. Kyle Rader. Kyle, I'll turn it to you. Good morning, everyone, and thanks for joining. Thank you, Dr. Irving. As mentioned, I'm Kyle Rader. I am the pediatric intensivist and vice chair of education at Duke Children's Hospital in Durham, North Carolina, and I'll turn it over to Nick. Good morning, welcome to everybody. I'm Nick Ettinger. I'm a pediatric intensivist at Texas Children's Hospital in Houston. And I'm very excited to have everyone here. Yeah, thank you so much again for joining. So with that, we'll just have you all introduce yourselves, if that works, our other panel of panelists members. So we'll start off with Dr. Yeya. Hi, I'm Nader Yeya. I'm one of the pediatric ICU physicians at the Children's Hospital of Philadelphia. Dr. Schwartz. Hi, I'm Stephanie Schwartz. I'm one of the pediatric ICU attendings at the University of North Carolina at Chapel Hill. Dr. Chetia. Hi, I'm Paul Kecky. I'm one of the pediatric cardiac intensivists at Texas Children's Hospital as well. And Dr. Timmy. Hey, good morning, everyone. My name is Sebastian Tuma. I'm one of the cardiac intensivists at Texas Children's Hospital. Welcome again to everybody. And so in terms of format, this will be more of a discussion between all of us. We have, everyone has looked at your slides and you know what you've put out there to us. So we'll just start with kind of a discussion. And I'm actually going to ask you a question, Dr. Chetia, am I saying that right? I hope so. No, that's all right. It's Keckia, but it's not an easy name, no worries. So I'm going to start out with you because I've done a little bit of work over the years in pediatric cardiac intensive care and done some publishing with cardiac more in terms of growth and such, but we've done such a good job over the last decades in terms of survival and improvement. And now we have these children that are young adults and into adulthood. And you did a wonderful job here in talking about heart failure. So how do we educate not only the patients themselves, but the other providers that as they transition to adult healthcare in terms of managing them with their congenital heart repairs or palliations and seeing heart failure in those, because it's not the traditional heart failure that our adult colleagues are used to seeing and managing. Well, that's an excellent question and one that really what, so we did something unique here at Texas Children's that probably can't be done elsewhere just because of the size and the resources, but we just built ourselves an adult congenital heart program and an adult congenital heart ICU just for the adult survivors of pediatric cardiac disease. And we know that that's unrealistic in terms of every other program, but you can't, not everyone can build their own standalone adult cardiac ICU. However, you're right. The majority of heart failure in a congenital, well, let me rephrase, congenital heart disease accounts for the bulk of what then ends up being chronic heart failure in a pediatric setting. And so the knowledge of where those lesions started and how that progression comes about to failure and then ultimately to survival is something that is now, I guess, from a generational standpoint, a nice new problem to have, right? Because I use in one of my Grand Rounds talks a few years ago, pointed out that if you were a child born in 1930s, for example, with congenital heart disease, you were going to die. It was just a matter of, did you die in the first hours or in the first few days, but either way, it was a non-survivable lesion, no matter what you had. Well, within what, a generation and a half, we now expect 100% survival when you get admitted with a congenital heart defect. We know that that's not realistic, but now these kids are growing up into adulthood and all these pediatric or the adult cardiac practitioners are like, we don't understand this piping. This was not what we signed up for. And so it is an evolution and all we can do is bridge that gap and we're not the only ones, right? Neurologic disease, cancer, lots of other chronic pediatric diseases turn into adult survivors, but this one's unique and it's going to take, I think, at least another generation of educational initiatives to providers to bridge that gap. Yes. Thank you. Thank you for that. I've got a practical question for you, Dr. Heckia, and also I'd love to hear from the others. So we've got a couple of cardiac intensivists and a couple of general intensivists on the call. You know, that patient that we have come in that we know has significant heart dysfunction and you, I really enjoyed, you kind of presented that plethora of pharmacologic medical options we have for managing heart failure. But you have that patient who comes in who has significant dysfunction, but yet at the same time is hypotensive. And so you want to provide that afterload, but you know, it's hard to do that in the face of that patient who's hypotensive in front of you. So we'd love to hear from the panel, kind of strategies, techniques, because I feel like that's a common clinical scenario at the bedside. I'm going to, let's see, Sebastian, let's see how close we are together on this. And I will tell you that first off, if you polled our faculty across the board, half would say, well, you start vasopressin and the other half would say, how dare you start vasopressin, right? So let's just, I know what I put in the slide. So Sebastian, I'm going to put it to you as well, and then we're going to go around and see how close we are. I would say it's one of the toughest situations that you can face, and actually in a setting of cardiogenic shock with hypotension and depressed function, because your options are very limited, certainly if you're not responding with inotropy enough. I think the limitation, and partially because it's part of my presentation here, is that we don't have robust enough hemodynamic data in pediatrics. We can't use swan-gans catheters, and we guide ourselves by what we call touch and feel rather than actual numbers of cardiac output and systemic vascular resistance that we could titrate to. So that's very important. When it comes to actually vasoactive agents, I think this is where we have opportunities to continue to improve as intensivists. I think there is a recent publication that came out by one of my colleagues, Dr. Bronicki, that actually highlights the importance of understanding ventricular compliance or pressure volume loops response to various inotropic support in heart failure patients. And for sure, vasopressin is not one of them. If anything, that's actually a very easy way to assassinate our patients in a setting of systolic dysfunction in a patient with hypotension, purely demonstrated multiple physiology and obviously educational type of publications that that's one way to cut down your cardiac output by a significant number. So I think, personally, for me, it's a very early indicator for mechanical circuit to support for these patients without even getting into complex pharmacological management strategies. That's the patient population that gets me very, very concerned. And usually I revert to a conversation with surgeons and heart failure teams in regards to mechanical support therapies. Yeah, if I could jump on that real quick as well, just to highlight the idea that you can manipulate, as you said, the cornucopia of drugs that you can throw at a kid in that state and you can manipulate it. We could probably, quote unquote, get by in the short term, but that is not a sustainable entity. As Sebastian pointed out, we have evolved into doing mechanical support extremely well, both in the short term and now in the longer term. And we no longer need to just get by with throwing around a lot of drugs and titrating based on a blind box that we have without monitoring to move to mechanical support faster than we've ever had is really the way to go. So Paul, one of the things you brought up in your talk, which I thought was a really excellent point, was there are various options to choose, and it's not so important which mechanical support option you choose, but making sure that it's a well-run program. So tying back into monitoring, what are some of the things that one has to have in place to have a well-executed mechanical support program from the pre-starting them on mechanical support to while they're on the medical, once they're actually on something? Well, I think first and foremost, it has to be the acceptance. Well, I guess let me put the trust that my statement that I had is applicable within your institution. And the statement that I made just a second ago was that you're doing mechanical support well. The people at the bedside have to trust that that actually is reality because we know that some of our colleagues in any place in the country will look at mechanical support in any venue, whether it be ARDS, shock, you name it, as, well, the kid's going to die anyway. Why are you doing that? I think that's an outdated way, but there is still that view. So first, you have to have trust that your program has excellent outcomes with mechanical support. Secondly, I don't view, and this I'm really going to rely on Sebastian for this one because I know we agree on this. I don't view therapy or intervention as a gauge of monitoring. In other words, don't just say, well, I'm on six inotropic medications, and then therefore I need mechanical support. Well, I can take you right now and put you on a variety of drugs, and though you're healthy, say, well, see, now you're on six different things and I'm turning like crazy, you should be on support. No, we have to monitor children effectively and just have a well understood, what are the thresholds? It is not one individual number of, well, when the SVO2 drops to whatever, if the lactate goes up to whatever. It really is a constellation of an understanding that this child is not going to go the way you want them to go, and we should go pull the trigger for mechanical support. And on that, I'm sure you're going to, I hope you're going to agree with me, Sebastian, on that. Yeah, I think it comes to implementing a therapy and actually seeing a response, and that has to be a positive response, and if it's not a positive response, then you have potentially other options, but very limited, because the more you put on, then typically these patients become worse candidates and much more debilitated, so I think the earlier the better, the better recognition of failure to response to therapy is your good signal, and that's all we have. We don't have the numbers in pediatrics, unfortunately, we have to rely on that. I want to bring Stephanie and Nader into that conversation, and what do you do, either similarly or different, in your institutions? Sure, as Sebastian was talking, my first thought was, my question is, where does mechanical support come in? Because that's why, you know, my first thought is those patients are rolling, as we're struggling with hypotension. I would say what we do at UNC, in our Pete's Cardiac ICU, which I do 50-50 between PICU and PCICU, but in our Pete's Cardiac ICU, it would be inotropes first. We are not quick to put vaso on for all the reasons that have been said, but then we start talking about mechanical support, if we're not able to achieve it with inotropiola. Yeah, I don't disagree. I practice exclusively in the PICU, and so I don't, we have a, we're blessed to have a separate cardiac ICU that I don't go to. We do occasionally get overlap patients, and patients in whom the diagnosis isn't quite straightforward at presentation. So some of this kind of depends on whether sepsis with myocardial dysfunction, or, you know, like the beginning stages of myocarditis is a very fuzzy area that has a lot of overlapping physiology with the problem you guys are describing. And so in those patients, like, certainly while things are being figured out for us, like I, things like epinephrine as well, is like a relatively low trigger for like norepinephrine as well, primarily for like improved myocardial, like oxygen supply-demand balance and improved coronary perfusions is like a drug that I'll reach for sooner rather than later. But once it becomes clear that the major malfunction is pump, okay, more so than the other things which are related, and that hasn't reversed in some time where the trajectory is such that it looks like it's moving toward like worsening rather than improving in any meaningful way. We also, we also tend to move toward ECMO fairly quickly. For exactly the reasons you guys are talking about is like most of those etiologies, like you can handle, you can finesse some degree of function, but that substrate tends to also have function plus dysrhythmia, or like those kinds of patients often have like, you know, like an additional problem. And like, any one of those things is hard enough on its own, but when you start stacking all the cardiac problems for this type of diagnosis on top of each other, it's just better just to bypass the entire problem while things cool off, I think. So once we, once in my hands, once these overlapping patients have clarified their diagnosis, if it seems more similar to something that you guys are talking about, then like, yeah, we tend to like also move toward mechanical support pretty quickly. I also love where you all went with that, because I feel like a big part of our role as leaders of the intensive care team, and by that, I mean physicians and our advanced practice providers and others, are to help the team understand where we're headed and anticipate what's coming next. And I think all of you all went there right away, you've got to deal with what's in front of you, but this is where we're going to be in five minutes, 10 minutes, 20 minutes, and we need to start prepping for that. So that was great. Thank you. Yeah, thank you. So I'm going to take exactly what you all said and shift to you, Sebastian, in terms of the monitoring. You mentioned that in pediatrics, we don't use thermal dilution monitoring and Swann Gantz and such. So how would you educate, as you said, Kyle, the team in terms of what kinds of things do you need to watch? And when I say the team, I mean your residents, your nurses, your nurse practitioners that may not be as familiar. How do you educate them? Because clearly you as the attending are not at the bedside all the time. So when do they need to be really heightened? You know, what kind of monitoring do you push them towards looking at and really becoming well adept at? That's a great question. I think I alluded to this a little bit in one of the comments I made, which is observe for response to your therapy. So if you put an inotrope on, ensure that you actually have a response to it. So either narrow down oxygen extraction ratio, clear of lactates, or improve perfusion pressures, right? So I think that's essential. After implementing therapy, you need to look for a response. I'm a little bit biased because obviously in a cardiac ICU, we're very heavy in regards to monitoring with NEARs, et cetera. And that's not always available in every unit out there. But I think to compensate for the lack of monitoring that we have in pediatrics, specifically with lack of Swan-Gans monitoring and thermodilution, we do have to utilize other technologies that give us signals. I always refer to, or at least emphasize to my fellows or residents on service, that it's essential for you to understand the errors in monitoring technology rather than actually accurate numbers. Because I think as a foundation of every intensivist, you should know what to do with true numbers. And you will know what to do. And you will know what medications to use. I think the failure that we have is we actually act on erroneous numbers or an inaccurate measurement technology. So I think this is essential that even sort of building on top of what you have already learned in these lectures, you continue to build your understanding of every one of these technologies. And that includes now this field shifting into a non-invasive hemodynamic monitoring technology such as non-invasive continuous pressure monitoring or a transpulmonary thermodilution technology which is utilized instead of a Swan-Gans with a less invasive method in pediatrics. I think the most important aspect of it is to understand its limitations. When you will get inaccurate numbers, because that's when you need to back away or amplify your therapies and understand that you might not be running with the right data. And that's why I think it's essential that we, you know, our representation is extensive. Supply yourself with a lot of monitoring so that you can be covered from various ends. And when combined, that data should be giving you a positive picture of where your patient is moving in response to therapy or where your patient is not responding to therapy. Yeah, I think with monitoring, it's tricky because as intensivists, we always want more data and we thrive on that. That being said, it's so hard to show which of that data really changes outcomes. And as you mentioned, Swan-Gans, you know, certainly that's been, I think the issue is to show how that truly changes outcomes. And so I think the tricky part, and would love to hear your thoughts is, A, how can we get that data to really show how this changes outcomes or what are those right patients when we know that this is the one that we need to get a Swan-Gans in even though it's not something that we use routinely? It's extremely difficult. If you dig deep into an entire studies with the Swan-Gans technology, and this is going to translate, I think, into many other technologies is how do you actually, what outcome do you look at? If you're going to be looking at mortality as an outcome of monitoring, I don't think that's the right approach to take. If you're going to be looking at minimizing adverse events or actually in the response to actually positive hemodynamic response or positive clinical response, I think that's much better way to approaching it. It's extremely difficult. And if you look deep into the Swan-Gans studies, et cetera, the patient population selection was terrible in some of them. It shouldn't be used in a straightforward patient that comes in, you know, with pneumonia into regular adult ICU and utilizing a Swan. There's no role for that device in there, but maybe shifting it into a focused patient population that you really need to be fine-tuning your therapies to a specific hemodynamic profile. So I think it's extremely complex. I don't have great sort of solutions or even suggestions of how to approach this. And we've sort of thought of it, we think about it a lot here, especially like here at Texas Children's with our group, and it's difficult. We've had some signals where we could potentially pick up some positive responses to utilization of these technologies in very selective population, but nothing very specific. If I could also add in there, even taking it one step earlier than the Swan, you know, I love the NIRS monitor, right? I just do because, not because I think that it's the number to hang a hat on, right? But it elevates the discussion amongst the bedside team. And specifically, it elevates the discussion that you have with that relatively recent new grad bedside nurse who you throw into the mix and they say, well, what am I supposed to look at? You know, that number turns red a lot. Well, instead of it just being a random number generator, it opens up the discussion to say, okay, well, that means that the oxygen extraction ratio has changed. So what does that mean? And we actually published this, God, now it's far too long ago, around 2000, at my first job when we got to Loma Linda, and the outcomes of their Norwoods were, to put it mildly, horrific, right? And one of the things we did was we, this was prior to NIRS, but we used the SVO2 drawn from a central venous catheter, and the bedside nurse did the oxygen extraction ratio calculation every time a venous blood gas was done. And they understood what was widening and what was narrowing and where it stood. And that triggered the conversation to an attending physician if there was a change in that. That alone, it wasn't the number. It wasn't that the SVO2 dropped to 30 and we kept it from doing that that changed the outcomes of these kids and went from a 10% survival to an 85% survival. It was one piece in the entire conversation of building a knowledge base about what's happening. And it's the same, I find it very funny because you could have the same conversation about an arterial blood gas. Show me actual data that shows that measuring a PaO2 in ARDS truly, truly changes outcome, right? But yet we do it and saturations could be the same thing, but it's in our lexicon of the way we approach a patient and everybody understands it. And if we have these conversations with hemodynamic monitoring, it's the same thing as Sebastian said, it avoids the touch and feel. Well, the feet are warm, so it must be okay. Oh, come on, we're way better than that, right? You gave us an excellent segue to go to Dr. Yeha and talk about ARDS, which I know is one of your favorite topics. Talk about how do we help our teams to really monitor without all of the lights and whistles, as I call them, in terms of ARDS and some of the non-invasive things that you talked about. How do we help them? So in terms of monitoring, then the problem with ventilators in general is the different brand names and the different modes all have a little bit of fussiness to them. So the pip in one thing is not necessarily the same thing as pip in another. And so people get lost in some of the nomenclature, particularly when people on this panel, I've been doing this for a while, probably understand the nuances in a way that I wouldn't need to explain them. But the people actually making the decisions at bedside, the entire system is operationalized with frontline providers who have variable levels of training and variable levels of understanding of the nuances of different modes and terms. And so it's very easy to get confused. Like a resident, first time they're playing with a ventilator, know about tidal volume and respiratory rate. They may know about pip and peep, they may know about FO2, but that's about it. And then the concern ends up being like, what am I missing? Are there different things that we should be monitoring? And I think having a better understanding of the machine that's in front of you, available in your institution, and really getting that is probably fundamentally more important than having access to newer and better monitoring technologies. You have access to what you have access to, use that well. And over the last probably 50 years of ARDS research, we haven't really moved the needle with respect to the degree of supportive care that we've provided. The positive trials have essentially said, don't use 12 mLs per kilo and let your pips and plateaus go to 50. And there seems to be a consistent signal with proning and there's fortunately seems to be a reasonably consistent signal with ECMO in the severest of patients. But everything else hasn't really evolved much more beyond that. The exact, the precise level of peep of just right, but not too much, the precise limit of should your pip or plateau be 30 or 40 or 45 isn't really there. It's really just like, don't do 50 and that's probably defendable. But everything else is not particularly defendable. You can't get too religious about it. And so you're stuck with this idea that I can probably damage the lungs if I overdo it. Okay. And I can probably damage the lungs if I underdo it, but there's this sweet spot in the middle that I'm trying to live at. And what are the best surrogates for this? And people have tried different things. So people have tried operationalizing tidal volumes at six per kilo, but because nobody believed it because of this entire conversation that we're having right now of like the trial really demonstrating that 12 per kilo is probably bad for you more so than six per kilo is good for you. Everybody lives at somewhere between six to eight per kilo or six to nine per kilo. And the top recommendations are five to eight per kilo, you know, because even that is a task acknowledgement that like even the six per kilo thing is probably like not true. And the precise limits on plateau pressures are like, you know, people then said, okay, like maybe, maybe forget about tidal volumes. There's enough variability there. Let's talk about plateau pressure. Certainly if you're like lung is being stretched past a certain point, then, you know, we can, we can at least follow the peak pressure of the plateau pressure, 90, well above 90% of like North American pediatric practitioners use some sort of decelerating flow, like either pressure control or PRVC is their primary modes of ventilation. So nobody necessarily measures plateau pressures on the routine. So the one thing that everybody's like labeling according to like referencing adult data to drive practice is referencing an inaccurate measurement relative to what the modality you're using. So it's impractical. So nobody does it. That also itself lends itself to a certain amount of fussiness. People then like more modern things, people have looked at things like, you know, like composite variables like driving pressure or PIP minus PIP or plateau minus PIP or power. And we're all getting at the same concept. We all have this idea that you can do too little or too much of it. And there probably is a sweet spot where you're in the middle, where your lung is just open enough, just being ventilated well enough to bypass the function of the lung, to help support the function of the lung. And at some point you're going to overdo it, at which point you're going to need either adjunct therapies or ECMO. And so I think we all have that sense of it, but we're still struggling to find like, what is the right monitor that's going to get me this? You know, questions as easy as pressure and volume haven't been answered in 50 years to any degree of satisfaction. So we're essentially puddling along, doing what we've done for the last 50 years, and just putting different types of window dressing on it. PEEP and PIP, for example, and Plateaus, with the, in adults, has been compounded by varying degrees of obesity over the last 50 years. So now, suddenly, the need or the utility of an esophageal manometer is suddenly very different than it was a while ago, just because of the changing population that gets ARDS. And that's true in pediatrics as well. We have a lot more kyphoscoliosis, and a lot more obesity, unfortunately, a lot more abdominal competition, where suddenly, your PEEP of 10 may not necessarily be a PEEP of 10 at the level of the lung. Is it important to know exactly what it is? Or is it, to Dr. Retter's point, is like, do you just need to know approximately, like, do you just need to be good enough? But knowing precisely what it is isn't as helpful as just having a ballpark sense of it. So do you need this specific equipment? And then to Dr. Tumey's point, how do you actually prove that measuring this specific number was, in fact, helpful? And so even in ARDS, we struggle with the same stuff that you guys are talking about in cardiology, and in general, ICU, I think, and with respect to monitoring. So following up on that point, Dr. Yeh, what's your personal practice when a child comes in with respiratory failure, acute lung injury, what's your personal practice in terms of, what are the things you're looking at, and admittedly, it's imprecise, to switch a child from conventional ventilation to APRV, or to switch a child from conventional ventilation to high-frequency, or from APRV to high-frequency? Like, what are the things you're thinking about in your head? Yeah, so my own cutoffs, like, if you reference, like, the adult plateau pressure limits of, like, 30, and the pallet guideline, which recommends of, like, you know, somewhere between 20 and 32, which is 30 plus minus two, then the community as a whole has kind of decided that around 30, people should start getting a little bit fussy, and looking a little bit more closely at whether you're approaching damaging levels of ventilation. And so my own practice is right around then, like, you know, and using, if you are either inadequately optionating, and you're unwilling or unable to go higher, because the ventilator pressures are reaching mid-30s or low-40s, okay? And, like, that's about the limit where I think people start seeing, they start seeing whether this will become better in a few hours, with just, they just, the patient just needs a little bit of time to re-recruit, and that those numbers will, in fact, improve to a more tolerable low-30s, high-20s, or whether this is gonna stay elevated, or, in fact, you're actually catching them at an escalating point, and it's only gonna get worse. So when you're in that, like, kind of mid-30s to low-40s kind of range is, I think, when a lot of people start thinking about alternative modes of ventilation. And then the question of whether it's, like, APRV versus the oscillator, versus, like, high-frequency percussive ventilation or jet ventilation, like, I think there's more nuances that go into that. If you're dealing primarily with oxygenation things, a lot of people will lean toward APRV or the oscillator. If you're leaning more toward ventilatory things, then, based on institution availability and practice, like, you may lean toward, like, high-frequency percussive ventilation or jet ventilation. And if it's a little bit of both, okay, then, like, then an argument could be made, like, what you think your worst problem is, and try to target your therapy toward that. Each of these modes have advantages. Each of these modes have disadvantages. None of them have been proven superior or particularly inferior to others in a convincing way, in my opinion. And so, like, I think the way I approach all non-conventional ventilation is that none of them have proven superiority to conventional. So they should all, at this stage, probably be considered salvages at best. And then what they salvage and how they salvage is probably nuanced enough that it's hard to kind of tease out, like, how to get the right patient on the right ventilator at the right time. But, like, but that, at this stage, I think that's where the data is. Okay, like, you probably shouldn't use these modes necessarily up front. I can't, there aren't many situations in which I think you can be that religious about saying this is the right mode for the patient at this time. But I think that, like, you can justify APRV or oscillator in certain hypoxemic situations. The oscillator, even in some ventilatory situations, I think you can justify high-frequency percussion or jet in certain ventilatory situations. I think you can justify partial cardiopulmonary bypass with, like, E-core devices or ECMO in very specific situations. Yeah. So that, yeah, I, you know, you've already answered the question when I was gonna push you on which is the right alternative mode to go to and make you choose one. Because I think, as you said, there's multiple potential advantages to each one and it depends on your patient. I will say, though, you said earlier you need to know the machine in front of you. And I feel like any of these modes have potential to do harm if you don't know what you're doing. And unfortunately, I think I've seen that with all of the modes that you've mentioned. And so thoughts about how do you prep? Again, I'm gonna focus back on the entire ICU team as you go into the alternative modes that you may not use very frequently. How do you prep them to make sure that we're not causing additional harm with these nontraditional modes? No, and this is a good question. I think it's also actually relevant to the conversation doctors Keke and Tume were having earlier with all of us. And you can find the right patient for, like, a PA catheter, but if you're only using this thing once every other year or something, then, like, you create a different problem. Like, people aren't comfortable enough with it that, like, then you get all risk and no benefit or minimal benefit, right? Because then it's like it's, and I think the less invasive the technology, you're more willing to tolerate the imperfections of NEARs because it's relatively low risk, you know, arguably, right? Compared to the PA catheter, at least, right? Whereas, like, the more invasive your technology gets and the rarer it gets and the more specified it gets and the less experience the culture has with it. And so then you create opportunities for more risk. And so there's absolutely, you gotta be sensitive to the fact that, like, that as much as these slideshows talk about, a given ventilator and a given patient, what you're actually doing is taking care of a patient in a system. And that system really needs to buy in and be, like, educated accordingly. And so for us, a lot of what we've done with respect to the modes of ventilation that we use, like, in a 4,000 admission ICU, okay? Like, the oscillator probably comes out about, like, maybe, like, I wanna say 30 times a year, okay? APRV comes out about 10 times a year and high-frequency percussive ventilation comes out about 20 times a year. ECMO for pediatric indications comes out about 15 times a year. So these are numbers relative to the 4,000 that are bit askew, right? And so how do you keep people aware? So there is a lot of focus on just-in-time training of, like, kind of huddling up the entire team and different treating teams, okay? Nurses turn over, like, in 12 hours and they, like, they cluster their shifts, okay, within three to five days. So there's kind of a constant attention to this as a component of caring for a patient on a different modality or an uncommon modality that is also part of your training. So you're more inclined to, like, have a list or a referencing of, like, this is a, you know, low-frequency but high-impact therapy and that perhaps there should be a little bit of thought to the entire team structure around it, not just that the residents know what they're doing or not, but, like, but actually everybody knows what they're doing or not. So that, like, you know, respiratory and nursing and the resident have a shared mental model of what suctioning at what frequency on the oscillator means without telling you what answer, like, I would think is correct for a given patient, right? It's like, it's like, as long as we all are thinking about it the same way, you're probably better off than those three disparate people having three disparate opinions about it. And I think it's more that, that, and so just in time training, like, being conscious about it, like, one way we've operationalized it is alternative modes of ventilation are actually called out in our safety huddles twice a day as a low-frequency, high-impact, low-frequency health, I guess, yeah, type of intervention. And so we actually call this out as, like, okay, like, people should pay some attention to this. The faculty around it, like, do try to do some specific teaching when those things are on, okay, to make sure that, like, and not just to the providers, but also, or the direct ordering providers, but also, like, the nursing and the respiratory staff to make sure that any misunderstandings or alternative understandings or other interpretations of the data, and this isn't to say that, like, you know, what the attending says is necessarily correct. I've talked to enough physicians in my life to know that's not true, but, including the mirror, but I think it does at least provide an open venue for everybody to kind of talk about what they think is going on and how this thing works. And I think that communication, I think it's, that's probably translatable to any of the stuff that we're talking about here. I think, Nada, you bring up a good point. All of you have brought up very good points about that, and, Paul, your point as well. Those conversations, like the nurse, as the nurse in the group and as the advanced practice provider in the group, having those conversations on a regular basis about varying things really empowers those nurses, those respiratory therapists and everybody at the bedside to not be afraid to ask because what happens is, you know, there's the assumption that they should know that, right? Or they should understand that. So having those conversations with not a ideology around whether or not you should know it, but just as we should go over this to make sure that we're all on the same page, to make sure that we are all thinking about things the same way, and that you as the bedside eyes and ears, whoever that is, knows when to pull the trigger and say, we've reached this threshold, and now what is there to do? You know, one of the things that I have always practiced as an advanced practice provider when I call my attendings and Nada could attest to this, I'll usually say, I've done A, B, C, D, and E that we've talked about. I don't know what the next set of things are. And we all come to the bedside and be like, what's next kind of thing. So I think that that's an excellent way to continue to educate our bedside providers at every level. So, you know, picking up on that as well in terms of, then I'm gonna transition to Stephanie when it comes to sort of burnout, because I look at the idea of what you're talking about as the source of burnout, right? There is a balancing act between, look, I think that cardiac ICU should be separate, right? I've made my career on that, because I think there's a wealth of knowledge, just as you were saying about what's specific to a certain physiology state that helps people get comfortable and therefore not burned out by trying to know everything. However, there's a balancing act, right? I don't know head trauma. And I've actually had instances in my career where we've admitted a Fontan, a teenager in a motor vehicle accident with head trauma, right? Now tell me that that's not fun physiology, but at the same aspect of things, that's where separate and specialized has to break down into team and everybody gets to know what their specialty is. It is an interesting thing that I have less burnout because I don't need to know everything. But at the same time, it puts me in sort of moral distress if I don't know something and I can't reach out to somebody else. So I'd love to hear people's thoughts about that balancing act. Yeah, Paul, I think that's a great point. And I think really the communication becomes so key in what we do in both the PICU and the PCICU side. And as Nader was talking, I was thinking about with our severe ARDS patients, particularly with junior members of the team, whether that's residents or new nursing staff, really having an open communication of what our goals are, right? Because if you read the police guidelines, right? As a sad of 89 and a kid with severe ARDS who's otherwise got inordinate and perfusion that is okay, I'm not worried about that kid sat and you're gonna potentially cause worse damage by turning things up. But my bedside resident may be very worried and concerned about that. So I think sitting down and making sure that we have open communication is so huge. That's one of the things that made me fall in love with PICU, right? Is that you have a chance to have a team approach to all of this and really working with open communication. And I think when we talk about burnout, the communication becomes a huge key factor. There's making sure that people are able to have conversations about what's going on. Stephanie, I wanna continue with that conversation. So we've talked a lot about the nuances and the technology and the devices and the monitoring. So how do you, how do we as a community working in these environments really protect ourselves and each other from burnout for the reasons that you said, Paul, like either feeling like you have to know something about everything or being so specialized that these other things come in and you're like, I have no idea what I'm dealing with. So how do we help ourselves and protect ourselves? That's a great question. And I'm assuming we need more work to be done in setting this in randomized control trials. But I think similar to several of the things that we've talked about already, right? I think it comes from both a systems approach and an individual approach. Having systems that allow for people to talk when things are going poorly, to feel respected in that communication and that conversation is hugely important to feel like their opinions matter and their thoughts matter is important and creating a culture that embraces that is important. And then also doing things on the individual side so that each member of the team to help build up your resilience of doing things that you're passionate about that matter to you for your career are super important. So I don't think it's one answer that is true. I think it's a combination of all of this. I was struck by your slides about work-life integration culture. And I wanted to ask you, what are you, just cause you didn't have a chance to dive into your slides, what are some of the key elements that really, in your opinion, go into that work-life integration culture? Yeah, I think that really it is, you know, we've shifted away from work-life balance, right? That that's different for everybody. And I think it's how you combine those two things and prioritizing things that are important to you and really open communication. I think it all comes down to that, that being able to talk about it together. It was interesting as we started talking about burnout, you know, I heard that idea of comfort and just that cognitive overload that we all experience, but something I heard Stephanie highlight, which I think is worth, you know, diving into a little bit more, is the fact that in our careers, we also thrive with getting to learn new things and continuing to expand our comfort level. And so the meaning that we find in our work, and one of those things being personal growth. And so I'll pull in here, the jobs resource demands model, which is it's not about how hard you're working, it's about if you're supported to do that work. In the same way, if you're going in and doing something you're completely comfortable with, even if you don't have a lot of resources, that's something that you can do without stressing yourself, but it still can set you up for burnout because you're not having that personal growth every day. And so then I think that brings back to making sure that we're thoughtful about how we support ourselves and our team members and institutions support us to be able to grow in careers. And I think that gets into things around succession planning and mentoring and other things like that, that sometimes we don't do a great job of. Paul, you smiled with that. My smile was sometimes we don't do a great job with. I think we're like, I mean, what you're saying, you're absolutely right. I equate it on a very simplistic way in terms of people's workload. I've gone round and round over my career with this, well, how many weeks on service is an appropriate workload? And a good friend of mine, Gil Warnofsky and I, I remember over dinner one evening, we finally settled on the idea that it has to be a factor that also accounts for the environment around you, right? And so you and I, we all know that you can be on service for 40 weeks a year if your average daily census is two patients, right? Because that's a very different entity than being on service for eight weeks a year when you're actually responsible for 36 patients all at once, right? That's a different level of burnout. And what I'm getting at is that nuanced conversation of what is work to us? And you sort of touched on it. What does make our lives enjoyable when we're in our profession? We're still figuring that out. And I think the past two years have proven that we need to just blow up everything that we thought and start over again, even from the point we were at. Yeah, and I love that you highlight a week of service is not a week of service is not a week of service. If you have four deaths on four consecutive shifts, that's gonna stick with you in a completely different way. Oh yeah, I find it's very telling that my wife will say that, I say, well, this was a particularly bad week because there were like five deaths. It's like, really? What other profession in the world is like, well, it got bad at the fifth death for the week, really? The other component of that, and I think Stephanie, you began to touch on this, with the integration is recognizing that as we progress through our careers, there's gonna be ebb and flows. And that at times, there may be something that is really, really interesting to you that you spend a lot of time on. And then for whatever reasons, either something else comes in or you've learned what you needed to learn on that. So I'm wondering if you could speak to how we support colleagues as they go through these ebb and flows and as they begin to think about, okay, so what's next? Maybe I've done ICU for 10 years, 15 years, and I wanna still have that environment, but think about some other things. Two things came to my mind there as you were talking about that is, I think first, empowering people that it's okay to say no sometimes. And I think a lot of intensivists, particularly, certainly looking at myself in the mirror here, I've struggled with that at times, that learning how to say no to. And I think Kyle sort of hit on this a second ago. I think having a good mentor is hugely helpful in those types of situations. And having a mentor who you're able to talk to about kind of what your big picture goals are, in five years, I'd like to be doing this, or this is what I'm passionate about. And then that mentor can also help you say, I'm not sure that that project is really what's gonna help you get to this spot. And so I think those are really important things. And I can't thank my mentors enough as I've started my career and continue to lean on them and call them and ask them for questions and advice. So it's one of the top pieces of advice that I give to our fellows. I'm the Associate Program Director here. And one of the main things I say to them is find a good mentor. It is invaluable for you as I'm moving forward. So Stephanie, I'm gonna throw out a question for you that feel free to send me a hate text after we finish talking here. But I guarantee someone listening to this recording or potentially even someone participating in the panel right now is at a place where they're feeling really burned out. And I think one of the challenges of burnout is you just, it's hard to come up with that inertia to know where to start. And so if we have one of those individuals, where should they start? What's that first step that they can take? Yeah, well, start with somebody that you trust, whether if you're a resident, your program director is a great example to talk to about that. If you're a fellow, your program director, junior faculty are on the call, either one of your colleagues or somebody who knows you well and that you're willing to talk to them about what's going on, I think is a great starting spot. I can throw the question right back at you though, Pascal. You're certainly one of the people I talked to about wellness and burnout more than anyone. So I'd love to hear your thoughts on it as well. No, I really love where you went with that about the having a conversation and certainly at points where I've had during my own career that I can reflect back and think having that discussion was the start of getting out of or getting to a better place, both mentally and being prepared to care for that next patient, which is a lot of what burnout is about as well. So I agree having the discussion. I think we often, medical training is so focused on, we have to be strong enough to do it ourselves and we have to be this shining beacon of the role model. And I think there has become a greater acceptance of the fact that we need to rely on each other in different ways. And sometimes we put it on ourselves, particularly in those moments where we're most burned out to think that it's not okay to reach out to someone. And so I would encourage folks as well to start with that conversation of someone you can trust just to talk about where you are. And resources are gonna be different in every institution, but yeah. What about, and I put this to everyone, what about when you begin to see signs in your colleagues? How do you reach out to your colleagues and help them? I know it's tough. I see it in my nursing colleagues as well and my other colleagues, but how do you begin to, in terms of, Stephanie, you talk about wellness and some of the things in terms of that burnout, but sometimes you might be the one that's seeing it or see that your colleague needs to have that first conversation. How do you, what do we do? How do we help them? I think at Duke, we just actually started a peer support program, which is that one-to-one reach out. And it's based, it's triggered sometimes by events and we've actually tried to set up a host of different triggers. One of the examples may be we review every mortality that occurs at Duke. And if we notice someone has multiple mortalities, five in a week, that may trigger someone to reach out. If it's a death in the OR, because that's a really rare event, fortunately, that's a trigger for us to reach out. We're really only a few months into this formal program. It's been shocking how much just the disbelief of folks that someone reached out to me and how much it meant to them. And so again, it's just the coming up with that, over that almost stigma or inertia of I need to do this and how valuable it is. But again, love to hear from others if they have other thoughts there. I think, Sharon, it's also important to set up a structure within each group to be able to depend on each other. I think it allows you to create an environment where people can easily reach out to each other. I think, I find challenging the systems where you get these messages of, call this number if you're in distress. These individuals have often challenges actually reaching out to these systems. And I think they're often sort of deep in the well at the time where it's really needed. And I think, like I said, I think it's essential that within our teams, we create the structure of mutual support, always checking in with each other, respect, maintaining very sort of a very supportive environment and allow these individuals to vent, to obviously reach out to you and say, hey, I'm in need of this or that and not feel isolated, right? Yeah. I think there's a top-down element, which can't be ignored. So much of medical training and the way we are trained in a, like I think part of our self-perception is that there's a professionalism that comes with, there's responsibilities that come with a professionalism that are just part of being a doctor. And one of the ways burnout manifests or can manifest I think is like, is either through mission creep or work creep or like little things creeping in where like those expectations that are being laid on you are either like not distributed or not shared or not compensated. And it ends up at the end of the day, it ends up either being extra work or some misalignment of expectation and reality. And so there's a lot of, and then even some of these solutions actually like presuppose a certain amount of responsibility on the part of the person who's burned out or their colleagues, their peers to like actually like kind of like notice that, fix that, like peer support groups and things like that. And what's missing there is to ensure that the system is in place from the top down, both from like the competing interest of like the division chief and the department chiefs and the leaders of the hospital to actually recognize that this is a real thing and that this is something which can't be overcome with our goodwill and our professionalism as simply as physicians without a cost because this is in fact the cost. Okay, like the things that you were getting by with like, you know, like either whether it be additional shifts or like high nursing turnover or like, or whatever it was, like this is being paid for whatever money you thought you were saving. In one area, you were actually being paid for it like in the emotional cost or the toll that's taking on your workforce. And I think that like articulating it that way is like, there's never a free lunch. And so the emotional toll of other decisions that are made from a top down level, I think thinking about like, how is that impacting my workforce for those of us in positions of leadership and things like that, like I think that's an important component of ensuring that the culture remains that this is in fact as much of a priority as everything else. I think that's an excellent, excellent point, Nader. And I appreciate that. I wanna be mindful of our time. We're at two minutes to go and I know everyone has, you know, busy work lives and it's a holiday weekend. So I want to, again, thank each of you. This has been an excellent discussion. And I wanna thank each of you for your time, for dealing with the changes that we had to do going from virtual to, from in-person to virtual and participating in our panel today. Thank you all so much. Nick, Kyle, anything to add? No, this has been terrific. We really appreciate everybody's time and efforts and rolling with the punches of how things changed from in-person to virtual and redoing your presentations and jumping in. So we really appreciate it and we hope those who are listening will join into our afternoon session today where we have at three o'clock Central, four o'clock Eastern to talk about pulmonary hypertension, transitions from pediatric patients to adult patients in terms of pharmacology, nutrition and thrive in the ABCDF bundle. So we look forward to people joining us then. Thank you all so much. Yes, thank you. This wonderful conversation. Thank you. Thank you everyone.

pediatric critical care

heart failure

hypotensive patients

ventilation strategies

ICU burnout

communication

team-based approach

patient monitoring

work-life integration