Critical Care

Episode 33: Pediatric Readiness with Stefanie Ames

Critical Care, Readiness

In this episode of Little Big Med, host Jason Woods talks with Dr. Stefanie Ames about the paper she first-authored titled “Emergency Department Pediatric Readiness and Mortality in Critically Ill Children”.

Key Points

  • Retrospective study, data from Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project, 2013
  • Included 20483 patients from 426 hospitals in Florida, Iowa, Massachusetts, Nebraska, and New York
  • Mortality decreased with increasing readiness score
  • Adjusted OR also showed that the highest “readiness” hospitals had the lowest mortality in this cohort
  • Some concern remains that the difference is at least partially related to case definition – ICU admission was included as an inclusion criteria, which may have falsely lowered the overall level of illness of patients admitted to an institution with a PICU. HOWEVER –
    • Cases were also followed through time – so patients that were transferred to a hospital with an ICU from a hospital without one had their data linked together.
    • In that case the presence or absence of an ICU at the index hospital would not have “counted against” the index hospital, unless that hospital were inappropriately admitting critical ill patients to a general ward instead of transferring to a facility with a PICU
    • The authors feel they addressed this by also considering PECARN illness severity scores, most of which were 4 or 5 (most severe illness)
    • Most deaths in this cohort occurred in the ED rather than in the ICU/floor, arguing that the ICU admission criteria itself did not drive mortality rates.
  • Another analysis of this article from EMA exists but comes to a different conclusion about the impact of this article. I’m linking here so you can listen to the differing viewpoints.

Guest

Stefanie Ames, Assistant Professor, Pediatric Critical Care Medicine, University of Utah

Audio Editor – Kellen Vu

References

  1. Ames SG, Davis BS, Marin JR, Fink EL, Olson LM, Gausche-Hill M, Kahn JM. Emergency Department Pediatric Readiness and Mortality in Critically Ill Children. Pediatrics. 2019 Sep;144(3):e20190568. doi: 10.1542/peds.2019-0568. Erratum in: Pediatrics. 2020 May;145(5): PMID: 31444254; PMCID: PMC6856787.
  2. Alessandrini EA, Alpern ER, Chamberlain JM, Shea JA, Holubkov R, Gorelick MH; Pediatric Emergency Care Applied Research Network. Developing a diagnosis-based severity classification system for use in emergency medical services for children. Acad Emerg Med. 2012 Jan;19(1):70-8. doi: 10.1111/j.1553-2712.2011.01250.x. PMID: 22251193.

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Episode 29: AHA Pediatric Post Cardiac Arrest Scientific Statement with Alexis Topjian

Cardiac Arrest, Critical Care, Emergency Medicine, Pediatric Emergency Medicine

On this episode, host Jason Woods talks with Alexis Topjian about the 2019 “AHA Pediatric Post–Cardiac Arrest Care Scientific Statement.” Dr. Topjian is the first author on the statement, which is the first pediatric post arrest care statement from the AHA (previously children had primarily been discussed as a special population within a primarily adult guideline). The document itself is long, but contains a large amount of useful information for bedside providers, health care administrators, and researchers.


Guests

Alexis Topjian MD, Associate Professor of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children’s Hospital of Philadelphia

References

  1. Topjian AA, de Caen A, Wainwright MS, et al. Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation. 2019;140(6):e194-e233. doi:10.1161/CIR.0000000000000697

Additional Resources

  1. Previous Little Big Med podcast with Dr. Topjian on post arrest hypotension in children

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Episode 24: Metabolic Resuscitation for Pediatric Septic Shock

Critical Care, Emergency Medicine, Sepsis

On this episode, host Jason Woods speaks with Dr Nelson Sanchez-Pinto, pediatric intensivist, about an article he co-authored that was just e-published in the last week! The article concerns a retrospective analysis of the use of HAT therapy (hydrocortisone, ascorbic acid, thiamine) at a single center PICU for the treatment of pediatric septic shock. The e-pub link is below and this post will update when it is published in print. This topic has caused significant controversy and strong emotions for the last several years, and I expect that to continue. Please take a look at the additional resources below, as well as Dr. Sanchez-Pinto’s twitter feed (@nelsonspinto), for even more information.

E-publication link: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1543LE

The highlights:

  • Study details
    • Single center, retrospective, propensity score matched
    • 557 septic shock patients in the PICU
    • 43 received HAT, 181 hydrocortisone alone, 333 neither
    • HAT patients matched 1:1 with the other groups
  • Results
    • HAT patients had lower mortality at 30-days (9 vs 28%, P=0.03) and 90-days (14 vs 37%, P=0.01) compared to no HAT or hydrocortisone
    • Similar results comparing mortality in HAT to those with hydrocortisone alone – 30-day (9 vs 30%, p=0.01) and 90 day (14 vs 37%, p=0.01)
    • No difference at 30 days in vasoactive free days or hospital free days

Guests

Nelson Sanchez-Pinto MD, Assistant Professor of Pediatrics and Preventative Medicine, Northwestern University, Feinburg School of Medicine

Pediatric Intensivist, Anne and Robert H. Lurie Children’s Hospital of Chicago

References

1.         Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238.

2.         Wilson JX. Mechanism of action of vitamin C in sepsis: ascorbate modulates redox signaling in endothelium. Biofactors. 2009;35(1):5-13.

3.         Fowler AA, 3rd, Syed AA, Knowlson S, Sculthorpe R, Farthing D, DeWilde C, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.

4.         Spoelstra-de Man AME, Elbers PWG, Oudemans-van Straaten HM. Making sense of early high-dose intravenous vitamin C in ischemia/reperfusion injury. Crit Care. 2018;22(1):70.

5.         Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.

6.        Wald EL, Sanchez-Pinto LN, Smith CM, Moran T, Badke CM, Barhight MF, Malakooti MR. Hydrocortisone-Ascorbic Acid-Thiamine Use Associated with Lower Mortality in Pediatric Septic Shock. Am Journal Respr and Crit Care Med. E-pub ahead of print. PMID: 31916841. DOI: https://doi.org/10.1164/rccm.201908-1543LE

7.        Fowler AA, Trust JD, Hite RD. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure – The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322(13):1261-1270. doi:10.1011/jama.2019.11825

Additional Resources

  1. SGEM discussion on the original Marik Trial
  2. PulmCrit on the recent CITRIS-ALI trial
  3. REBEL EM on the original Marik trial

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