Good afternoon, everyone. My name is Michelle Ramirez. I am a pediatric intensivist in the Hassenfeld Children's Hospital at the NYU Langone Medical Center, and it is my pleasure to be here today and talk to you about women's contribution to critical care medicine in the last year, that is 2021. I'm also so happy that the society is taking on the responsibility of highlighting the women of critical care medicine in this ongoing effort to level the playing field and increase gender equity. So in this section, I am going to be discussing the achievements of women in the medical field. Others will talk about nursing and pharmacy contributions. For my disclosures, I have no relevant financial relationships to report for this activity. My learning objectives for today are to discuss the importance of amplifying and collaborating with women in critical care medicine, to review the impact of women in critical care medicine in medical literature for the year 2021, and to explore some of the key critical care literature published by women in 2021. In terms of my selection process, both adult and pediatric critical care medicine papers were selected. I performed a search on PubMed and critical care medicine journals, including CHEST, Journal of the American Medical Association, Critical Care Medicine, Journal of Critical Care, Pediatric Critical Care Medicine, and the Journal of Pediatric Intensive Care, looking at the most read critical care articles in 2021. Inclusion criteria, they had to be published between January and November of 2021, and the first author had to be female. There was a higher likelihood of selection if the last author was also female, or there were more than two female authors. I ended up with 40 articles and narrowed it down to 10. As you can see, there was a vast array of overall topics covered by women of critical care medicine in both pediatric and adult intensive care. I won't go through all of them for the sake of time, but you can see the topic list in here, and we will be covering a few of these topics. And I would like to start the discussion with these two articles that came out last year which do a wonderful job of answering the question why. Why is this type of activity both necessary and important? So the first paper we see here is an editorial from the Journal of Intensive Care, October 2021. It's titled Gender Equity and Diversity in Pediatric Critical Care Medicine, We Must Do Better. Written by seven powerhouse women in the field of pediatric critical care medicine. First author is Dr. Vanessa Suarez-Lanciotti and a senior author is Dr. Sapna Kutchakar. The other is an article written by an adult intensivist, Dr. Shaula Siddiqi. She's out of Beth Israel Deaconess in Boston and it was part of a special volume of the Journal of ICU Management and Practice looking at gender in the ICU and the article is titled Women in Critical Care. So Dr. Siddiqui tells us that compared with other medical specialties, for example anesthesiology or dermatology, critical care medicine is a medical specialty with some of the lowest representation of women. And while we have seen an increase in women in critical care medicine, we continue to be underrepresented in roles such as full professors in academic critical care medicine, authors of scientific literature, speakers at international conferences, editors in journals, members of scientific boards, authors of guidelines, and members of task force panels. And what's more, currently in the US only 3% of healthcare CEOs are women, 6% are department chairs, 9% are division chiefs, and 3% are serving as chief medical officers. This is despite women comprising 80% of the healthcare workforce. So in her paper she goes on to discuss one of the obstacles women in medicine have to surmount, this idea of gendered leadership, where there is an association between good leadership with male characteristics and weak leadership with female characteristics. And this is an ongoing stereotype that we need to continue to break. Now if we look at Dr. Solaris Lanziotti's paper, we can see that there is a similar picture in pediatric critical care medicine. For example, in the Pediatric Sepsis Guidelines group, women comprised only 11 of 42 authors, and the 2020 Society of Critical Care Medicine Congress plenary presentation was composed of a full manual with six men and no women. Furthermore, in her article they discussed how gender inequity is clear among speakers at critical care conferences worldwide with proportions of female physician speakers as low as 1%. They also highlight additional obstacles that women face, the higher burden of home responsibilities in addition to the possibility of child bearing and rearing, increased exposures to abuse and harassment at the workplace, and the ever-present pay gap, which according to some studies will take until the year of 2059 for women to reach salary equity. Altogether, this translates to fewer opportunities and publications, increased time to promotion, and lower pay. And you can see this graph in the paper. The authors give us a picture of our pre-COVID reality and how COVID has worsened this reality, leading to even more women dealing with child care issues, which in turn has led to a lower number of female COVID-19 experts and leaders portrayed in the media, and a decrease in grant applications and manuscripts. So for many of us, the pandemic has brought professional setbacks, and the authors do provide strategies to reduce gender disparities in our field, including saying no to manholes, ensuring gender parity in editorial boards and meeting committees, sponsoring and supporting women, and holding institutions accountable, not to mention the importance of holding these kinds of sessions that the SECM has been promoting over the last few years. And I'll finish talking about this paper by mentioning that the senior author of this paper, Dr. Sabna Kutchetkar, in an effort to highlight and promote achievements of women in medicine, has developed a list of interprofessional pediatric critical care medicine women speakers. You can see the link in the bottom of the slide. Please feel free to sign up and add your name to the pool. All right, so that was our why, why it is important for us to hold these types of sessions. Now let's move on and focus on the medical literature out there. And since we are in the middle of a pandemic and there's no shortage of COVID-19 studies, let's start discussing a few of those. This first study is titled Association of Intensive Care Unit Patient Load and Demand with Mortality Rates in U.S. Department of Veterans Affairs Hospitals During the COVID-19 Pandemic. It was published in JAMA Network Open in January of 2021. The first author is Dr. Don Bravata, professor of medicine at Indiana University, and senior author is Dr. Salome Kihane, who is a professor of medicine at UCSF Medical School. This is a cohort study and the authors wanted to examine whether COVID-19 mortality was associated with COVID-19 ICU strain. They had over 8,000 patients. The main outcomes were all-cause mortality through 30 days after discharge from the hospital. They noticed a couple of interesting things. Mortality, as we might expect, varied over time with an overall trend of higher mortality early in the pandemic, 22.9% dying in March versus 12.8% of patients dying in August. They also noted that patients with COVID-19 who were treated in the ICU during periods of increased COVID-19 ICU demand had increased risk of mortality compared with patients treated during periods of low COVID ICU demand, and they defined low demand as 25% or less. They gave us adjusted hazard ratios for all-cause mortality depending on ICU load, with ratios increasing from 0.99 for patients treated when COVID-19 ICU demand was more than 25 to 50, 1.19 when ICU demand was more than 50 to 75%, and 1.94 when ICU demand was more than 75 to 100%. And no association between COVID-19 ICU demand and mortality was observed for patients not in the ICU. So it seems that that critical 50% area seems to be where our patients start having worst outcomes. So this next study shows two interesting things. One of them is how COVID-19 affected pediatric patient mortality and also pediatric patient admissions into the ICU. It is titled Pediatric ICU Utilization and Clinical Trends During the Coronavirus Pandemic. First author is Dr. Janine Eze-Cheng, who is a pediatric intensivist at Indiana University School of Medicine. It was published in CHESS in August of 2021. It is a retrospective observational cohort study looking at over 160,000 children admitted to the PICU across 77 sites in the U.S. They used a virtual pediatric systems database and what they did is they compared pre-COVID-19 quarters to during COVID-19 quarters. They saw that the average number of admissions was similar between pre-COVID-19 quarter one and COVID-19 quarter one, but decreased by 32% from pre-COVID-19 quarter two to COVID-19 quarter two, which we know during quarter two we would have been already in the middle of the pandemic and many pediatric beds were being used for adult COVID units. The largest decrease in admissions were seen in respiratory conditions including asthma and bronchiolitis and interestingly they noted that admissions for diabetes increased and poisonings and ingestions increased. They did a multivariable model and illness severity adjusted odds of ICU mortality for PICU patients during COVID-19 quarter two increased compared with pre-COVID-19 quarter two. Okay so now let's talk about some non-COVID pediatric specific studies. So as a pediatric intensivist who doesn't often get to see how patients are doing once they leave the unit, I really enjoyed this next paper looking at functional outcomes at one year after PICU discharge in critically ill children with severe sepsis. It came out in January of 2021 in Pediatric Critical Care Medicine. This paper has two women first authors. One is Dr. Juma Sankar who is a pediatric intensivist in New Delhi at the All India Institute of Medical Sciences and the other is Dr. Sarvanti Modu also from the same institution. It is a prospective observational cohort study. They looked at 121 children with severe sepsis between 2 months and 17 years of age admitted to the PICU. They used two different scoring systems, one for overall disability and one for cognitive disability and the interesting things that they noted is that at admission 33% of patients had mild to moderate overall disability, 26% had mild to moderate cognitive disability. By the time they were discharged this number went up to 50.5% with new overall disability and 28% had new cognitive disability. When they follow them up at three months, the new disability at PICU discharge had improved in 65% in the overall disability category and in 50% of those with cognitive disability. At one year follow-up only 5% of patients had residual new disability and overall function and 14% had residual new disability and cognitive function. They also looked at their overall PICU mortality which was 26% and they looked at risk factors for worse outcomes and on multivariate analysis only day one pediatric sequential organ failure assessment scores and receiving cardiopulmonary resuscitation during the ICU stay were found to be statistically significant. So it was comforting to see that most children will recover a function within one year after ICU admission. So this next paper gives a little perspective on organ donation and what we can do to improve interest. It is from Pediatric Critical Care Medicine from March 2021 and it talks about organ donation authorization after brain death among patients admitted to PICUs in the United States 2009 to 2018. This is an all-female author paper with the first author being a PhD who works in NICU and PICU research at Children's Minnesota Research Institute and the senior author is Dr. Judith Zeyer who is a pediatric intensivist at Children's Minnesota. It is a retrospective cohort study. They used a database from the virtual pediatric system and this database includes 123 PICUs and collected data from 2009 to 2018. They had over 2,700 eligible patients and almost 2,000 or 70% authorized organ donation. Some of the highlights of this paper is that authorization rate remained unchanged over time, hospitalizations lasting greater than seven days had lower odds of authorization, white patients had higher odds and other race ethnicity groups of authorization and authorization was higher for trauma related encounters and when donation was discussed with an organ procurement organization coordinator. Of 123 hospitals, 28% met or exceeded the 75% organ donation authorization target threshold and these hospitals more often had an organ procurement organization coordinator discussing organ donation. So that just highlights the importance of having a coordinator talk to families at the time of organ donation discussions. So this last pediatric study that we'll talk about is a neuro ICU study and it is an interesting study because it questions our current thresholds that we use in ICP management and CPP goals. It discusses intracranial and cerebral perfusion pressure thresholds associated with in-hospital mortality across pediatric neurocritical care. Published in Pediatric Critical Care Medicine in February of 2021, the first author is Dr. Kendra Royce Woods, a pediatric intensivist from the University of Pittsburgh and the senior author is also an intensivist from Pittsburgh, Dr. Alicia K. Au. It is a retrospective chart review with a total of 262 patients, 87 traumatic brain injury, 175 non-traumatic brain injury patients. There's a lot of interesting information in this study but for just a highlight, traumatic brain injury in the traumatic brain injury subset, the mean intracranial pressure greater than 15 millimeters of mercury, male sex, and traumatic brain injury status were independently associated with in-hospital mortality as was the mean cerebral perfusion pressure less than 67 millimeters of mercury. And then for the non-traumatic brain injury subset, mean intracranial pressure had an area under the receiver operating characteristic curve of 0.77 with an intracranial pressure cut point of 15 millimeters of mercury. In this group however, the mean cerebral perfusion pressure was not predictive of in-hospital mortality. All right, so let's move on and discuss some of the adult studies. This first adult study that we'll discuss I think gives us a good amount of food for thought in terms of formalizing maybe our weaning strategies and investigating a little more on our spontaneous breathing trials. It's titled Ventilator Weaning and Discontinuation Practices for Critically Ill Patients, published in JAMA on March of 2021. First author is Dr. Karen Burns, an intensivist from the University of Toronto, and the last author is Dr. Maureen O'Mean out of McMaster University, also in Canada. It is a prospective multinational observational study of critically ill adults who received invasive mechanical ventilation for at least 24 hours from 142 intensive care units, and they had over 1,800 patients. Of those, 22.7 underwent direct extubation, 49.8 underwent initial spontaneous breathing trial, of which 81.8% had successful extubations, 8% had direct tracheostomies, and 19.5% died before a weaning attempt. So besides the wide variation of ventilator weaning practices, the authors also found, interestingly, that compared with initial direct extubation, patients who had an initial spontaneous breathing trial, patients whose initial spontaneous breathing trial failed, and those patients who underwent late spontaneous breathing trial, which they defined as more than 2.3 days after intubation, had higher ICU mortality, longer duration of ventilation, and longer ICU stay. Now the authors note that the data is descriptive and analysis were not adjusted for patient characteristics and things like illness severity, so we don't really know why we see this association, but certainly lays the groundwork for maybe some future studies on this. This is an interesting paper following up on some case theories that reported an association between dexmedetomidine use and hyperthermia. It was published in Critical Care Medicine in July 2021. It discusses the effect of early sedation with dexmedetomidine on body temperature in critically ill patients. The first author is Kim Grayson, who is an adult intensivist out of New Zealand. It is a post hoc analysis from a portion of the SPICE 3 study, so they took only 17.7% of the patients from the SPICE 3 study, and this is a multi-center randomized controlled trial that evaluated early sedation with dexmedetomidine in critically ill patients undergoing invasive mechanical ventilation in the ICU, and they looked at a total of 703 mechanically ventilated patients. The outcomes were recorded for five days after randomizing in the ICU, and the results showed that the mean daily temperature was not different between the dexmedetomidine versus usual care group. However, the peak daily temperatures over the first five ICU days showed that more dexmedetomidine group patients had a temperature greater than or equal to 38.3 and greater than or equal to 39.0 degrees Celsius. Both of these were statistically significant. Results were similar after adjusting for diagnosis, admitting temperature, age, weight, study site, sepsis occurrence, and the time from dexmedetomidine initiation to first hypothermia recorded, and they summarized these findings by noting a significant dose-response relationship with temperature increasing by 0.3 degrees Celsius for every additional 1 microgram per kilo per hour of dexmedetomidine received with a p of 0.0002. So I want to wrap things up with this last study, and this is a little different study because it doesn't have an intensivist author, although it does meet the female author requirements, and these authors are public health epidemiology and ID physicians working with the CDC and the DOH for the most part. It is relevant to the ICU, and I think it's particularly relevant to this talk because we have been talking about gender disparity, and this highlights another disparity we have a problem with in our health care system, and that's racial disparity. And with COVID, a lot of these have been unearthed, and you know, due to a variety of reasons including access to health care, socioeconomic status, vaccine hesitancy, we have had a lot of discussion about this, and this study in particular is pre-COVID. It came out on JAMA Network in August of 2021. The first author is Alyssa O'Halloran, who is with the CDC, and the last author is Dr. Sheikha Garf, also with the CDC. It is a cross-sectional study, and it looked at rates of influenza-associated hospitalizations, intensive care unit admission, and in-hospital death by race and ethnicity in the United States from 2009 to 2019. So some of the more interesting facts that are pertinent to the ICU in this study, when they looked at people younger than 75 years of age compared with white persons of the same ages, black persons were more likely to be hospitalized and to be admitted to the ICU as were American Indian or Alaskan Natives younger than 50. When they looked at children four years of age or younger, compared with white children, hospitalization rates were higher in black children, Hispanic children, American Indian, or Alaska Natives, as were rates of ICU admission. In this same age group, in-hospital deaths compared to white children were higher among Hispanic, black, Asian, or Pacific Islander children. And of all the groups, black persons had the highest age-adjusted hospitalization rates and ICU admission rates. So I think it is clear that we still have much work to do, not only within our jobs in medicine, but also for our patients, so that we may continue to narrow the gap between gender and racial inequity until it closes. And I hope more of the women in critical care medicine will be motivated and inspired to produce and publish their work. We really do need more female authors. And with that, I thank you for your time, and I hope you enjoy the rest of the conference.

women in critical care medicine

PubMed search

COVID-19 studies

pediatric ICU utilization

gender inequity

publishing work