Good afternoon, everyone, and thank you for joining us for this session of 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 pediatric critical care nurse practitioner at Children's Hospital of Philadelphia. And it is my honor to work with this esteemed panel today, including my co-chair and my past chair of Current Concepts, and I will turn it over to Kyle. Thanks so much, Sharon. So again, welcome to you all. We really look forward to having a good discussion around some of the presentations we've seen as part of the Current Concepts course. So we will go through in a moment and have each of our speakers introduce themselves. We are, unfortunately, one person short today. Dr. Maripudi was unable to join us, but we will dive in a little bit to the Thrive and ABCDEF bundle that we have seen really applied throughout the country, and so a lot of us do have experience with that. So as Sharon mentioned, I'm the co-chair of Current Concepts Committee, and I will highlight Nick as our past chair, and I'll let him introduce himself. Good afternoon. I'm Nick Ettinger. I'm a Pediatric Intensivist at Texas Children's Hospital, and I'm very excited to have our group here and hear the discussion. And with that, I think I realized I forgot to mention where I was from, so I'm a Pediatric Intensivist at Duke Children's, so that's my home. And then let's hit our other two panelists today, so Corey. So I'm Corey Tartan. I'm also a Pediatric Intensivist at Texas Children's Hospital and Baylor College of Medicine, and then half the time, I'm a Pediatric Pulmonary Hypertension Specialist. And Gideon. Hi, everyone. I'm Gideon Stitt. I'm a Pediatric Clinical Care Clinical Pharmacist, and currently took a step back from clinical care, and I'm doing a postdoc in clinical pharmacology focused on PK-PD modeling, primarily with antimicrobials and critically ill children. Excellent. Thank you, and I really want to highlight how much I'm enjoying the interprofessional nature of this panel in particular, and the diversity that's represented there, because I think that will improve our discussion. But with that, let's go ahead and dive into it. And so let's start with you, Dr. Sharton. One of the questions I have for you, as you went through all of the different options that we have at our disposal for managing pulmonary hypertension, none of which are perfect, where do you really see the future of pulmonary hypertension heading in terms of management? What may fall away, and what are the things that you think will really start to become the primary management? I think that's kind of a loaded question, in a way. I think from a critical care standpoint, we don't have that many medications that we have at our disposal. We have different, the three mechanisms of medications that we typically use, so we have our PDE5 inhibitors, we have our ERAs, and we have our prostacycline group. Depending on the patients, depending on how significant their underlying disease is, they may end up on single, double, triple agent, at least from a systemic standpoint. I think from a critical care nature, the ability to utilize aerosolized type of medications or inhaled medications for pH, I think have really been much more helpful for us. If you have a patient who comes in who's critically ill, and they have, say, a pretty nasty ARDS that leads them to have worsening RV dysfunction and pulmonary hypertension secondary to that pneumonia, the ability to utilize not only INL, but also something like inhaled Ioloproste, or inhaled eucloprostanol, or something like that as a second agent to kind of help decrease the RV pressure, I think has been very helpful. When we talk about kind of future of some of the medicines that you'll probably start seeing being utilized more in pediatrics, one of the newer ones that's been really nice that you may have seen at your institution is something called Celexapag, so it's one of the newer oral prostacycline agents. For patients who have significant either idiopathic genetic versions of pulmonary hypertension who typically would either be on continuous IV remodulin or continuous subcutaneous remodulin, and all the things that come with that where you have increased infection risk, especially having kind of long-term lines, or just the pain and the discomfort that comes along with having this continuous subcutaneous line that's in, inability to swim, go to the beach, all the things that little kids like to do and enjoy, this new medication transition has been really helpful for some of our patients. The mainstay of our job as PH docs in this patient population specifically, so just the idiopaths or the genetic versions, is to really stall the progression of their disease, right? So it's not curing it, it's not having it typically recover back to normal, it's to stall its progression so that we can kind of treat them so that they can either plan to have longer life, that's quality of life, but then also to kind of prepare for what the next step is. And so that transition to oral medication I think has been really great for a lot of our patients. Once the patients start having a little bit more of associated RV dysfunction with it, because there's a limit to how high you can go from a dosing standpoint, then those patients typically will have to transition to kind of our older sub-cure IV remodeling medicines. But I think that's one of the things that I think is new and is kind of going to be coming forward a little bit more often. One of the other things that has been done in adults is they've tried, at least Dallas was one of the areas in Dallas, Texas, to do not just subcutaneous pumps, but implantable pumps. So that's something that has been looked at in the past, but not something that we're utilizing at least in the pediatric world yet. And then I think the other thing that at least I'm a big part of, I'm the Associate Director of our Right Ventricular Failure Program at Texas Children's, and I think for these kids specifically, having a plan and a multidisciplinary approach to what to do next in these patients. We know, especially the sick pH patients that have progressive disease, that if they don't have something in their future, so whether that's lung transplantation or something else, having a plan of what to do next. So for our institution, surgical procedures like a POTS procedure, which is typically a left pulmonary artery to descending aorta shunt that's placed, or a reverse POTS, either via a PDA stent or something like that, that could be a palliative type of shunt. All of those things I think are kind of starting to pop up at different institutions throughout. So I think seeing more of these patients who are sick or living longer with kind of worsening pH and some RV dysfunction, I think is the thing that we're going to start to have to be taking care of as intensivists in these big centers. One of the things we talked about in the last session with Dr. Keke and Dr. Tume was sort of mechanical support, and not so much that which device you're using may vary center to center, but sort of having a program of excellence and really focusing on whatever you're doing it, doing it well. So I think with a lot of these sort of more rare things, there's been a push to sort of regionalization of care for some of these more complex therapies. And I wonder what your thoughts are, you know, obviously TCH is a big place for pulmonary hypertension, and we get a lot of kids referred here, but do you think that's a health, you know, is that a positive thing? Is it a healthy thing? How do people who don't work at those centers should think about it? Yeah, you know, it's a good question, and I think that's something that's been coming up a lot more often. We are a center, a referral center, a center of excellence for pulmonary hypertension. And so we get all of the surrounding states that pretty much send everyone to us. I think, you know, when we're talking about mechanical support and kind of mechanical support, any type of shunts that are created for this type of disease, any type of surgical intervention or even just triple therapy in general, I think should be done at centers of excellence that have more experience with it. I think, you know, one of my mentors, Dr. George Mallory, who's a pediatric pulmonologist that does pulmonary hypertension and lung transplant, he's just retired, but he always used to say, like, dabbling in pH is not a good idea. And I think that most of us agree with that. So I think, you know, having some understanding of how to manage the patient, stabilize the patient in the correct way when they're critically ill, I think is really important as a general intensivist because these kids could walk into any ER anywhere or have a thinkable event at any soccer field near you, which is typically how they present. But I think having the ability to know what to do to stabilize and then give us or one of the other big centers a call, I think would be the most helpful. From a mechanical support standpoint, I think, you know, we are already starting to kind of work together at like some of the centers. So typically, our center, St. Louis is one of the other centers, Columbia, which is kind of a combined program, like we're all working together, talking together, we're actually starting up a collaborative called PDRV, which is about to start soon, to really talk about these really difficult cases, what's best, because there's not a whole lot of literature that's out there on like what to do with these kids. You know, we are kind of creating that literature now, just because it hadn't existed prior to this. So, you know, pot shunts, whether AFDs are really a good option, should we try to recantalize PDAs and kids that have remnants of them, like all those types of things are kind of coming out and being discussed, and then also mechanical support. You know, we're an institution that have done a couple of central cannulations with Berlin cannulas, which is, you know, it's, whether it's ideal or not, it's unclear, but I think it has allowed some of our patients who come, you know, in an extreme condition with severe RV dysfunction, to add the bridge to transplant has allowed them to do physical therapy to eat and get nutritionally healthy and prepare them kind of for their transplant. And so I think for that specifically, it's been helpful and it's something that kind of all these institutions are talking about as a group. That leads me to a question. You brought up some really high tech, high level, both medications and devices and equipment and such that we use for these patients. What about access? How does that look in terms of a diverse population that I know is there in Houston and in the surrounding and in other places, how do we either ensure or help them access resources once they're, even once they're diagnosed? Because it's a lot to manage these children. Yeah, I think that's a great question. And, you know, I think that we have difficulty with that, even in a big city like Houston, where we have all these resources and all of this at our disposal. I think, for instance, because we're a referral center, we have a lot of patients that come outside of the country to come to get diagnosed and then potentially being started on therapy. And so one of the things we run into, you know, typically Stildenafil is a medicine that can kind of be obtained anywhere and is not unbelievably expensive, like our continuous prostacyclin therapies that without insurance, without something like that, there's no way that people could afford it. You know, one of the other medicines that has become an issue in the recent past has been RERA, so the endothelial receptor antagonist. And one of the issues with it comes with REM certification that Gideon probably has heard of and has dealt with. And so that's typically is a, it's a nationwide program where we kind of, there are specific prescribers that are allowed to prescribe these medications because we have to sign off and say that these patients are, have been counseled on understanding that during childbearing years or anyone that's around that these have teratogenic effects. And so it's important that if either the mother that's, you know, getting the pill ready for her child, wears gloves, knows that this is a medication that could have an issue. So REMs alone, just being able to prescribe and get the medication outside of the United States has been extremely hard. So for patients who come from other areas, we've had a patient recently from the UAE who like, I don't know how they were able to do this, but they were able to get like six months supply of Tocentin, which, you know, at any other place would be very difficult to do. So I think talking about diversity and being able to get the medications that we know would be beneficial for the patients, but not being able to actually get it for them can be difficult. So there's a lot of charity type organizations. I don't specifically work outpatient anymore, so I'm not as close to any of that anymore, but we have a couple of nursing coordinators who are fantastic that work with our group. And also two specific companies, which has also helped us kind of narrow down our ability to supply these medicines appropriately. So CVS is one of the, one of the pharmaceutical companies and then Acredo, which is like a specialty pharmacy, are really the two pharmacies that we use for pulmonary hypertension management in the country. And it's somewhat, they have a lot of ability to kind of help patients that are not able to afford the medications and things like that, if for some reason their insurance doesn't cover it. I think that's a great example of, you know, just why some of these centers of excellence are so important with these complex patients because of the interdisciplinary care that can also be provided. Like you were saying with nursing coordinators, a number of the big centers will have specific clinical pharmacists that will help with these patients and not only help manage the medications, but those inpatient and outpatient transitions where so many things can fall through the cracks. And that's certainly something that I've seen, you know, on the pharmacist side, managing these patients, you know, talking to Acredo directly and making sure we're getting correct doses or setting patients up for success as they go home is such a team effort that I think the bigger centers are really able to put all of their internal resources together and set the patients up for success. Yeah. I love that point, Gideon. Thanks for jumping in with that. And also the understanding of what these medicines and follow-up is needed for long-term because often as intensivists, realistically, we do focus on that short-term acute management and don't do as great of a job of thinking long-term. And I think there's been improvements in that in terms of recognizing, you know, post-intensive care syndrome. And we're going to talk some more about later about the, not only nutrition and making sure kids are growing and thriving that way, but also the other things we can do. But in terms of the acute management of pulmonary hypertension, because you kind of mentioned that briefly, one thing I did want to ask about, Dr. Tartan, was you talked about your own personal inotrope preference, which was epinephrine and vasopressin, I believe, low dose epi and vaso. But yet you showed other data that the one of the most common or popular is going to be dobutamine instead, which is going to give that inotropy, but it's also going to have the opposite effect on SVR. So I don't know if you want to expound on that a little bit more or give your thoughts. Yeah, I think dobutamine is an okay option. I think there was some of the older data suggested that that could be beneficial. You'll also see some data out there for like isoproterenol as a potential option for patients that either need rate control, but also it does drop your pulmonary vascular resistance as well. I think some of the newer things that we're thinking of now that we have other agents and also knowing what your anatomy and physiology that you're dealing with is probably the most important thing. So aiming for the receptors that you're wanting to aim for, I think, makes much more sense. If you have a patient that has just isolated RV dysfunction, your estimated RV pressures are elevated. You want to help use low dose epinephrine. And typically, I think I spoke about this when I spoke about low dose epinephrine and not necessarily anything higher than 0.05. You don't want to get really the alpha effect from epi. We're going to typically get this systemic vascular resistance squeeze from something else, either vasopressin or norepinephrine if necessary. I think we tend to like to stay on the low dose epinephrine side and use that specifically for contractility benefit, but also we don't want to go higher than that because the arythmagetic potential that you can throw these kids into VTAC, especially knowing that their RVs are dysfunctional, their hypertrophy, their TR jet is higher, their RA is already stretched, and so their SA node is potentially stretched. These kids have the potential to have some of these issues. And then I harp on our epi-vasopressin combo, at least at our institution pretty often, and Nick could probably talk about that. But I think vasopressin for these patients who really have an RV that's giant with this interventricular septum that's bowing into the LV, their LV is tiny, if they have LV function that's normal. In a kid with biventricular dysfunction, obviously, this would not be a great choice. But if you have just isolated RV dysfunction, typically squeezing that vasculature, not on the alpha receptors, but using vasopressin specifically, increasing the SVR, let that left ventricle do a little bit more work. Typically it's hyperdynamic, so it typically is okay to do. And then open up and have that geometrical size of the LV be a little bit better to allow for cardiac output to improve. So that's typically the epi-vasopressin combination. There are patients that low dose epi and the amount of vasopressin that you're wanting to use is not enough. And so my next step is typically low dose epi, some vasopressin, and then some norepinephrine is typically my trio if I need to use that. And then thinking about efficacy at the same time, obviously. Excellent. Thanks. Well, I do want to pivot a little bit here and let me turn towards you Gideon, if I may. And pediatric dosing is so challenging at baseline. And we thought about when does that pediatric patient become an adult, but can you talk a little bit more about the obese patients that we're seeing more and more often? Because just weight alone is not always telling in terms of the underlying physiology of that patient and the factors that we think of in terms of clearance and volume distribution and such. So I'd love if you could give a little bit more thoughts on that. Yeah. I think that's a great question and something that is a real clinical challenge. I think it's related to the title of my talk, but to be honest, the obese teenagers are almost easier to manage than the obese young children. Because I mentioned that once a patient is 12, 14 years old, metabolically, they're essentially an adult. Their SIP enzymes, their phase two enzymes are pretty much all fully developed. They're going to metabolize drugs like an adult. You can sort of default to adult dosing. It's the younger patients that have sort of some immature clearance and metabolic processes, but also have these altered volumes of distribution because of obesity that I think are the bigger clinical challenge really. And so the way that I kind of think about these patients is the obese teenagers, largely, I'm going to pull from adult obesity literature, particularly if they're the size of an obese adult. And a lot of that extrapolates very, very well to the obese teenagers. Because really, physiologically, they're so similar to an adult that it's a small jump. The bigger challenge comes with, like I said, the younger obese patients, at which point now I start really thinking about hydrophilic versus lipophilic drugs. And do I want to dose this on a total body weight or an ideal body weight or somewhere in between with an adjusted body weight? And so really, as a clinical pharmacist, I get to focus just on that stuff for the most part. And so I'm pretty familiar with it, but also really guide people towards one of the papers that I listed in my talk that has an amazing chart. I think it came out of the University of Colorado. And it's a number of years old now, but it really still holds and gives a great bedside reference for, with these patients, what weight should I be using? And how do I adjust for them? So the rule of thumb is most drugs are total body weight. And if there are exceptions, then you adjust for those exceptions. But really, it's just thinking about where is this drug going to go? And based on where it's going to go, does this patient have altered physiology that will be affected by that? So Gideon, this is something near and dear to me, is managing these patients. Because one of the challenges that we have is just exactly what you said. Do you use actual body weight, ideal body weight, something in between? Do you just use a cutoff? It's all over the place. It is all over the place. And so can you speak a little bit about how we can, as a critical care, as a Peds critical care community, begin to really think about these children, and I will say children, because I agree with you, when you get to about 12 years of age, you're pretty okay. But under that, how do we as a critical care community really approach and address management of these kids? It's complicated. I wish there were an easy solution for it. What I have expounded or suggested to the teams that I've always worked with is default to total body weight, particularly because there are so many drugs that are used in critical care that we very quickly are going to see an effect. So if I'm dosing epinephrine, I'm going to see that effect very quickly. And it may be that this patient, based on total body weight, needs a very, very low dose, 0.01, 0.02, but be aware that you might see some effects that you would get at a higher dose in another patient. So for those drugs where you can see a quick effect, total body weight is a great default. If you take all drugs used in critical care, over half of them are recommended to be dosed on total body weight. So default to total body weight. I've worked with, I think, three different EMRs at this point. And most of them have got what is your patient's actual body weight and what do you want your default dosing weight to be. And I think the safest option is to keep that as their total body weight and work closely with your clinical pharmacist. If it's overnight, call your overnight pharmacist. And if there are questions, dose specific medications based on an ideal or adjusted body weight, but default to total body weight, keeping in mind that I might see a little more sedation than I would expect for this dose because I'm dosing on total body weight. So be cautious about that. But I think using the current systems, what we have, defaulting to total body weight is going to dose the most drugs the most appropriately. I think in the future, it would be great to have EMRs with integrated adjustments. We automatically calculate things like BMI and at the click of a button, we can plot these kids on a growth chart. It's not a huge jump to then be able to automatically calculate an adjusted body weight and apply it and say that, hey, if this patient's BMI is over this, adjust their dosing weight for their aminoglycosides to this adjusted body weight and default to that. I think that would be the next step. But currently, it's really a lot of proactive attention and forethought about what we're doing with each of the medications. Thank you for that. We'll be in touch. Just because I know you've done some work in this area in terms of drug dosing, this is a little bit outside your official topic, but drug dosing with extracorporeal support. Obviously, CRT is a very different animal where you have to adjust dosing for multiple drugs, but do you know if there's differences among different extracorporeal support types like AVAD versus ECMO versus, I don't know, an Impella or something like that? I'm not an Impella probably, but... Yeah, it's a good question. Most of it really comes down to the patient to device size ratio, and the smaller your patient and the bigger the device, the more change you're going to see. Number one, just to the additional blood volume that you're adding in, so a neonate on ECMO, you can nearly double their circulating blood volume, whereas if you put your eye on an ECMO circuit, we might have an extra 10% to 20% blood volume at the most, but it's not going to affect us very much. In terms of circulating volume, really just thinking about how big is this circuit relative to my patient. If you know the prime volume, that's great, but if not, you can estimate based on that and know that this tiny little patient on a big VA circuit, they're going to need more drug up front to just fill that volume. Added to that is then you're going to lose more drug to circuit adsorption, so there's more surface area in a big circuit for a drug to stick to, and so again, that's additional effective volume that you're going to have to fill up. So I think about when you want to think about what drugs stick to a circuit, the more lipophilic the drug is, the more it's going to stick. So any of your sedatives are going to stick to a circuit, and know that your patients may need additional sedation either early in their ECMO runs, or if they needed a circuit change for some reason, they're going to need more drug up front, and eventually those requirements will come down as that circulating volume fills with drug and as that circuit saturates with drug. Conversely, when they come off that circuit, they're going to be seeing quite a bit more drugs, so you may need to come down on their dosing requirements. So broadly speaking, there are some changes in clearance when you're on an extracorporeal circuit, and there are different theories about pulsatile versus non-pulsatile flow and how that may affect drug clearance, a project I'm working on, so stay tuned. But largely I think about volume of distribution, and just knowing that the bigger the circuit relative to my patient, the more drug I'm going to have to put in. You're killing us with the suspense. There's never been any debate about pulsatile versus non-pulsatile flow and how that might affect things. For sure. But to bring up a good point that I think all of us can appreciate, and we've talked about this in each of our sessions thus far, is when you know that things like that, you as the provider who has the expertise in that area, it is so important to make sure that the team, the entire team, is aware of those changes. And I'm the nurse in the group again, so I'm definitely going to bring it up for my bedside nursing colleagues and my advanced practice colleagues who may not know the same things to that level of granularity. But they're the one that's sitting at that bedside or standing at that bedside when that circuit is going to be changed or whatever the case may be. So I think that you bring up a good point that I would like to hear any and all of us talk about in terms of how do we do that, we tend to call it just-in-time training or just-in-time education, to make sure that the team, the entire team, is on the same page and knows what to anticipate and how to react to that anticipation. So anybody? I'll kick it off with you. Go ahead, Kyle. Please, go. I was just going to say, you know, I think it comes down to two things, right? There's broadly communication, right, which is something that everybody does perfectly all the time, obviously. The more we can have open lines of communication, you know, and it's without getting on a soapbox, having pharmacists in the unit, right, and integrated into the teams, having bedside nurses, make sure that we give them support so that they can join rounds where some of these discussions are going to take place, that the residents and fellows, everyone is really able to sort of do that huddle at some point in the day and say, these are the things that we know are going to happen. But then even beyond that, you know, because not everyone can be there all the time, good education sort of outside of those specific patient examples and, you know, team education sessions, things like that, where we know, okay, hey, this is an ECMO patient. I remember that we had a, you know, a talk about they're going to need more sedatives early on, or I should use, you know, morphine might be a better choice than fentanyl in this patient. Some of that education sort of has an ongoing activity, I think, for the whole interdisciplinary team is going to sort of help make sure that we get ahead of some of those just-in-time conversations. And I think empowerment as well. You know, it's not just having the pharmacist on that team, but they feeling empowered to be able to speak up and make their contribution and give their, you know, educated professional advice. Yeah. And I was going to bring up even before we dove into this. So Sharon, you were thinking just like I was around that communication and particularly, you know, we know that best practice is to have pharmacists on rounds with us every day. We also know that not every place can do that. And not every place can, even the bigger places can't always do it seven days a week. And so what are those other strategies? And nutritionists. Yes. And nutritionists. And arguably even a more scarce resource, yeah, to have there every day. But, you know, I really, Gideon, love some of the things you brought up and you as well, Nick. So I'll hit what Nick said first about that idea of empowering these individuals. And I'm going to use the term role activation, which is the idea of saying, Gideon, as a pharmacist, what do you think about this? Because this is really me hitting and I'm highlighting the expertise that you bring to the team. And I think as leaders of rounds, this is a place that they can really highlight that individual expertise. And then the other thing I love that you brought up Gideon is the idea of huddles. And, you know, it may not be on rounds, but when is that key time that you bring all the team members together? And that first day on ECMO can be a really important time to bring everyone together and say, okay, here's some of the things we're going to be doing differently. And the other time that I try to use it as an internal trigger for huddles is anytime we're doing something that is not part of our standard protocol. It's, you know, because people, a lot of us, and, you know, and correct me if you disagree, Sharon, I'd say nurses more than anyone really like that protocol-based care and management. And if we're going to deviate from that, then you have to over-communicate why. So that people understand not only that we are doing it differently, but what the reasoning behind that. So if the patient changes and your reasoning doesn't apply anymore, it's time to revisit that. I think I agree with you to a large extent. I think protocols are good and that they can get us into trouble, right? Because you have to be able to recognize when your patient no longer fits that protocol. And sometimes you need to be able to recognize that two steps before you're there, right? So, and I just recently had this discussion with some people. It's like protocols are good. I like to use protocols, pathways, guidelines, whatever you want to call it. I'll say protocols and pathways as teaching utensils and teaching tools as well with the bedside nurses. And I'll say, let's go through this so that you have an idea as to what may be coming next. Because if that kid doesn't look like this, or you see something different, now's the time to be calling people, you know, that kind of thing. So I agree with you to some degree that it can make the delivery of care a little bit more like, okay, I got this because we're on this protocol. But at the same time, you need to be very astute and be able to recognize when you should no longer be on that protocol. But I'd love to hear other thoughts about this. Well, I was going to say, you know, protocols and standardization of care has been a recurring theme for all the talks we've had here. And, you know, with regards to nutrition, I feel very lucky that I have the support that I have here at Texas Children's, but I know that's not necessarily the case at all institutions. So one of the questions I wanted to ask you, Sharon, was for somebody who is at a place where they don't quite feel that that standardization protocols are in place, what are steps that they can move towards to improve nutritional support for critically ill patients? Great question. And something that's all the time. But, you know, I was talking with Kyle earlier that about a year, a year and a half ago, one of the residents from Duke, because at the time they did not have the protocol or were in the process of putting the protocol together, reached out to me and said, how do we do this? And how do we put this together? So I think in this age of virtual reality, I'll call it that, right? Many people are publishing their protocols. And that's what I put in the chat for us. Like that's our PICU protocol, right? For our, our guideline for feeding nutrition with a lot of information about how to troubleshoot various things. So I think that's one way is to go online because a lot of people have them published. But I think the most important thing when you talk about an approach to nutrition is to be one step fast. What is your goal? Okay. Because one of the things that people used to do was like, I don't want to feed because the gut's not ready because it's not ready and that's not ready. But if you really think about what are the hazards of not feeding someone who is critically ill, then that's a different scenario to play out, right? If you think about that, you want to stay ahead of and prevent any breakdown in the gastric, in the intraluminal gastric system. If you think about, you want to stay a little bit ahead of translocation. If you think about, you want to help their pro-inflammatory, anti-inflammatory. If you think about it that way, it may not be that you're going to feed them full force because most of our kids cannot, but you may begin to be a little more comfortable with the use of low dose feeds and trophic feeds or something a little bit above that, that helps. So that's part one of it. Part two of it is that the team has to be recognizing that feeding is a good thing, right? I just had a course with some NP students and they work in various places around the country and they're like, my attendings would die if I said feed a child who's on norepinephrine. So I said, but you have to take that into context, right? I'm not talking about the child who you've just resuscitated for the last four hours and you're increasing their doses, right? We're talking about the kid that you've gotten somewhat stable, everything else looks good and you're just going to begin to help their gut remember what it's supposed to do, right? So I think those kinds of conversations are very important and knowledge and recognition of the benefits of nutrition and not always thinking of it as, oh, that's the thing we do when they're better, because it's going to take a lot longer for them to get to better if we're not giving them some nutrition. This is really a nice segue into moving to talk about nutrition a little bit more. And first, before we share, and I'll say, I don't know that we really disagreed at all. It was just, you stated it much more eloquently than I did about the advantages and potential pitfalls of protocols. But this actually fits into one of the questions we did get that was emailed in from the audience was, where are the resources that exist? Because so many places have internal protocols or pathways that have been developed, but they're not always shared in the way we'd like. And are there places, you mentioned that the CHOP protocol, I don't know how we can potentially make that available to everyone via chat, but it is available on the CHOP site under the clinical pathway for initiation of advancement of nutrition in children. You have a fairly detailed protocol there. Are there other places that are really good resources in terms of pathways, specifically around nutrition? Yes. So Boston Children's also has a really nice protocol. There's Cincinnati has some nice ones. So one of the ways that it took me some time even to find this, not only just talking to my colleagues, is a lot of places are now beginning to publish them online, right, on the web so that they're readily available. And so you just have to kind of do some of that search. And I've bookmarked others as well. I will say that our adult colleagues are light years ahead of us in terms of doing this. In some instances, the Canadian groups under Dan Heyman, like, they have protocols all over the place, right? I do some work with colleagues in Europe and they're beginning to put some more things out there. So you have to be steadfast. And when you find them, you have to be able to, like, pull them out and say, how does this work for us? And is this the appropriate thing to do at this point in time for this particular patient? Something else that we were talking beforehand about the use of metabolic carts or things like that to really be able to assess a child's needs. But realistically, most of the folks who may be watching this don't have ready access to that. In fact, I would argue most have never seen a metabolic cart in the way that we were discussing during a pre-conference. You know, what are those things that you have seen that can really help people best assess that can really help people best assess the child's nutritional needs beyond daily weights? Daily weights. I would love to see weights gotten on a regular basis, but that's a whole nother discussion. So let me first talk about metabolic carts. It's not like we work in children's hospitals. That's right. So let me talk about metabolic carts. So you can get a vast amount of very good information from metabolic carts. You have to be very steadfast and very clear about when you're going to use them and the population that you're going to use them on, right? So most of the kids that we think about using metabolic carts can be intubated and on high amounts of oxygen. Anything over about 60% oxygen, your numbers are off and you have to make sure that your ventilator has closed circuitry because how does a cart work, right? It gathers up the CO2 and does the internal calculations using a modified weir so that you can come out with what your respiratory quotient is, what your energy expenditure is, right? But if you are losing gases and you don't have a closed system, you're not going to get real numbers. And so your ability to direct nutritional therapy based on that can be erroneous. So that's one part about metabolic carts. The other part is with all that I just said, you need personnel that know how to run these carts and know how to troubleshoot these carts. And then you need people that know how to interpret the output correctly, right? So when you think about the population of children, for the first anywhere from 24 to, I'm going to say 96 hours, our kids are changing constantly, right? And most ICUs have about anywhere from three to five day length of stay. And then we get those kids out of there longer. So when you think about the resources that it takes to do that, right? You're not going to change what you are giving them energy wise every day. And so you have to really think about who's the right population to use this on. And when is the right time to use this? And do you have the equipment, the personnel to dedicate to that? Especially now when everybody's feeling a deficit in terms of personnel and equipment and such. So that's the one thing about metabolic carts. Oh yeah. No, that's... And that's the big thing, right? Yeah. And certainly why I think a lot of folks don't see them because it is a significant learning curve investment and understanding of being able to use it correctly. So you asked me about, so what do we use? Okay. So one of the things that I've begun to use more and more over the last few years is mid-upper arm circumference, right? In addition to just kind of a weekly weight, right? Because what you don't want to do is have our patients lose lean mass. Mid-upper arm circumference is one of the last places that you'll see edema, but it is one of the places that you can see loss of lean body mass. Okay. Because it's that combination, right? Of fat and muscle and bone that you're measuring there. So that's one of the things that we've been beginning to use more and more and more in terms of assessment. Weight, you have to be really careful because we resuscitate and weights can be up and down. And what really is their dry weight or their ideal body weight or their admission weight? Because how sick were they before they came in, right? So you don't know definitively. I mean, that's the one that we use because that's the best that we have. But that whole conversation is something that I've talked to so many colleagues across the country, and we all struggle with that because getting a daily weight, two things about it. One is that if you get a daily weight, please use the data for something. Yeah. Because don't have the nurses just doing it and just reporting it out and we don't do anything with it. Even if you just use it. I think that's probably the number one reason we can't get daily weights is because it's getting done and we don't do anything with it. It's exactly, you know, I mean, I am an old bedside nurse that, you know, every night, I worked nights for a long time, every night between somewhere around 5am and 630am, everybody got weighed. And then the next night, everybody got weighed, but nobody did anything with that data. So it's kind of like, if you're going to get it, then let's do something with it. There are certain populations that a daily weight is very helpful. Kids on CRRT, you know, you have certain populations that a daily weight is very helpful, but let's get the weight around the same time every day. Has mid-upper arm circumference been studied outside the, studied in the, you know, sort of high income critical care population? I know it's been used in a global health context extensively by WHO, but has it been studied in a critical care context? It's beginning to be more and more studied. Okay. More and more. The, where I have seen it and used it more is in the cardiac populations. Okay. Cause you know, those kids have their own set of issues and challenges around growth and such. So it's used more in that population, but it is being studied more and more as a way to use, because the things, the other things that we use, right. It's hard to get protein studies. It's hard to get any of those other things in real time so that you can begin to apply them. So you have to think about and begin to really test and look at non-invasive kinds of means and things that don't necessarily need a laboratory exam because you know, those things are not as helpful to really look at nutrition status over the course of time in an ICU. Let me add that in an ICU because we're doing so many different things to that. Yeah, absolutely. And I'm sure we could go into a whole nother discussion about wet and dry weights and pulling Gideon and dosing of our meds. This is a little off topic, but still on nutrition. And I'm going to bring it up because I just saw another article in the past week around it. But Sharon, I would love to hear your thoughts around probiotics in the ICU for our patients because it comes up surprisingly and often from external sources, from families who were asking about that and really trying to partner with families around care for these children. So it's a really good question and I don't know that we have a definitive answer for the ICU. Let's start there. But when you think about some of the therapies that we do to the ICU, in the ICU, we are really changing. And this is going to kind of push me a little bit into the whole microbiome and metabolomics and such, right? We change it. We know that within, there was one very small study that I looked at a while ago that you can change the microbiome within 24 to 48 hours in a different environment, changing their food stuff, giving medications, changing fluids, all of that, your microbiome will change. So how do probiotics play into that and help that? It's one of those things that the adults have looked at a little bit more than we have. And if you don't try to maintain some equilibrium, for lack of a better term, between what's going on in the gut, you can find yourself on either ends of that spectrum and be in a really bad spot. So ironically, the families that have the chronically, critically ill that we talked about a little bit yesterday, those are the families that use it a lot, right? And they know how their child reacts. And they will tell you if we don't do this and they don't have a stool or they don't do this or they don't do that, they're going to be really sick. And we have to listen to those families who know those kids and include it, as you said, Kyle, into the care delivery that we give them, right? And so it may not be on day one, it may not be on day two, but as they are getting better, it may behoove you to begin to incorporate some of those things again for those children. We talked about the complex patients and those are another population of patients that are often on these things because the families know them and they know them well. And they know from a nutrition and GI tract function, how they work and how they don't work and what will cause them more problems. So I think we have to pay attention to that. And that brings us to that whole thing around family-centered care. But in terms of what we do in the ICU, we have to think about how we're changing what their GI intestinal tract looks like with our pure therapies that we do to save their life, right? But what are we doing to them and how do we work together to get them back to some degree of normalcy? So I think there is a role, but I think it's, you talk about individualized medicine, there you go, right? Because I don't think it's one fits all. Yeah, exactly. And what we just talked about there as well also pivots into our last topic, which is the ABCDEF bundle and F being that family engagement. But the other things each day, which get into the idea of what are we doing to these children and how can we mitigate those effects? So paying attention daily to their pain levels, to their sedation level, to liberating them from the ventilator, to moving them forward with early mobility and such. One of the questions I'd love to hear from all of you all is as we consider this, obviously this was adapted from adults, which often is the case with many of the things we do, is there the place that all children should be treated equally on this? Or should we have different ABCDEF bundles for different ages or such considering the wide heterogeneity in development and physiology for our patients? I look at it more of as a, we have different ABCDEF approaches depending on the stage of their illnesses. Early in a very, very sick person, very, very sick patient, right? The priority is not letting them wake up from their sedation because they're that ill and we need to be in that much control of their physiology, but very quickly that changes. And so I see it more of as a phase of illness more than a disease specific thing. I agree, but I would add on there too that you have to do the buckets, if you will, by age groups, right? Because the infant, you need to think about things a little bit differently than the toddler, than the school age and the adolescent, right? So I think you have to, you know, by default, because we're all in the world of pediatrics, we do that, but we have to think about it. I'm going to use the infants in particular when we think about neurodevelopment, right? And so we need to know what their neuro status is. And so, you know, there are a lot of places that do the holidays. I don't know that I'm completely in agreement with that, but I think that there are particular times and particular patients that you need to be able to assess what is their neuro status now, you know, and so your bundle may change a little bit based on both disease, age group, and what you know about the patient prior to them coming in. Yeah, the spontaneous awakening trials, in my understanding, that's the one piece that hasn't fully translated from the adult world to the pediatric world. Pretty much all the other elements have and have at least some data to support them, but that's the one piece that potentially doesn't translate from the adult data. Because, you know, what do our kids do when they wake up? They're feeling all this stuff, they're going right at it. Yeah. They're going right at it. So to me, you know, I have a 15-month-old that I'm letting wake up and the first thing they're doing is going for the stuff on their face like, okay, you're there. To some degree, you're there. That's an appropriate neurologic response. You know, right? Because to some degree, you know that whatever we have on you should not be there. Yeah. And that is the trick of also delirium assessment. I'm sorry. Go ahead, Corey. I was just going to say, I agree with both Nick and Sharon. I think, you know, having a bundle that's at least discussed on rounds and to discuss kind of where you are in that patient specific trajectory and to talk about those things every day, I think is important. Like, we go back to kind of the algorithmic approach to medicine, which I think to an extent is important, but I also agree that being able to, you know, understand the underlying physiology, not necessarily just having a pattern recognition type approach to medicine is important. And I think as intensivists, that's how we're trained, right? Like we're trained on physiology as opposed to some of the other specialists and other specialties that really harp on pattern recognition specifically in just algorithmic medicine. So, but I think I agree with Nick that like, it changes depending on the type of like what their disease process is doing at the time, at least for me. Yeah, Corey. Yeah. I like what you said there. I really agree with everything that you all said around this, but it's not about the fact that we're treating every patient the same every day, but it's that forcing us to think of these key factors in terms of moving the patient's care forward and ultimately liberating them from the ICU. Agreed. That's what I was going to bring up. Like the bronchiolitis, I like to use bronchiolitis, right? Because it's our bread and butter to some degree. We all see a lot of bronchiolitis, but you see the bronchiolitis that you need non-invasive, you know, care, and then the ones that get worse and progress to intubation and mechanical ventilation. But that bronchiolitis that necessarily needs respiratory support, but are screaming their head off because they are hungry. So how do you manage that? Right? The nurses, I've had this discussion so many times. Some of my nursing colleagues are like, I need sedation. And I'm like, no, no, no, no, no. Let's think of some other things. What else can we do? Now, if they're escalating, no, I don't want to feed them because, you know, who knows what direction they're going to take, but sometimes a little bit goes a long way. And now you can get that kid to calm down and let whatever ventilation, non-invasive ventilation you're trying to give them work. Not true for every bronchiolitis, not true for every infant. Nick, you're smiling, but you know that I'm telling the truth. I'm a hundred percent agreeing with you. Yeah, I think, you know, we mentioned the spontaneous awakening trials and such, and those may not work as well in toddlers, but I will say one of the things I think that definitely we've learned from the restored trials and other things that have really helped guide us through the ABCDF bundle in kids is that we can let kids be more awake. And one of the key ways that's allowed us to do that is recognition and treatment of delirium. And that's, you know, in the ICU, that's been one of the biggest changes in management since my training days has been the fact that we really do recognize that and treat it now. And I think that allows us to move forward in a different way. Agreed, agreed. Try and prevent it in the first place, really. That as well, yes. And as best you can. You can't always prevent it, but doing your best you can. Recognizing meds that we can avoid. You know, benzos were automatic for every intubated patient at one point in my career, and that has certainly changed. And bringing in other professionals, child life, huge resource to use with some of these patients, intubated or not, huge resource to use. So bringing them in and utilizing family and tapes and those kinds of things that, you know, there was a point in time we didn't do that. But, you know, to have a family record a book or the music that, you know, that child will hear their voice and those kinds of things. I think we've learned a lot, as you said, Kyle, and really been able to expand the care delivery for our patients. I think that's been the biggest thing recently in delirium research, you know, whether it's in adults or pediatrics, is really that drugs are the absolute last line treatment, you know, and certainly prevention is always best. And I understand the patient who's a danger to themselves or others, but, you know, for the vast majority of these patients, it really is less pulling things away, you know, less drugs, reintroducing things that are familiar to them, and, you know, pharmacy therapies as the very, very last line has really been so consistent now across the studies. And that's from our pharmacist, who's our charge moving forward to use less drugs. Use less drugs, less is more, you know, less is definitely more. Yes, yes. So we are kind of nearing the end of our time. Certainly, I want to thank you all very much for being here. I'll check a moment quickly to see if there's any other final thoughts. I say thank you to all of the panelists and to everyone for their time and such. This has been really such a rich experience. So thank you as well for, Nick, for putting me on the panel. No, I echo your comments because, you know, we changed from an in-person model to this electronic, online, and Q&A model. And I really appreciate all of our panelists' flexibility and stick with this. So thank you very much. It's been great to talk with everybody. Yes, thank you. Thank you again for the invitation to participate. This has been a real pleasure. Thank you. We appreciate all of you. And I guess on that note, we will say goodbye to 2022 Critical Care in Pediatrics, current concepts of Critical Care in Pediatrics. Thank you. Thanks, everyone. Thank you. Goodbye.

pediatric critical care

pulmonary hypertension

drug dosing

nutrition in ICU

standardized protocols

individualized care

probiotics

family engagement

interdisciplinary teamwork