PICU Doc On Call

A child with septic shock develops worsening oxygenation after initial fluid resuscitation. Another presents with seizures, hypotension, and a widened QRS following a suspected tricyclic antidepressant ingestion. What should happen next? Dr. Pradip Kamat and Dr. Rahul Damania tackle these questions and more in the final installment of their three-part pediatric critical care board review series.

Through 21 rapid-fire, case-based questions, the hosts explore gastrointestinal emergencies, nutrition, toxicology, sepsis, trauma, sedation, medical ethics, and research interpretation. They explain why enteral nutrition is generally preferred in critically ill children, how ECG findings guide treatment in toxic ingestions, when early airway intervention is essential, and why a normal pulse does not exclude compartment syndrome.

With practical clinical pearls and bedside-focused explanations, this episode offers a concentrated review for pediatric critical care trainees and clinicians preparing for certification or recertification.

Show Highlights:

• Gastrointestinal emergencies, including variceal bleeding, octreotide, and malrotation with volvulus

• Enteral versus parenteral nutrition, indirect calorimetry, and nutritional markers

• Toxicology emergencies involving tricyclic antidepressants, acetaminophen, salicylates, and toxic alcohols

• Carbon monoxide and cyanide poisoning, serotonin syndrome, neuroleptic malignant syndrome, and malignant hyperthermia

• Pediatric septic shock, vasoactive support, and the Phoenix Sepsis Criteria

• Streptococcal toxic shock, chronic granulomatous disease, and invasive fungal infections

• Trauma, burns, inhalation injuries, compartment syndrome, and environmental emergencies

• Propofol infusion syndrome, neuromuscular blockade, sedation, and delirium assessment

• Ethics involving emergency treatment, informed consent, end-of-life care, and pediatric research

• Positive predictive value, Type I and II errors, statistical power, risk reduction, and number needed to treat

• Choosing statistical tests and evaluating quality improvement outcomes

Resources:

GI and Nutrition

• APSPGHAN statement on endoscopic variceal bleeding hemostasis (2026): pediatric octreotide use and antibiotics in cirrhosis-associated variceal bleeding.

• Fivez T, et al. Early versus Late Parenteral Nutrition in Critically Ill Children (PEPaNIC). N Engl J Med. 2016;374:1111–1122.

• Evans DC, et al. The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper. Nutr Clin Pract. 2021;36:22–28.

Toxicology

• American Heart Association. 2023 focused update on life-threatening toxicity due to poisoning.

• Dart RC, et al. Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement. JAMA Netw Open. 2023;6.

Additional Board Review Resources

• PICU Doc On Call — Podcast episodes, management cards, and board review equation sheets: https://picudoconcall.org/

Equations and Interpretation

Respiratory Quotient (RQ)

Formula: RQ = VCO₂ / VO₂

Interpretation: A measured value above 1 may reflect overfeeding or net lipogenesis. Measurement conditions and nonsteady-state physiology matter.

Absolute Risk Reduction (ARR)

Formula: ARR = Control Event Rate − Treatment Event Rate

Interpretation: Use absolute benefit for the defined outcome and follow-up period.

Number Needed to Treat (NNT)

Formula: NNT = 1 / ARR

Interpretation: Enter ARR as a proportion. If adverse events fall from 20% to 10%, ARR = 0.10 and NNT = 10 over the study's follow-up. Round noninteger NNTs up.

Positive Predictive Value (PPV)

Formula: PPV = True Positives / All Positive Tests

Interpretation: Lower prevalence generally lowers PPV when sensitivity and specificity are comparable.

Statistical Power

Formula: Power = 1 − β

Interpretation: The probability of rejecting the null hypothesis under a specified alternative and study assumptions. A nonsignificant result does not establish equivalence.

Traditional Parkland Estimate

Formula: 4 mL × Weight (kg) × % Total Body Surface Area (TBSA) Burned over 24 hours

Interpretation: This is a historical starting estimate, not a universal pediatric prescription. Follow the local burn-center protocol. Traditionally, half is allocated to the first 8 hours from injury and half to the next 16 hours. Account for fluids already administered and titrate to response. Pediatric protocols may use a different coefficient, and smaller children need separate maintenance fluid and glucose assessment.

Choosing a Statistical Test

Continuous Outcome: Two Independent Groups

Common approach: Unpaired t-test; Welch's version accommodates unequal variances.

Check first: Independence, distribution, and outliers.

Continuous Outcome: Same Patients Before and After

Common approach: Paired t-test.

Check first: Distribution of within-patient differences.

Continuous Outcome: Several Independent Groups

Common approach: ANOVA or an appropriate variant.

Check first: Assumptions, group structure, and planned comparisons.

Nonparametric Comparison of Two Groups

Common approach: Mann–Whitney test for independent observations; Wilcoxon signed-rank test for paired observations.

Check first: Pairing and the specific distributional hypothesis. These tests are not interchangeable.

Categorical Outcomes

Common approach: Chi-square test or Fisher's exact test.

Check first: Independence and expected cell counts.

Adjusted Binary Outcome

Common approach: Logistic regression.

Check first: Model specification, confounding, and adequate information.

Time-to-Event Outcomes

Common approach: Kaplan–Meier curves, log-rank comparison, or Cox regression.

Check first: Censoring assumptions and proportional hazards for standard Cox regression interpretation.

A child with DKA develops a worsening headache, altered mental status, and bradycardia: the hosts explain why suspected cerebral injury should be treated before imaging. Dr. Pradip Kamat and Rahul Damania bring that same bedside focus to a rapid-fire pediatric critical care board review, covering medication dosing, kidney and electrolyte emergencies, endocrine crises, and liver failure. Along the way, they explain why a normal anion gap can hide acidosis when albumin is low, how a dangerously wide QRS in hyperkalemia changes the treatment order, and why acute liver failure can meet criteria even without obvious encephalopathy. Short cases, clear answers, and practical physiology make this a focused review for the PICU and the boards.

Show Highlights:

• Medication dosing in acute kidney injury, including loading versus maintenance doses
• Phenytoin’s nonlinear kinetics and extended-infusion beta-lactam antibiotics
• Kidney and electrolyte disorders, including metabolic alkalosis, hypokalemia, and anion-gap interpretation
• Hyponatremia, sodium correction, cerebral salt wasting, and pseudohyponatremia
• Hyperkalemia management, rhabdomyolysis, and kidney replacement therapy
• Diabetic ketoacidosis and suspected cerebral injury
• Endocrine emergencies, including adrenal crisis, thyroid storm, and hypoglycemia
• Metabolic disorders, including urea cycle disorders and hyperammonemia
• Pediatric acute liver failure and lactulose’s role in ammonia management
• Nutrition assessment and the effects of inflammation on albumin and prealbumin

References:

Medication questions

• FDA Dilantin prescribing information: saturable metabolism and interpretation of unbound phenytoin in hypoalbuminemia and renal/hepatic disease.
• Fuhrman & Zimmerman’s Pediatric Critical Care, 6th edition: background pharmacology, renal physiology, acid–base, and endocrine chapters.

Electrolytes and kidney support

• Royal Children’s Hospital clinical guideline: Hyponatraemia.
• Royal Children’s Hospital clinical guideline: Hyperkalaemia.
• Gaudry S, Palevsky PM, Dreyfuss D. Extracorporeal Kidney-Replacement Therapy for Acute Kidney Injury. N Engl J Med. 2022;386:964–975.https://doi.org/10.1056/NEJMra2104090doi:10.1056/NEJMra2104090.
• Stanski NL, Fuhrman D, Basu RK. Controversies in paediatric acute kidney injury and continuous renal replacement therapy. Curr Opin Crit Care. 2021;27:604–610.https://doi.org/10.1097/MCC.0000000000000888doi:10.1097/MCC.0000000000000888.

Endocrine and metabolic questions

• Glaser N, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022;23:835–856.https://www.ispad.org/static/6dd62eae-c8cb-4b4a-84e1efc768505746/Ch11PediatricDiabetes.pdfFull guideline.
• Kuppermann N, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378:2275–2287. The trial did not find significant neurologic outcome differences among the fluid regimens studied.
• American Thyroid Association: Hyperthyroidism in Children and Adolescents;https://doi.org/10.1089/thy.2016.02292016 ATA guideline.
• Additional background and references are provided in the linked hypoglycemia and hyperammonemia episodes.

Liver and nutrition questions

• Squires JE, et al. NASPGHAN Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr. 2022;74:138–158.https://naspghan.org/wp-content/uploads/2022/01/North_American_Society_for_Pediatric.23.pdfFull position paper.
• Squires RH, et al. Intravenous N-acetylcysteine in Pediatric Patients with Non-Acetaminophen Acute Liver Failure. Hepatology. 2013;57:1542–1549.
• Evans DC, et al. The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper. Nutr Clin Pract. 2021;36:22–28.https://pubmed.ncbi.nlm.nih.gov/33125793/PubMed.

Board review scope

• American Board of Pediatrics: Pediatric Critical Care Medicine Content Outline.

A hemoglobin increase from 8 to 12 can boost oxygen delivery far more than raising oxygen saturation from 88% to 98%—but that doesn’t mean transfusing every child to 12 is the right call. In part one of this pediatric Critical Care Board Review, Dr. Pradip Kamat, Dr. Rahul Damania, and Dr.Monica Gray connect high-yield equations to urgent bedside decisions: when intubation may improve a failing heart, why a normal blood gas can hide impending respiratory failure, and how hyperventilation can lower intracranial pressure while dangerously reducing cerebral blood flow. They also tackle ventilator waveforms, ECMO anticoagulation, transfusion complications, and the test-taking strategies that make physiology easier to apply under pressure.

Show Highlights:

• Board-preparation strategies and physiology-based clinical reasoning
• Oxygen delivery, oxygen content, and hemoglobin’s role
• Cardiac shunts, Qp:Qs, and duct-dependent congenital heart disease
• Cardiopulmonary interactions, ventilation, and hemodynamics
• Rhythm disturbances, CPR, and ECMO perfusion concepts
• Gas exchange, alveolar gas equation, and oxygenation indices
• Ventilator pressures, waveforms, time constants, and dead space
• Cerebral perfusion, traumatic brain injury, and neurologic emergencies
• Neuromuscular respiratory failure, seizures, and brain death assessment
• Anticoagulation, transfusion complications, sickle cell disease, and other hematologic emergencies

Resources:

• American Board of Pediatrics. Pediatric Critical Care Medicine Content Outline.https://www.abp.org/sites/abp/files/outline-critical-care-updated.pdfhttps://www.abp.org/sites/abp/files/outline-critical-care-updated.pdf
• Fuhrman & Zimmerman’s Pediatric Critical Care, 6th ed. (Elsevier) — chapters on cardiopulmonary interactions, respiratory physiology and mechanical ventilation, neurocritical care, and hematologic emergencies. (add chapter numbers)
• Emeriaud G, et al. Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med. 2023;24(2):143–168.
• Greer DM, et al. Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination: Consensus Guideline. Neurology. 2023.
• Kochanek PM, et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition. Pediatr Crit Care Med. 2019;20(3S Suppl 1):S1–S82.
• American Heart Association & American Academy of Pediatrics. 2025 Pediatric Advanced Life Support Guidelines.https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-advanced-life-supporthttps://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-advanced-life-support
• Kapur J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). N Engl J Med. 2019;381:2103–2113.
• Lacroix J, et al. Transfusion Strategies for Patients in Pediatric Intensive Care Units (TRIPICU). N Engl J Med. 2007;356:1609–1619.
• Valentine SL, et al. Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children (TAXI). Pediatr Crit Care Med. 2018;19(9):884–898.

In this episode of *PICU Doc on Call*, Drs. Pradip Kamat and Rahul Damania dive into the topic of beta-blocker toxicity. They walk through a case of a 15-year-old who comes in with bradycardia, hypotension, hypoglycemia, and altered mental status after an intentional ingestion. Using a board-style question, they break down how to tell the difference between beta-blocker and calcium channel blocker poisoning and review key points about cardiac physiology and receptor signaling.

Drs. Kamat and Damania discuss management strategies, including glucagon, high-dose insulin therapy, vasopressors, calcium, and ECMO as a last resort. They also spend some time focusing on specific agents like propranolol and sotalol, highlighting what makes their toxicologic profiles unique. This is a high-yield episode packed with pearls for pediatric intensivists!

Show Highlights:

• Clinical case of a 15-year-old patient with bradycardia and hypotension due to intentional drug ingestion
• Beta-blocker toxicity and its clinical features
• Differentiation between beta-blocker and calcium channel blocker toxicity
• Key physiological concepts related to cardiac action potentials and beta receptor function
• Clinical presentation and diagnostic workup for beta-blocker toxicity
• Management strategies for beta blocker overdose, including airway control and fluid resuscitation
• Specific toxicologic profiles of common beta-blockers (e.g., propranolol, sotalol, metoprolol)
• Importance of recognizing hypoglycemia and CNS effects in beta-blocker toxicity
• Summary of critical management steps and take-home points for pediatric intensivists
• Encouragement for further learning and engagement on related topics

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 126. Toxidromes and their treatment. Joshi P. Pages 1504-1505
• Reference 1: Rogers textbook of Pediatric Intensive Care: Chapter 36: Poisoning. Nares M, Jeyapalan A, Weisman R: pages 525-543
• Reference 2: Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR; American Heart Association. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023 Oct 17;148(16):e149-e184. doi: 10.1161/CIR.0000000000001161. Epub 2023 Sep 18. PMID: 37721023.
• Suarez F, Koyfman A, Long B. Pearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity. J Emerg Med. 2026 May;84:1-11. doi: 10.1016/j.jemermed.2026.01.021. Epub 2026 Jan 27. PMID: 41833262.

In this episode of PICU Doc on Call, third-year PICU fellow Dr. Alexandria Edwards joins Drs. Pradip Kamat, Monica Gray, and Rahul Damania for a quick and practical dive into pediatric transport medicine. Dr. Edwards walks us through her go-to framework for handling transport calls, highlighting the importance of systematically checking vitals, respiratory support, the physical exam, labs, and any interventions. The team uses a real-life case of a 12-year-old with severe status asthmaticus to talk through how to pick the right transport mode, why it’s best to avoid intubation if you can, and how to make sure you’re on the same page with the ICU team before the patient arrives. The main message? Build a solid, structured approach to transport calls and practice it every time.

Show Highlights:

• Overview of pediatric intensive care unit (PICU) fellowship and training
• Importance of transport medicine in the PICU setting
• Framework for handling transport calls effectively
• Key considerations for assessing patient stability during transport
• Importance of vital signs and current patient status in decision-making
• Strategies for communicating with referring providers
• Discussion of a specific case involving a pediatric patient with asthma exacerbation
• Decision-making process for mode of transport (ground vs. air)
• Role of critical care transport teams in patient transfer
• Tips for preparing the receiving ICU team for incoming patients

We welcome your feedback and reviews. Please visit our website at https://picudoconcall.org/, where you can find our episodes.

In this episode, Drs. Pradip Kamat, Monica Gray, and Rahul Damania talk through a heartbreaking case involving a 14-year-old girl with a history of psychiatric illness who intentionally took 45 tablets of metformin and empagliflozin. Things went downhill quickly—she developed severe lactic acidosis, hypoglycemia, acute kidney injury, and eventually suffered a cardiac arrest that required ECMO and continuous dialysis. Sadly, even with the most aggressive care, she didn’t make it. The doctors walk listeners through the pharmacology and toxicity of metformin and empagliflozin, discuss how these drugs can cause harm, and share key management strategies. They really stress the importance of early recognition, using extracorporeal therapies, and working as a multidisciplinary team when dealing with severe pediatric overdoses of antidiabetic medications.

Show Highlights:

• Case study of a 14-year-old girl with intentional ingestion of an oral antidiabetic agent
• Presentation of severe lactic acidosis, hypoglycemia, acute kidney injury, and cardiac arrest
• Discussion of the pharmacology and toxicology of metformin and empagliflozin
• Mechanisms of metformin toxicity and its effects on metabolic processes
• Differentiation between types of lactic acidosis related to metformin
• Importance of early recognition and management of metformin toxicity
• Supportive care strategies for managing severe metformin overdose
• Role of extracorporeal therapies, including ECMO and dialysis, in treatment
• Multidisciplinary approach involving intensivists, nephrologists, and toxicologists
• Clinical implications and outcomes of severe metformin toxicity in pediatric patients

Resources:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter: Nothing found
• Reference 1: Noites I, Figueiredo M, Shchomak Z, Boto L, Camilo C. Fatal Pediatric Metformin-Associated Lactic Acidosis: When Severity Goes Unnoticed. Cureus. 2026 Feb 16;18(2):e103719.
• Reference 2: Bebarta VS, Pead J, Varney SM. Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatr Emerg Care. 2015 Aug;31(8):589-90.

In this episode of *Pediatric Critical Care Insights*, Dr. Monica Gray and Dr. Pradip Kamat chat about how capnography, specifically end-tidal CO2 monitoring, is used in the pediatric ICU. They walk through a real-life case of a 9-year-old with respiratory failure from influenza A, showing how ETCO2 monitoring helps confirm endotracheal tube placement, guides ventilation, spots cardiac arrest, and even helps assess the quality of CPR. Along the way, they break down how to interpret capnography waveforms, discuss different types of devices, and explain the key physiological concepts. The episode is packed with practical, bedside tips for intensivists caring for critically ill kids.

Show Highlights:

• Importance of capnography (end-tidal CO2 monitoring) in the pediatric intensive care unit (PICU)
• Clinical case study of a 9-year-old boy with respiratory failure due to influenza A
• Use of capnography for confirming endotracheal tube placement and assessing ventilation status
• Detection of cardiac arrest and guidance for CPR quality through ETCO2 monitoring
• Overview of capnography physics and physiology, including terminology distinctions
• Types of capnography: mainstream vs. sidestream, and their applications in pediatric patients
• Assumptions for accurate ETCO2 approximation of arterial CO2 and conditions affecting this relationship
• Analysis of capnography waveform phases and their clinical significance
• Prognostic value of ETCO2 during cardiac arrest and its correlation with patient outcomes
• Practical applications of ETCO2 monitoring in critical care, focusing on airway, breathing, and circulation management

References:

• Noninvasive respiratory monitoring and assessment of gas exchange. David F. Butler; Kenneth A. Schenkman. Fuhrman and Zimmerman's Pediatric Critical Care, 43, 483-491.e3
• Humphreys S, Schibler A, von Ungern-Sternberg BS. Carbon dioxide monitoring in children—A narrative review of physiology, value, and pitfalls in clinical practice. Pediatr Anaesth. 2021;31:839–845. https://doi.org/10.1111/pan.14208
• Lasa JJ, Dhillon GS, Duff JP, et al. Part 8: Pediatric Advanced Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2026;157(1):e2025074351
• O'Flaherty. Capnography: principles and practice. London: BMJ Publishing Group; 1994.
• Aminiahidashti H, Shafiee S, Zamani Kiasari A, Sazgar M. Applications of End-Tidal Carbon Dioxide (ETCO2) Monitoring in Emergency Department; a Narrative Review. Emerg (Tehran). 2018;6(1):e5. Epub 2018 Jan 15. PMID: 29503830; PMCID: PMC5827051.

In this special episode of *PICU Doc on Call*, hosts Dr. Monica Gray and Dr. Rahul Damania welcome new pediatric critical care fellows across the U.S. with practical advice for day one of fellowship. Joined by third-year PICU fellow Dr. Alexandra Bryant, the episode covers three key areas: navigating PICU logistics, protecting mental health, and managing the overwhelming volume of critical care knowledge. Dr. Bryant shares candid insights from her own training journey, offering actionable strategies for success. The hosts remind listeners that fellowship is a learning process and that new fellows can make a meaningful impact.

Show Highlights

• Introduction to pediatric critical care fellowship for new fellows and learners
• Key insights and advice for first-year fellows in pediatric intensive care
• Importance of understanding logistics in the PICU environment
• Strategies for effective communication and collaboration within the PICU team
• Managing mental health and self-care during fellowship
• Techniques for absorbing and retaining vast knowledge in pediatric critical care
• Recommendations for organizing study materials and resources
• Emphasis on lifelong learning and accessing information effectively
• Practical tips for time management and responsibility organization
• Suggested resources for mindfulness and emotional support in medical training

Resource:

PICU Doc on Call Episode 31

In this episode of *PICU Doc on Call Shorts*, pediatric ICU physicians Dr. Pradip Kamat and Dr. Rahul Damania discuss respiratory time constants and their clinical relevance in pediatric critical care. Using a case of a six-year-old with near-fatal status asthmaticus on mechanical ventilation, they explain how prolonged time constants from high airway resistance cause air trapping, dynamic hyperinflation, and intrinsic PEEP. They emphasize recognizing these issues through ventilator waveforms and highlight that increasing respiratory rate can worsen hypercapnia in obstructive disease. Key management strategies include reducing respiratory rate, extending expiratory time, and accepting permissive hypercapnia to ensure hemodynamic stability.

Show Highlights

• Respiratory time constants and their clinical significance in pediatric patients
• Case study of a six-year-old boy with near-fatal status asthmaticus
• Management of severe obstructive respiratory failure in pediatric patients
• Understanding airway resistance and lung compliance in relation to time constants
• Impact of ventilator settings on patient outcomes, including air trapping and intrinsic PEEP
• Importance of adequate expiratory time to prevent dynamic hyperinflation
• Recognizing signs of inadequate expiratory time in mechanically ventilated patients
• Strategies for managing hypercapnia and optimizing ventilator settings
• Differences in time constants related to various pediatric respiratory conditions
• Key takeaways for pediatric critical care practice and ventilator management

References

• Depta F, Kallet RH, Gentile MA, Kassis EN. Expiratory time constants in mechanically ventilated patients: rethinking the old concept — a narrative review. Intensive Care Medicine Experimental. 2025;13:40. The review summarizes the definition of expiratory time constant, the relationship to resistance and compliance, the 63/86/95/98/99% rule, and clinical applications in obstructive and acute lung injury states.
• Depta F, et al. Six methods to determine expiratory time constants in mechanically ventilated patients: a prospective observational physiology study. Intensive Care Medicine Experimental. 2024. This study describes expiratory time constant as a parameter that can guide respiratory rate and I:E adjustment to support complete exhalation.
• Alibrahim O, Rehder KJ, Miller AG, Rotta AT. Mechanical Ventilation and Respiratory Support in the Pediatric Intensive Care Unit. Pediatric Clinics of North America. 2022;69(3):587–605. This pediatric review specifically discusses passive exhalation, the expiratory time constant, and why asthma and bronchiolitis require longer expiratory times to avoid gas trapping.
• Arnal JM. Monitoring respiratory mechanics in mechanically ventilated patients. Hamilton Medical Knowledge Base. This source provides a practical bedside description of time constants, waveform-based respiratory mechanics, and typical RCexp ranges, while emphasizing dependence on resistance and compliance.
• Emeriaud G, López-Fernández YM, Iyer NP, et al.; PALICC-2 Group; PALISI Network. Executive summary of the second international guidelines for the diagnosis and management of pediatric ARDS. Pediatric Critical Care Medicine. 2023;24(2):143–168. The PALICC-2 guideline framework supports lung-protective ventilation in PARDS, including attention to tidal volume, PEEP, plateau pressure, and driving pressure.

In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat explore procedural sedation in the pediatric ICU. They cover sedation levels, pre-screening, risk stratification using ASA classifications, and medication selection tailored to each patient's hemodynamic and respiratory status. Through real-world case discussions involving respiratory failure, septic shock, and acute neurological decline, they highlight the importance of end-tidal CO2 monitoring and early adverse event recognition. Key takeaways include avoiding the term "conscious sedation," preparing rescue plans, and prioritizing patient safety through careful assessment and monitoring.

Show Highlights:

• Definitions and levels of sedation (minimal, moderate, deep sedation, and general anesthesia)
• Importance of terminology in procedural sedation
• Monitoring sedation levels using scales like the Richmond Agitation-Sedation Scale (RASS)
• Pre-screening and risk stratification considerations for pediatric patients
• ASA physical status classification system for assessing patient risk
• Unique challenges of procedural sedation in critically ill children
• Adverse events associated with pediatric procedural sedation, particularly respiratory complications
• Management strategies for specific cases requiring sedation (e.g., respiratory failure, septic shock)
• Importance of end-tidal CO2 monitoring during sedation
• Key takeaways for safe sedation practices in the pediatric ICU setting

References:

• Nir Atlas; Rahul C. Damania; Pradip P. Kamat In Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 135, 1624-1628
• Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia by Committee on Quality Management and Departmental Administration. Last Amended: October 23, 2024.
• Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019 Jun;143(6):e20191000. doi: 10.1542/peds.2019-1000. PMID: 31138666.x
• Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006 Mar 4;367(9512):766-80. doi: 10.1016/S0140-6736(06)68230-5. PMID: 16517277.
• Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth. 2024 Mar;132(3):491-506. doi: 10.1016/j.bja.2023.11.050. Epub 2024 Jan 6. PMID: 38185564.
• Smith, Heidi A. B. MD, MSCI (Chair)1,2; Besunder, James B. DO, FCCM3,4; Betters, Kristina A. MD1; Johnson, Peter N. PharmD, BCPS, BCPPS, FCCM, FPPA, FASHP5,6; Srinivasan, Vijay MBBS, MD, FCCM7,8; Stormorken, Anne MD9,10; Farrington, Elizabeth PharmD, FCCM11; Golianu, Brenda MD12,13; Godshall, Aaron J. MD14; Acinelli, Larkin CPNP-AC, ACHPN15; Almgren, Christina CPNP16; Bailey, Christine H. MD17; Boyd, Jenny M. MD18,19; Cisco, Michael J. MD20; Damian, Mihaela MD, MPH21,22; deAlmeida, Mary L. MD23,24; Fehr, James MD13,25; Fenton, Kimberly E. MD, FCCM14; Gilliland, Frances DNP, CPNP-AC/PC26,27; Grant, Mary Jo C. CPNP-AC, PhD, FAAN28; Howell, Joy MD29; Ruggles, Cassandra A. PharmD, BCCCP, BCPPS30; Simone, Shari DNP31,32; Su, Felice MD21,22; Sullivan, Janice E. MD33,34; Tegtmeyer, Ken MD, FAAP, FCCM35,36; Traube, Chani MD, FCCM29; Williams, Stacey CPNP-AC37; Berkenbosch, John W. MD, FAAP, FCCM (Chair)33,34. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatric Critical Care Medicine 23(2):p e74-e110, February 2022. | DOI: 10.1097/PCC.0000000000002873
• Benzoni T, Agarwal A, Cascella M. Procedural Sedation. [Updated 2025 Mar 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK551685/https://www.ncbi.nlm.nih.gov/books/NBK551685/
• Kerson AG, DeMaria R, Mauer E, Joyce C, Gerber LM, Greenwald BM, Silver G, Traube C. Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children. J Intensive Care. 2016 Oct 26;4:65. doi: 10.1186/s40560-016-0189-5. PMID: 27800163; PMCID: PMC5080705.
• Tel-Dan SF, Shavit D, Nates R, Samuel N, Shavit I. Emergency Physician-Administered Sedation for Thoracostomy in Children With Pleuropneumonia. Pediatr Emerg Care. 2021 Dec 1;37(12):e1209-e1212. doi: 10.1097/PEC.0000000000001975. PMID: 31929389.
• Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med. 2022 Dec;80(6):485-496. doi: 10.1016/j.annemergmed.2022.05.002. Epub 2022 Jun 23. PMID: 35752522.
• Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, Gelman B; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006 Sep;118(3):1087-96. doi: 10.1542/peds.2006-0313. PMID: 16951002.

In this episode of *PICU Doc on Call*, Dr. Monica Gray and Dr. Pradip Kamat are joined by fellow Dr. Hope Vancleve to discuss a complex case of a 12-year-old with MRSA septic shock requiring VA ECMO. The conversation covers sepsis-induced myocardial dysfunction, including its pathophysiology, diagnosis, and management. The hosts also explore differential hypoxia, or Harlequin syndrome, a serious VA ECMO complication causing upper body deoxygenation, and discuss monitoring strategies and circuit reconfiguration to prevent cerebral and myocardial ischemia.

Show Highlights:

• Clinical case discussion of a 12-year-old male patient with MRSA septic shock.
• Complications of sepsis, including sepsis-induced myocardial dysfunction and refractory shock.
• Management strategies for septic shock, including antibiotic therapy and fluid resuscitation.
• Use of venoarterial ECMO support in pediatric patients with severe cardiac dysfunction.
• Pathophysiology of sepsis-induced myocardial dysfunction and its impact on cardiac function.
• Differential hypoxia (North-South syndrome) in patients on femoral VA ECMO.
• Diagnostic approaches for sepsis-induced myocardial dysfunction, including echocardiography and biomarkers.
• Importance of monitoring and managing end-organ function in septic patients.
• Strategies for addressing differential hypoxia in ECMO patients, including circuit reconfiguration.
• Discussion of the risks and benefits of various ECMO configurations and management techniques.

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter
• Reference 1: Torre DE, Pirri C. Harlequin Syndrome in Venoarterial ECMO and ECPELLA: When ECMO and Native or Impella Circulations Collide - A Comprehensive Review. Rev Cardiovasc Med. 2025 Aug 26;26(8):39992. doi: 10.31083/RCM39992. PMID: 40927093; PMCID: PMC12415751.
• Reference 2 : Cove ME. Disrupting differential hypoxia in peripheral veno-arterial extracorporeal membrane oxygenation. Crit Care. 2015 Jul 22;19(1):280. doi: 10.1186/s13054-015-0997-3. PMID: 27391473; PMCID: PMC4511033.

In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat discuss a 15-year-old girl who attempted suicide by ingesting rat poison, acetaminophen, ibuprofen, and amlodipine. The episode focuses on long-acting anticoagulant rodenticides (LAARs), such as brodifacoum, which inhibit vitamin K epoxide reductase, causing delayed coagulopathy. Key topics include clinical presentation, diagnostic evaluation, and management, emphasizing vitamin K1 as the primary antidote and prothrombin complex concentrate or fresh-frozen plasma for major bleeding. The patient stabilized with aggressive supportive care, including vasoactive agents and NAC therapy, alongside psychiatric intervention. Listen to learn more!

Show Highlights

• Clinical case of a 15-year-old girl who attempted suicide through polypharmacy ingestion
• Ingestion of multiple substances, including chewable rat poison, acetaminophen, ibuprofen, and amlodipine
• Discussion of toxicology related to long-acting anticoagulant rodenticides (LAARs) like brodifacoum
• Symptoms and clinical presentation following acute ingestion, including metabolic acidosis and elevated lactate
• Diagnostic evaluation and laboratory findings, including coagulation studies and liver function tests
• Management strategies for LAAR poisoning, including the use of vitamin K and supportive care
• Importance of monitoring for delayed coagulopathy and serial INR testing
• Consideration of calcium channel blocker toxicity in the context of the patient's clinical instability
• Overview of the mechanisms of action of LAARs and their impact on vitamin K-dependent clotting factors
• Key take-home points regarding the recognition and management of rodenticide ingestion in pediatric patients

References

Reference: King N, Tran MH. Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management. Transfus Med Rev. 2015 Oct;29(4):250-8.

Reference 2: Feinstein DL, Akpa BS, Ayee MA, et al. The emerging threat of superwarfarins: history, detection, mechanisms, and countermeasures. Ann N Y Acad Sci. 2016 Jun;1374(1):111-22.

In this episode of PICU Doc on Call, Dr. Monica Gray and Dr. Pradip Kamat chat about flexible fiberoptic bronchoscopy (FFB) in the pediatric ICU. They walk through a case involving an eight-year-old who’s dealing with respiratory failure after a stem cell transplant. Along the way, they talk about when and why you might use bronchoscopy both for diagnosis and treatment—plus how to approach sedation and what effects the procedure can have on the heart and lungs. They also dive into important topics like managing hypoxia, handling increased airway and pulmonary vascular resistance, and what to keep in mind if your patient has a traumatic brain injury. The episode wraps up with tips for managing fever after the procedure and a quick look at how rigid bronchoscopy compares.

Show Highlights:

• Use of flexible fiberoptic bronchoscopy (FFB) in the pediatric ICU (PICU)
• Indications for performing bronchoscopy (diagnostic and therapeutic)
• Management of sedation and analgesia during bronchoscopy
• Cardiovascular effects associated with bronchoscopy procedures
• Respiratory effects and complications during bronchoscopy
• Special considerations for bronchoscopy in patients with traumatic brain injury (TBI)
• Post-procedure complications, including fever and its management
• Overview of rigid bronchoscopy and its indications
• Importance of understanding physiological changes during bronchoscopy
• Educational focus on acute pediatric care for current and aspiring PICU interns

References:

Reference 1: Sachdev A, Chhawchharia R. Flexible Fiberoptic Bronchoscopy in Pediatric Practice. Indian Pediatr. 2019 Jul 15;56(7):587-593. PMID: 31333214.

Reference 2: Li SX, Tao XF, Wu HJ, Jin F, Zhu GH, Wang YS, Tang LF, Chen ZM, Wu L. Advances in pediatric flexible bronchoscopy. World J Pediatr. 2025 Oct;21(10):945-956. doi: 10.1007/s12519-025-00967-7. Epub 2025 Oct 4. PMID: 41045338; PMCID: PMC12578761.

Reference 3: Truitt BA, Kasi AS, Kamat PP, Fundora MP, Simon DM, Guglani L. Cryoextraction via flexible bronchoscopy in children with tracheobronchial obstruction. Pediatr Pulmonol. 2023 Sep;58(9):2527-2534. doi: 10.1002/ppul.26540. Epub 2023 Jun 23. PMID: 37350368.

In this episode of "PICU Doc on Call," Drs. Monica Gray and Pradip Kamat from Children's Healthcare of Atlanta dive into the use of inhaled anesthetics, especially isoflurane, in the pediatric ICU. We’re focusing on those tough cases: refractory status asthmaticus and status epilepticus.

We’ll chat about why isoflurane is our go-to over other agents like sevoflurane, desflurane, or nitrous oxide, and break down its bronchodilatory and anticonvulsant properties. We’ll also touch on important pharmacology concepts, such as MAC and the blood-gas partition coefficient, and discuss how we approach dosing and ventilator management when using isoflurane.

Of course, we’ll also discuss the potential adverse effects that can come with prolonged use, and why it’s important to stop other sedatives and beta-agonists once you start isoflurane. Join us as we walk through the practical aspects and pearls for using inhaled anesthetics in the PICU!

Show Highlights:

• Use of inhaled anesthetics in pediatric intensive care units (PICU)
• Focus on isoflurane for managing refractory status asthmaticus and status epilepticus
• Comparison of inhaled anesthetic agents: isoflurane, sevoflurane, nitrous oxide, and desflurane
• Importance of minimum alveolar concentration (MAC) and blood-gas partition coefficient in anesthetic pharmacodynamics
• Mechanism of action of isoflurane in airway management and bronchodilation
• Clinical administration techniques for isoflurane in critically ill children
• Ventilator management principles for intubated children with status asthmaticus
• Role of isoflurane in refractory and super-refractory status epilepticus
• Potential adverse effects and considerations for prolonged isoflurane use
• Summary of pharmacologic concepts essential for safe isoflurane therapy in pediatric patients

References:

• Rogers Text Book of Pediatric Intensive Care: Chapter 47: Acute Severe Asthma. Stewart C, Brilli RJ. pages 763-775
• Reference 1: Stetefeld HR, Schaal A, Scheibe F, Nichtweiß J, Lehmann F, Müller M, Gerner ST, Huttner HB, Luger S, Fuhrer H, Bösel J, Schönenberger S, Dimitriadis K, Neumann B, Fuchs K, Fink GR, Malter MP; IGNITE Study Group, with support from the German Neurocritical Care Society (DGNI). Isoflurane in (Super-) Refractory Status Epilepticus: A Multicenter Evaluation. Neurocrit Care. 2021 Dec;35(3):631-639. doi: 10.1007/s12028-021-01250-z. Epub 2021 Jul 20. PMID: 34286464; PMCID: PMC8692280.
• Reference 2: Zeiler FA, Zeiler KJ, Teitelbaum J, Gillman LM, West M. Modern inhalational anesthetics for refractory status epilepticus. Can J Neurol Sci. 2015 Mar;42(2):106-15. doi: 10.1017/cjn. 2014.121. Epub 2015 Jan 9. PMID: 25572922.
• Reference 3: Werner HA. Status asthmaticus in children: a review. Chest. 2001 Jun;119(6):1913-29. doi: 10.1378/chest. 119.6.1913. PMID: 11399724.
• Reference 4: Gill B, Bartock JL, Damuth E, Puri N, Green A. Case report: Isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation. Front Med (Lausanne). 2022 Nov 8;9:1051468. doi: 10.3389fmed. .2022.1051468. PMID: 36425104; PMCID: PMC9679515.

In this episode of *PICU Doc on Call*, Drs. Monica Gray, Pradip Kamat, and Rahul Damania chat about a 17-year-old girl who ended up with acute liver failure after she intentionally took 22.5 grams of acetaminophen. She came in 48 hours later with really high transaminases and an INR of 5.5, so she was admitted to the PICU. The hosts break down how acetaminophen affects the body, walk through its four clinical stages, and discuss how to manage it—focusing on N-acetylcysteine as the primary antidote. They also touch on other treatments, like fomepizole. Thankfully, this patient recovered without needing a liver transplant, which really shows how important it is to have a team approach with intensivists, hepatologists, toxicologists, and psychiatry all working together.

Show Highlights:

• Clinical case presentation of a 17-year-old girl with acetaminophen ingestion leading to acute liver failure
• Mechanism of acetaminophen toxicity and its metabolic pathways
• Epidemiology of acetaminophen toxicity in pediatric populations
• Pathophysiology of acetaminophen overdose and its effects on liver function
• Clinical manifestations and progression of acetaminophen toxicity through various stages
• Evaluation and diagnostic criteria for assessing acetaminophen toxicity
• Management strategies for acetaminophen overdose, including the use of N-acetylcysteine (NAC).
• Discussion of adjunctive therapies such as fomepizole in severe cases.
• Importance of supportive care in managing complications of acute liver failure
• An interdisciplinary approach to treatment involving various medical specialties

References:

Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.

Reference 1: 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Brooks DE, Dibert KW, Rivers LJ, Pham NPT, Ryan ML. Clin Toxicol (Phila). 2020;58(12):1360.

Reference 2: Pepin L, Matsler N, Fontes A, Heard K, Flaherty BF, Monte AA. Fomepizole Therapy for Acetaminophen-Induced Liver Failure in an Infant. Pediatrics. 2023 Oct 1;152(4):e2022061033. doi:10.1542/peds. 2022-061033. PMID: 37681263.

Reference 3. Chiew AL, Buckley NA. Acetaminophen Poisoning. Crit Care Clin. 2021 Jul;37(3):543-561.

Reference 4. Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr. 2022 Jan 1;74(1):138-158. doi: 10.1097/MPG.0000000000003268. PMID: 34347674.

In this episode of "PICU Doc on Call," Drs. Monica Gray, Pradip Kamat, and Rahul Damania discuss the use of intranasal medications in pediatric intensive care. Using the case of a four-month-old infant needing an MRI, they explore when and why intranasal drugs are preferred over IV access, the science behind nasal drug delivery, safe administration techniques, and common medications used. The episode highlights the benefits of intranasal sedation—such as rapid onset and needle-free delivery—while emphasizing teamwork and careful monitoring for safe, effective pediatric care.

Show Highlights:

• Use of intranasal medications in pediatric intensive care settings
• Case study of a four-month-old infant requiring sedation for an MRI.
• Advantages of intranasal delivery over IV access
• Pharmacokinetics and neuroanatomy related to intranasal drug absorption
• Techniques for safe and effective administration of intranasal medications
• Comparison of intranasal dosing to oral and IV routes
• Common intranasal medications used in the pediatric ICU
• Importance of timing and monitoring during sedation procedures
• Teamwork and communication in administering intranasal medications
• Clinical applications and implications for patient comfort and care delivery

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.
• Reference 1: Tsze DS, Woodward HA, McLaren SH, Leu CS, Venn AMR, Hu NY, Flores-Sanchez PL, Stefan BR, Shen ST, Ekladios MJ, Cravero JP, Dayan PS. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. 2025 Sep 1;179(9):979-986. doi: 10.1001/jamapediatrics. 2025.2181.
• Reference 2: Prescott MG, Iakovleva E, Simpson MR, Pedersen SA, Munblit D, Vallersnes OM, Austad B. Intranasal analgesia for acute moderate to severe pain in children - a systematic review and meta-analysis. BMC Pediatr. 2023 Aug 18;23(1):405. doi: 10.1186/s12887-023-04203-x.
• Reference 3: Chabowski L, Mahboobi Z, Navolokina A. Intranasal ketamine for procedural sedation in children. Am J Emerg Med. 2023 Jun;68:195. doi: 10.1016/j.ajem.2023.04.013.
• Reference 4: Sulton C, Kamat P, Mallory M, Reynolds J. The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Emerg Care. 2020 Mar;36(3):138-142. doi: 10.1097/PEC.0000000000001199.

In this special “PICU Doc On Call Shorts” episode, pediatric ICU physicians Dr. Monica Gray, Dr. Pradip Kamat, and Dr. Rahul Damania break down the concept of Mean Arterial Pressure (MAP). Using a case of a six-year-old in septic shock, they discuss how to calculate MAP, normal pediatric values, and the physiological determinants and clinical significance of MAP. The hosts highlight MAP’s role in guiding management of critically ill children, review autonomic and endothelial regulation, and reinforce learning with a board-style question. This episode emphasizes practical bedside application for pediatric interns and ICU providers.

Show Highlights:

• Overview of Mean Arterial Pressure (MAP) and its clinical significance in pediatric critical care.
• Introduction of a clinical case involving a 6-year-old child in septic shock.
• Explanation of the formula for calculating MAP and its application to the clinical case.
• Discussion of normal reference values for MAP in children and their clinical implications.
• Physiological determinants of MAP, including cardiac output and systemic vascular resistance.
• Role of the autonomic nervous system in regulating MAP through baroreceptor reflexes.
• Importance of maintaining adequate MAP for organ perfusion, particularly in critically ill patients.
• Clinical applications of MAP monitoring and management strategies in the PICU.
• Summary of key takeaways regarding MAP calculation, physiological determinants, and clinical relevance.
• Mention of related topics, such as invasive versus non-invasive blood pressure monitoring.

References:

• DeMers D, Wachs D. Physiology, Mean Arterial Pressure. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
• Pediatric Blood Pressure Metrics and Hypotension Thresholds (details the task force data used to derive the 5th and 50th percentile MAP estimation formulas for children)
• Berlin DA, Bakker J. Starling curves and central venous pressure. Crit Care. 2015 Feb 16;19(1):55.
• Magder S. Volume and its relationship to cardiac output and venous return. Crit Care. 2016 Sep 10;20(1):271

In this episode of "PICU Doc on Call," Drs. Pradip Kamat and Rahul Damania dive into a pediatric ICU case involving a 4-year-old girl who presents with severe anemia and bleeding, ultimately diagnosed with von Willebrand disease (VWD). They chat about the causes and different types of VWD, walk through the key clinical features, and break down how to diagnose and manage this condition. Drs. Kamat and Damania highlight the important roles of desmopressin and factor concentrates in treatment. Throughout the episode, they stress the need to recognize VWD in kids who have mucosal bleeding and offer practical tips for intensivists on lab evaluation and treatment strategies for this common inherited bleeding disorder.

Show Nighlights:

• Clinical case discussion of a 4-year-old girl with severe anemia and bleeding symptoms
• Diagnosis of von Willebrand disease (VWD) and its significance in pediatric critical care
• Etiology and pathogenesis of von Willebrand disease
• Classification of von Willebrand disease into types (Type 1, Type 2 with subtypes, Type 3)
• Clinical manifestations and symptoms associated with VWD
• Diagnostic approach for identifying von Willebrand disease, including laboratory tests
• Management strategies for VWD, including desmopressin and von Willebrand factor concentrates
• Role of adjunctive therapies such as antifibrinolytics and hormonal treatments
• Importance of multidisciplinary collaboration in managing complex bleeding disorders
• Overview of the pathophysiology of von Willebrand factor and its role in hemostasis

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.
• Reference 1: Leebeek FW, Eikenboom JC. Von Willebrand's Disease. N Engl J Med. 2016 Nov 24;375(21):2067-2080.
• Reference 2: Ng C, Motto DG, Di Paola J. Diagnostic approach to von Willebrand disease. Blood. 2015 Mar 26;125(13):2029-37.
• Platton S, Baker P, Bowyer A, et al. Guideline for laboratory diagnosis and monitoring of von Willebrand disease: A joint guideline from the United Kingdom Haemophilia Centre Doctors' Organisation and the British Society for Hematology. Br J Haematol 2024 May;204(5):1714-1731.
• Mohinani A, Patel S, Tan V, Kartika T, Olson S, DeLoughery TG, Shatzel J. Desmopressin as a hemostatic and blood-sparing agent in bleeding disorders. Eur J Haematol. 2023 May;110(5):470-479. doi: 10.1111/ejh.13930. Epub 2023 Feb 12. PMID: 36656570; PMCID: PMC10073345.

In this episode of "PICU Doc On Call," Drs. Pradip Kamat and Rahul Damania discuss the acute management of a 14-year-old boy with severe rectal bleeding and hypertension, ultimately diagnosed with inflammatory bowel disease (IBD). They review the approach to pediatric lower GI bleeding, diagnostic workup, and imaging, emphasizing early recognition and resuscitation. They outline IBD management, including steroids, biologics such as infliximab, and nutritional support, while highlighting the importance of screening for infections before immunosuppression. The episode provides practical insights for PICU physicians on handling acute GI emergencies in children.

Show Nighlights:

• Clinical case of a 14-year-old male with hypertension and rectal bleeding.
• Diagnosis of inflammatory bowel disease (IBD) following significant blood loss.
• Approach to pediatric rectal bleeding and its implications.
• Diagnostic workup including laboratory tests and imaging modalities.
• Management strategies for IBD in acute pediatric care.
• Importance of early recognition and resuscitation in cases of shock.
• Physiological principles related to blood loss and shock in children.
• Differential diagnoses for lower gastrointestinal bleeding in pediatrics.
• Initial evaluation and stabilization protocols for pediatric patients.
• Nutritional support and multidisciplinary care in managing IBD.

References:

• Romano C, Oliva S, Martellossi S, et al. Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology. World J Gastroenterol. 2017;23(8):1326-1337.
• Pai AK, Fox VL. Gastrointestinal bleeding and management. Pediatr Clin North Am. 2017;64(3):543-561.
• Padilla BE, Moses W. Lower gastrointestinal bleeding and intussusception. Surg Clin North Am. 2017;97(1):63-80.
• Kaur M, Dalal RL, Shaffer S, Schwartz DA, Rubin DT. Inpatient management of inflammatory bowel disease-related complications. Clin Gastroenterol Hepatol. 2020;18(11):2417-2428.
• Ashton JJ, Ennis S, Beattie RM. Early-onset paediatric inflammatory bowel disease. Lancet Child Adolesc Health. 2017;1(2):147-158.
• Bouhuys M, Lexmond WS, van Rheenen PF. Pediatric inflammatory bowel disease. Pediatrics. 2022;150(6):e2022059341.
• Rosen MJ, Dhawan A, Saeed SA. Inflammatory bowel disease in children and adolescents. JAMA Pediatr. 2015;169(11):1053-1060.
• Conrad MA, Rosh JR. Pediatric Inflammatory Bowel Disease. Pediatr Clin North Am. 2017 Jun;64(3):577-591.
• Turner D, Ruemmele FM, Orlanski-Meyer E, et al. Management of Paediatric Ulcerative Colitis, Part 1: Ambulatory Care-An Evidence-based Guideline From European Crohn's and Colitis Organization and European Society of Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2018 Aug;67(2):257-291, correction can be found in J Pediatr Gastroenterol Nutr 2020 Dec;71(6):794.

In this episode of "PICU Doc on Call," Dr. Pradip Kamat and Dr. Rahul Damania dive into a fascinating case of a 9-month-old infant who comes in with hypoglycemia and seizures. Together, they break down the basics of glucose metabolism, walk through the causes of hypoglycemia, and discuss the best diagnostic strategies and acute management steps. They put a special spotlight on using diazoxide for hyperinsulinemic hypoglycemia, discussing not only how it works but also its potential side effects. The conversation also discusses dietary interventions for metabolic disorders and highlights the importance of rapid diagnosis and personalized treatment.

Show Highlights:

• Pediatric hypoglycemia and its implications in infants
• Case study of a 9-month-old infant with hypoglycemia and seizures
• Physiology of glucose metabolism and its regulation
• Causes of hypoglycemia, categorized into primary and secondary etiologies
• Diagnostic approaches for identifying the cause of hypoglycemia
• Initial management strategies for acute hypoglycemia
• Long-term treatment options based on underlying causes
• Importance of timely diagnosis and intervention in the PICU setting
• Pharmacologic management of hyperinsulinemic hypoglycemia, including the use of diazoxide
• Multidisciplinary care and follow-up for pediatric patients with hypoglycemia

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 84 Alder M et al. Pediatric Sepsis. Pages 1293-1309
• Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024. Crit Care Med. 2024 Apr 1;52(4):e161-e181. doi: 10.1097/CCM.0000000000006174. Epub 2024 Jan 19. PMID: 38240484.
• Rosenfeld E, Thornton PS. Hypoglycemia in Neonates, Infants, and Children. 2023 Aug 22. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. South Dartmouth (MA):http://mdtext.com/http://mdtext.com/, Inc.; 2000–. PMID: 37665756.
• Rayas MS, Salehi M. Non-Diabetic Hypoglycemia. 2024 Jan 27. In: Feingold KR, Ahmed SF, Anawalt B, Blackman MR, Boyce A, Chrousos G, Corpas E, de Herder WW, Dhatariya K, Dungan K, Hofland J, Kalra S, Kaltsas G, Kapoor N, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, Levy M, McGee EA, McLachlan R, Muzumdar R, Purnell J, Rey R, Sahay R, Shah AS, Singer F, Sperling MA, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. South Dartmouth (MA):http://mdtext.com/http://mdtext.com/, Inc.; 2000–. PMID: 27099902.
• Nakrani MN, Wineland RH, Anjum F. Physiology, Glucose Metabolism. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK560599/https://www.ncbi.nlm.nih.gov/books/NBK560599/
• Chen X, Feng L, Yao H, Yang L, Qin Y. Efficacy and safety of diazoxide for treating hyperinsulinemic hypoglycemia: A systematic review and meta-analysis. PLoS One. 2021 Feb 11;16(2):e0246463. doi: 10.1371/journal.pone.0246463. PMID: 33571197; PMCID: PMC7877589.
• Kucharczyk P, Albano G, Deisl C, Ho TM, Bargagli M, Anderegg M, Wuest S, Konrad D, Fuster DG. Thiazides Attenuate Insulin Secretion Through Inhibition of Mitochondrial Carbonic Anhydrase 5b in β -Islet Cells in Mice. J Am Soc Nephrol. 2023 Jul 1;34(7):1179-1190. Doi: 10.1681/ASN.0000000000000122. Epub 2023 Apr 17. PMID: 36927842; PMCID: PMC10356162.