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 ICU
• Use of the "DOPE" mnemonic (Displacement, Obstruction, Pneumothorax, Equipment failure) for troubleshooting
• Systematic approaches in emergency situations in pediatric critical care
• Assessment and management of sudden desaturation in intubated patients
• Evaluation of potential causes of desaturation, including tube displacement and obstruction
• Role of equipment failure in acute deterioration and strategies to address it
• Significance of continuous capnography and manual ventilation techniques
• Prevention strategies for unplanned extubation in pediatric ICU settings
• Emphasis on teamwork, communication, and simulation training in crisis management
• Review of literature insights related to hypoxemia and equipment issues in pediatric intubation

References:

• 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.

Welcome to "PICU Doc on Call," the podcast where the world of pediatric critical care comes alive! Today, Dr. Monica Gray, Dr. Pradip Kamat, and Rahul Damania delve into a fascinating case involving a 16-year-old male presenting with headache, photophobia, anemia, and cerebral venous thrombosis. After some detective work, the diagnosis? Paroxysmal nocturnal hemoglobinuria, or PNH.

Join us as we break down the pathogenesis and clinical features of PNH, walk through the diagnostic workup, and discuss management strategies, especially the game-changing role of complement inhibitors like Eculizumab. We’ll also review this patient’s clinical journey, highlighting the key pearls for recognizing and treating PNH in the pediatric intensive care unit.

So, tune in to hear more!

Show Highlights:

• Clinical case presentation of a 16-year-old male with symptoms including headache, photophobia, and anemia
• Diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) and its clinical significance
• Pathogenesis of PNH, including the role of the PIGA gene mutation and GPI-anchored proteins
• Clinical features and complications associated with PNH, such as thrombosis and hemolysis
• Diagnostic workup for PNH, including laboratory tests and flow cytometry
• Management strategies for PNH, focusing on complement inhibitors like Eculizumab
• Importance of supportive care in the PICU for patients with PNH
• Discussion of emerging therapies and advancements in PNH treatment
• Patient outcome and clinical course following treatment for PNH
• Key takeaways regarding the diagnosis and management of PNH in pediatric intensive care

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care.
• Reference 1: Brodsky RA. Paroxysmal nocturnal hemoglobinuria. Blood. 2014 Oct 30;124(18):2804-11.
• Reference 2 Waheed A, Shammo J, Dingli D. Paroxysmal nocturnal hemoglobinuria: Review of the patient experience and treatment landscape. Blood Rev. 2024 Mar;64:101158.
• Reference 3: Kokoris S, Polyviou A, Evangelidis P, Grouzi E, Valsami S, Tragiannidis K, Gialeraki A, Tsakiris DA, Gavriilaki E. Thrombosis in Paroxysmal Nocturnal Hemoglobinuria (PNH): From Pathogenesis to Treatment. Int. J. Mol. Sci. 2024 Nov 11;25(22):12104.

In today’s episode, Dr. Monica Gray and Dr. Pradip Kamat sit down with neurosurgeon Dr. Neal Laxpati, MD, PhD, to chat about intracranial pressure (ICP) monitoring in pediatric critical care. Using real case studies, they dive into how and when to use external ventricular drains (EVDs) and ICP bolts, walking listeners through setup, potential risks, and everyday challenges. The group discusses device complications, ways to prevent infections, how to interpret waveforms, and shares practical bedside tips. It’s a must-listen for intensivists looking for hands-on advice and key insights to help optimize care for kids with brain injuries or hydrocephalus.

Show Highlights:

• Pediatric critical care unit (PCU) case discussions
• Intracranial pressure (ICP) monitoring in pediatric patients
• Case studies involving a 10-year-old girl with diffuse midline glioma and a 16-year-old male with a ruptured arteriovenous malformation (AVM)
• Cerebrospinal fluid (CSF) physiology and its role in ICP management
• Types of ICP monitoring devices: external ventricular drains (EVDs) and intraparenchymal monitors
• Indications and complications associated with ICP monitoring
• Interpretation of ICP waveforms and their clinical significance
• Management strategies for elevated ICP and CSF drainage
• Risks and challenges of ICP monitoring, including infection and device malfunction
• Importance of interdisciplinary communication and meticulous bedside care in pediatric critical care settings

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 118. Traumatic brain injury. Kochaneck et al. Page 1375 -1400
• Rogers textbook:
• Reference 1: Forsyth RJ, Parslow RC, Tasker RC, Hawley CA, Morris KP; UK Paediatric Traumatic Brain Injury Study Group; Paediatric Intensive Care Society Study Group (PICSSG). Prediction of raised intracranial pressure complicating severe traumatic brain injury in children: implications for trial design. Pediatr Crit Care Med. 2008 Jan;9(1):8-14. doi: 10.1097/01.PCC.0000298759.78616.3A. PMID: 18477907.
• Reference 2: Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol. 2019 Nov 26;10:1261. doi: 10.3389/fneur.2019.01261. PMID: 32038449; PMCID: PMC6988791.

Ever wondered how PICU teams make those critical calls about blood pressure and vasoactive meds? On this episode, Dr. Monica Gray and Dr. Pradip Kamat dive into the real-world questions that come up during pediatric intensive care rounds. They break down the pros and cons of arterial line versus non-invasive cuff measurements, talk through blood pressure targets for tough cases like sepsis and brain injury, and share practical tips for weaning kids off vasoactive drugs. With a focus on the latest guidelines and research, Monica and Pradip offer actionable advice to help you fine-tune hemodynamic management for your sickest patients. Tune in!

Show Highlights:

• Relationship between blood pressure and cardiac output in pediatric patients
• Comparison of arterial line (invasive) versus non-invasive cuff measurements for blood pressure monitoring in the PICU
• Blood pressure targets for critical illnesses such as sepsis, traumatic brain injury, and respiratory failure in children
• Strategies for weaning vasoactive medications in critically ill pediatric patients
• Importance of accurate blood pressure measurement and monitoring in the PICU
• Discussion of organ autoregulation and its impact on blood pressure management
• Clinical assessment and individualized care in setting blood pressure goals
• Recommendations for initial vasoactive agents in pediatric septic shock
• Challenges and considerations in vasoactive medication selection and weaning
• Need for further research on pediatric vasoactive medication management strategies

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 110. Alder M et al. Pediatric Sepsis. Pages 1293-1309.
• Rogers Textbook of Pediatric Critical Care Medicine. Chapter 88. Fitzgerald J et al. Bacterial Sepsis.Pages 1469-1485.
• Reference 1 Weiss S. Vasoactive Selection for Pediatric Septic Shock-Where to begin. JAMA Network Open, 2025;8(4):e254726.
• Reference 2 Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD; Society of Critical Care Medicine Pediatric Sepsis Definition Task Force. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA. 2024 Feb 27;331(8):665-674.

Welcome to PICU Doc on Call, the podcast where we break down real-life cases from the pediatric intensive care unit and share practical insights for clinicians everywhere! I’m Dr. Monica Gray, and I’m joined by my co-host, Dr. Pradip Kamat.

Today, we’re diving into a fascinating case: a 13-year-old boy who suddenly developed muscle weakness and was found to have severe hypokalemia. After some detective work, he was diagnosed with familial hypokalemic periodic paralysis, a rare but important condition to recognize in the PICU.

We’ll discuss the genetic underpinnings, classic clinical features, and common triggers associated with this disorder. Additionally, we’ll guide you through the differential diagnosis, key management strategies, such as potassium supplementation, and explain why genetic testing is so crucial. We’ll also cover essential considerations for anesthesia and cardiac monitoring in these patients.

Whether you’re a pediatric intensivist or just interested in acute neuromuscular care, stick around for some practical pearls you can use on your next shift!

Show Highlights:

• Clinical case discussion of a 13-year-old male patient with muscle weakness and hypokalemia
• Diagnosis and management of familial hypokalemic periodic paralysis
• Genetic basis and mutations associated with hypokalemic periodic paralysis (CACNA1S and SCN4A)
• Physiological mechanisms underlying hypokalemic periodic paralysis
• Common clinical presentations and triggers for episodes of muscle weakness
• Differential diagnoses for muscle weakness and hypokalemia in pediatric patients
• Laboratory investigations to confirm hypokalemic periodic paralysis
• Treatment options for hypokalemic periodic paralysis, including potassium supplementation and prophylactic medications
• Importance of avoiding triggers and coordinating care with anesthesia

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 68: Weimer M et al. Acute neuromuscular disease and disorders page 840
• Rogers Textbook of Pediatric Intensive Care Medicine: Management of Sodium and Potassium Disorders. Pages 1876- 1883
• Reference 1: Weber F, Lehmann-Horn F. Hypokalemic Periodic Paralysis. 2002 Apr 30 [Updated 2018 Jul 26]. In: Adam MP, Feldman J, Mirzaa GM, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1338/
• Reference 2: Channelopathies. Clin Exp Pediatr. 2014;57(1):1-18. Published online January 31, 2014**DOI: https://doi.org/10.3345/kjp.2014.57.1.1**
• Reference 3: Statland JM, Fontaine B, Hanna MG, Johnson NE, Kissel JT, Sansone VA, Shieh PB, Tawil RN, Trivedi J, Cannon SC, Griggs RC. Review of the Diagnosis and Treatment of Periodic Paralysis. Muscle Nerve. 2018 Apr;57(4):522-530.

Learn how to sharpen your pediatric intubation skills and make evidence-based decisions at the bedside. Today, Dr. Pradip Kamat, Dr. Monica Gray, and Dr. Rahul Damania expertly dissect the nuances of selecting optimal induction agents for critically ill children in the PICU. Through engaging, real-world case scenarios, our hosts guide you through drug choices in complex situations such as cardiogenic shock, septic shock, and elevated intracranial pressure—always prioritizing hemodynamic stability and patient safety. Gain valuable insights into the advantages, limitations, and clinical pearls of agents like propofol, fentanyl, ketamine, and midazolam, along with practical strategies for rapid sequence intubation, neuromuscular blockade, and individualized patient care. Don’t miss this high-yield discussion, packed with actionable knowledge!

Show Highlights:

• Induction agents for endotracheal intubation in critically ill children
• Clinical scenarios highlighting optimal choices of induction agents and neuromuscular blockers
• Importance of maintaining hemodynamic stability during intubation
• Pharmacology and clinical considerations of various induction agents (e.g., propofol, ketamine, fentanyl, etomidate)
• Use of neuromuscular blocking agents (NMBAs) in pediatric intubation
• Differences between depolarizing and non-depolarizing neuromuscular blockers
• Risks associated with specific induction agents in patients with cardiac dysfunction or septic shock
• Modified rapid sequence intubation (RSI) techniques for unstable patients
• Key takeaways for managing critically ill pediatric patients requiring intubation
• Practical tips for optimizing intubation conditions and minimizing complications

References:

1. Fuhrman & Zimmerman - Textbook of Pediatric Critical Care 6th Edition. Chapters 127 - 135, Pages 1510 - 1610
2. Hendrix JM, Regunath H. Intubation Endotracheal Tube Medications. [Updated 2025 Jan 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459276/
3. Agrawal, Dewesh. Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis. UpToDate. Last updated Dec 4, 2024.
4. Vanlinthout LE, Geniets B, Driessen JJ, Saldien V, Lapré R, Berghmans J, Uwimpuhwe G, Hens N. Neuromuscular-blocking agents for tracheal intubation in pediatric patients (0-12 years): A systematic review and meta-analysis. Paediatr Anaesth. 2020 Apr;30(4):401-414. doi: 10.1111/pan.13806. Epub 2020 Mar 9. PMID: 31887248.
5. Tarquinio KM, Howell JD, Montgomery V, Turner DA, Hsing DD, Parker MM, Brown CA 3rd, Walls RM, Nadkarni VM, Nishisaki A; National Emergency Airway Registry for Children; Pediatric Acute Lung Injury and Sepsis Investigators Network. Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study. Pediatr Crit Care Med. 2015 Mar;16(3):210-8. doi: 10.1097/PCC.0000000000000319. PMID: 25581629.
6. Conway JA, Kharayat P, Sanders RC Jr, Nett S, Weiss SL, Edwards LR, Breuer R, Kirby A, Krawiec C, Page-Goertz C, Polikoff L, Turner DA, Shults J, Giuliano JS Jr, Orioles A, Balkandier S, Emeriaud G, Rehder KJ, Kian Boon JL, Shenoi A, Vanderford P, Nuthall G, Lee A, Zeqo J, Parsons SJ, Furlong-Dillard J, Meyer K, Harwayne-Gidansky I, Jung P, Adu-Darko M, Bysani GK, McCarthy MA, Shlomovich M, Toedt-Pingel I, Branca A, Esperanza MC, Al-Subu AM, Pinto M, Tallent S, Shetty R, Thyagarajan S, Ikeyama T, Tarquinio KM, Skippen P, Kasagi M, Howell JD, Nadkarni VM, Nishisaki A; National Emergency Airway Registry for Children (NEAR4KIDS) and for the Pediatric Acute Lung Injury and Sepsis Investigators...

Ready for a deep dive into a real-life pediatric ICU situation? Today, Dr. Pradip Kamat, Dr. Monica Gray, and Dr. Rahul Damania will walk you through the case of a seven-year-old girl with Hemoglobin SC (HbSC) disease, who presents with abdominal swelling, pneumonia, low oxygen, and pain.

In this episode, our team unpacks the spleen’s anatomy and its crucial role in immunity, then zooms in on how sickle cell disease can throw a wrench in splenic function. You’ll hear how they approach the diagnosis and management of acute splenic sequestration crisis, sharing clinical pearls along the way. Plus, they’ll break down why quick recognition is so important and discuss strategies for both immediate and long-term care in pediatric sickle cell patients. Don’t miss these practical insights from the frontlines of pediatric critical care!

Show Highlights:

• Case study of a seven-year-old girl with hemoglobin SC disease
• Presentation of symptoms: abdominal distension, pneumonia, hypoxia, and body pain
• Discussion of acute splenic sequestration crisis as a complication of sickle cell disease
• Anatomy and physiology of the spleen
• The role of the spleen in sickle cell disease and how sickled cells affect splenic function
• Acute splenic sequestration crisis, including clinical features and laboratory evaluations
• Management strategies for acute splenic sequestration crisis in the ICU
• Importance of blood transfusions and supportive care in treatment
• Prophylactic measures to prevent recurrence of splenic sequestration
• Educational emphasis on recognizing clinical signs and the need for timely intervention

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 88. Hemoglobinopathies. Baender, MA, Marsh Anne. Pages: 1457-1470
• Rogers' textbook of pediatric intensive care: Hematologic Emergencies. McCory MC, Bhar S, and Blaine E. Pages 2003-2005
• Brousse V, Buffet P, Rees D. The spleen and sickle cell disease: the sick(led) spleen. Br J Haematol. 2014 Jul;166(2):165-76. doi: 10.1111/bjh 12950. Epub 2014 May 26. PMID: 24862308.
• Waleed S, Aldabsa M, Gouher S. Splenic Sequestration Induced by Parvovirus B19: A Case Report. Cureus. 2024 May 23;16(5):e60937. doi: 10.7759/cureus. 60937. PMID: 38915956; PMCID: PMC11195323.
• Solanki DL, Kletter GG, Castro O. Acute splenic sequestration crises in adults with sickle cell disease. Am J Med. 1986 May;80(5):985-90. doi: 10.1016/0002-9343(86)90649-2. PMID: 3706382.
• Karna B, Jha SK, Al Zaabi E. Hemoglobin C Disease. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559043/

Welcome to "PICU Doc on Call," the podcast where real cases meet real expertise at the bedside! Join Dr. Monica Gray, Dr. Pradip Kamat, and Dr. Rahul Damania as they unravel the mysteries of pediatric critical care. In today’s episode, our team dives into the compelling case of a previously healthy seven-year-old girl who arrives with seizures, right arm weakness, and sudden respiratory failure. Together, they’ll break down the diagnosis and management of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease, also known as MOGAD. This autoimmune demyelinating disorder can challenge even the most seasoned clinicians.

Tune in as our experts walk you through the clinical features, essential diagnostic workup, and the critical importance of early immunosuppressive therapy. Whether you’re at the bedside or on the go, this episode is packed with practical pearls and a multidisciplinary approach to recognizing and treating acute pediatric neuroimmunological emergencies in the PICU. Let’s get started!

Show Highlights:

• Presentation of a complex pediatric case involving a seven-year-old girl with new-onset seizures and acute respiratory failure
• Discussion of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD) as an autoimmune demyelinating disorder
• Overview of the clinical presentation and diagnostic criteria for autoimmune encephalitis
• Importance of a broad differential diagnosis, including infectious and autoimmune causes, in pediatric patients with seizures and neurological deficits
• Diagnostic approach involving MRI, lumbar puncture, and antibody testing for MOGAD
• Management strategies for MOGAD, including stabilization, seizure control, and immunosuppressive therapy
• Neurocritical care considerations for monitoring and treating elevated intracranial pressure
• Long-term management challenges and the need for multidisciplinary care in pediatric patients with MOGAD
• Discussion of potential outcomes and the risk of relapse in children with MOGAD.
• Emphasis on the importance of early and comprehensive diagnostic testing to avoid misdiagnosis

References:

1. Fuhrman & Zimmerman - Pediatric Critical Care 6th Edition, Chapter 64
2. Gole S, Anand A. Autoimmune Encephalitis. [Updated 2023 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK578203/
3. Salama S, Khan M, Pardo S, Izbudak I, Levy M. MOG antibody-associated encephalomyelitis/encephalitis. Mult Scler. 2019 Oct;25(11):1427-1433. doi: 10.1177/1352458519837705. Epub 2019 Mar 25. PMID: 30907249; PMCID: PMC6751007
4. Lancaster E. The Diagnosis and Treatment of Autoimmune Encephalitis. J Clin Neurol. 2016 Jan;12(1):1-13. doi: 10.3988/jcn.2016.12.1.1. PMID: 26754777; PMCID: PMC4712273.
5. Fisher KS, Illner A, Kannan V. Pediatric neuroinflammatory diseases in the intensive care unit. Semin Pediatr Neurol. 2024 Apr;49:101118. Doi: 10.1016/j.spen.2024.101118. Epub 2024 Feb 1. PMID: 38677797.
6. Hébert J, Muccilli A, Wennberg RA, Tang-Wai DF. Autoimmune Encephalitis and Autoantibodies: A Review of Clinical Implications. J Appl Lab Med. 2022 Jan 5;7(1):81-98. Doi: 10.1093/jalm/jfab102. PMID: 34996085.
7. Lopez JA, Denkova M, Ramanathan S, Dale RC, Brilot F. Pathogenesis of autoimmune demyelination: from multiple sclerosis to neuromyelitis optica spectrum disorders and myelin oligodendrocyte glycoprotein antibody-associated disease. Clin Transl Immunology. 2021 Jul 26;10(7):e1316. doi: 10.1002/cti2.1316. PMID: 34336206; PMCID: PMC8312887.