PICU Doc On Call

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 symptomsDiagnosis of von Willebrand disease (VWD) and its significance in pediatric critical careEtiology and pathogenesis of von Willebrand diseaseClassification of von Willebrand disease into types (Type 1, Type 2 with subtypes, Type 3)Clinical manifestations and symptoms associated with VWDDiagnostic approach for identifying von Willebrand disease, including laboratory testsManagement strategies for VWD, including desmopressin and von Willebrand factor concentratesRole of adjunctive therapies such as antifibrinolytics and hormonal treatmentsImportance of multidisciplinary collaboration in managing complex bleeding disordersOverview of the pathophysiology of von Willebrand factor and its role in hemostasisReferences: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 infantsCase study of a 9-month-old infant with hypoglycemia and seizuresPhysiology of glucose metabolism and its regulationCauses of hypoglycemia, categorized into primary and secondary etiologiesDiagnostic approaches for identifying the cause of hypoglycemiaInitial management strategies for acute hypoglycemiaLong-term treatment options based on underlying causesImportance of timely diagnosis and intervention in the PICU settingPharmacologic management of hyperinsulinemic hypoglycemia, including the use of diazoxideMultidisciplinary care and follow-up for pediatric patients with hypoglycemiaReferences:Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 84 Alder M et al. Pediatric Sepsis. Pages 1293-1309Honarmand 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): 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): 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/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.

Today, Dr. Monica Gray, Dr. Pradip Kamat, and Rahul Damania discuss a critical case involving a 10-year-old boy who developed post-intubation desaturation. Using the DOPE mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure), they systematically troubleshoot the emergency, highlighting the importance of teamwork, capnography, and manual ventilation. The team emphasizes structured approaches, simulation training, and essential bedside tools to ensure rapid, effective management of acute deterioration in intubated children, turning a life-threatening crisis into a controlled, solvable situation.Show Highlights:Clinical case discussion of a ten-year-old boy with post-intubation desaturation in the pediatric ICUUse of the "DOPE" mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure) for troubleshootingSystematic approaches in emergency situations in pediatric critical careAssessment and management of sudden desaturation in intubated patientsEvaluation of potential causes of desaturation, including tube displacement and obstructionRole of equipment failure in acute deterioration and strategies to address itSignificance of continuous capnography and manual ventilation techniquesPrevention strategies for unplanned extubation in pediatric ICU settingsEmphasis on teamwork, communication, and simulation training in crisis managementReview of literature insights related to hypoxemia and equipment issues in pediatric intubationReferences:Topjian AA, et al. Part 4: Pediatric Basic and Advanced Life Support—2020 AHA PALS Guidelines. Circulation. 2020.Foundational pediatric resuscitation guidance endorsing early switch to manual ventilation and structured troubleshooting for the deteriorating intubated child.Cook TM, et al. Major complications of airway management in the UK: NAP4. British Journal of Anaesthesia. 2011.Seminal audit highlighting ICU/ED airway failures and the critical role of waveform capnography in preventing unrecognized esophageal intubation.Volpicelli G, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Medicine. 2012. High-impact consensus placing lung ultrasound at the bedside to rapidly diagnose pneumothorax during post-intubation deterioration.Prekker ME, et al. Video vs direct laryngoscopy for ED intubation—randomized trial. New England Journal of Medicine. 2023.NEJM RCT showing higher first-pass success with video laryngoscopy—relevant to preventing displacement/misplacement drivers of desaturation.Chrimes N, et al. Preventing unrecognised oesophageal intubation: consensus guideline. Anaesthesia. 2022.Modern, practice-changing guidance: sustained waveform capnography is the mainstay to exclude esophageal placement and avert catastrophic hypoxemia.