Severity of Illness Scoring for Pediatric Interfacility Transport: A North American Survey.

OBJECTIVE: Severity of illness scoring during pediatric critical care transport may provide objective data to determine illness trajectory and disposition and contribute to quality assurance data for pediatric transport programs. The objective of this study was to ascertain the breadth of severity of illness scoring tool application among North American pediatric critical care transport teams. METHODS: A cross-sectional quantitative survey using REDCap was distributed to 137 North American pediatric transport programs. Baseline team characteristics were established along with questions related to severity of illness tool application.Descriptive statistics were used for analysis. RESULTS: There were 55 responses (40%), and of those, 13 (24%) use a severity of illness scoring tool within their practice. A variety of tools were used including: Transport Risk Index of Physiologic Stability, Children's Hospital Medical Center Cincinnati, Canadian Triage and Acuity Score, Transport Risk Assessment in Pediatrics, Pediatric Early Warning Scores, Levels of Acuity, Transport Pediatric Early Warning Scores, and an unspecified tool. The timing of scoring, team personnel who applied the score, and the frequency of analysis varied between transport programs. CONCLUSIONS: Severity of illness scoring is not consistently performed by pediatric interfacility transport programs in North America. Among the programs that use a scoring tool, there is variability in its application. There is no universally accepted or performed severity of illness scoring tool for pediatric interfacility transport.Future research to validate and standardize a pediatric transport severity of illness scoring tool for North America is necessary.

Serial Clinical Scoring to Assess Transported Pediatric Patients.

OBJECTIVES: The objective of this study was to evaluate serial Transport Risk Assessment in Pediatrics (TRAP) scoring during pediatric critical care transport as a potential measure for specialized pediatric transport teams (PTTs). METHODS: This was a retrospective study with a provincial PTT from a tertiary hospital pediatric intensive care unit. All acutely ill children who were transported by the PTT between 2018 and 2019 were included in the study. The TRAP scores were measured at time of transport team arrival (TRAP1), time at arrival to tertiary center (TRAP2), and 4 hours postarrival to tertiary center (TRAP3). RESULTS: A total of 300 transports were included. Patients' mean age was 54 months, with lower respiratory tract infection (40.7%) as the most common diagnosis. There were significant differences between TRAP1-TRAP2 (P < 0.01) and TRAP1-TRAP3 (P < 0.01), but not between TRAP2-TRAP3 (P = 0.67). The most significant improvements of ΔTRAP1-TRAP2 scores were seen in septic shock (mean, 2.0; SD, 1.7). CONCLUSIONS: The TRAP scores improved following the PTTs' arrival to acutely ill children, particularly with sepsis. Serial TRAP scoring may present a system for evaluation of team performance and/or characterize disease states that are positively impacted by PTTs. Future prospective evaluation is needed to validate TRAP for this purpose.

The World Brain Death Project: The More You Say It Does Not Make It True.

The World Brain Death Project clarified many aspects of the diagnosis of brain death/death by neurologic criteria. Clearer descriptions than previously published were presented concerning the etiology, prerequisites, minimum clinical criteria, apnea testing targets, and indications for ancillary testing. Nevertheless, there remained many epistemic and metaphysical assertions that were either false, ad hoc, or confused. Epistemically, the project was not successful in explaining away remaining brain functions, complex reflexes as "spinal," the risk and lack of utility of the apnea test, the ignored and often present confounders of central endocrine dysfunction and high-cervical-spinal-cord injury, the limitations of ancillary tests, or the cases of reversibility of some findings of brain death/death by neurologic criteria. Metaphysically, the World Brain Death Project variously suggested different concepts of death that were not supported with argument. Concepts offered included simply restating the criterion of brain death/death by neurologic criteria; personhood, without recognizing it is a higher-brain concept; and emergent functions of the organism as a whole, without specifying what these might be, if not biologic anti-entropic integration that actually remains after brain death/death by neurologic criteria. The World Brain Death Project only offered confused metaphysical discussion, and gave no reason why the state they described as brain death/death by neurologic criteria should be considered death itself. The main epistemic and metaphysical problems with brain death/death by neurologic criteria remain untouched by the World Brain Death Project.

Evaluation of transport-related outcomes for neonatal transport teams with and without physicians.

OBJECTIVE: The aim of this study was to evaluate if the presence of a physician in the neonatal transport team (NTT) affects transport-related outcomes and procedural success. DESIGN: Retrospective cohort study with propensity score matching. SETTING: Canadian national study. PATIENTS: Neonatal transports from nontertiary centres between January 2014 and December 2017. INTERVENTIONS: Comparison of transports conducted by NTTs with physicians (MD Group) and without physicians (noMD Group). MAIN OUTCOME MEASURES: The primary outcome was the change in patient acuity as measured by the transport risk index of physiologic severity (TRIPS) score. Secondary outcomes included mortality within 24 hours of NICU admission, clinical complications during transport, procedural success, and stabilization time. RESULTS: Among 9,703 eligible cases, 899 neonatal transports attended by NTTs with physicians were compared to 899 neonatal transports without physicians using propensity score matching. No differences were seen in the improvement of TRIPS score or mortality ≤24 hours of NICU admission. The MD Group had more clinical complications (7.7% versus 5.0%, P=0.02). No differences were seen in success rates of invasive procedures. The MD Group had shorter stabilization times. In multivariable analysis, the MD Group was not a significant predictor for the improvement in TRIPS score after adjustment for covariates. CONCLUSIONS: Neonatal transports conducted by teams including physicians compared to teams without physicians, did not have higher improvement in TRIPS scores and had similar success rates for procedures. These results provide insights for the planning of the structure and training of specialized interfacility neonatal transport programs.

Rural Residence and Diagnostic Delay for Amyotrophic Lateral Sclerosis in Saskatchewan.

BACKGROUND: Diagnostic delay in amyotrophic lateral sclerosis (ALS) is common. In a recent Canadian study evaluating provincial differences in care, Saskatchewan had the longest delay at 27 months. Since Saskatchewan has a large rural population, this study sought to determine whether geographically determined access to a neurologist at tertiary centers could be contributing to this lengthy delay. METHODS: A retrospective chart review of 171 patients seen in the ALS clinic in Saskatoon, Saskatchewan was performed. Urban or rural location, distance from nearest tertiary center, and clinically relevant data were collected. RESULTS: There was no difference between urban and rural populations for delay in symptom onset to diagnosis. For rural patients, linear regression modeling did not uncover a significant relationship between distance from tertiary center and time to diagnosis. Additionally, there were no differences between urban and rural dwellers either for referral or utilization of feeding tube, noninvasive ventilation, riluzole, or communication devices. Contrary to the previous data showing a 27-month diagnostic delay in Saskatchewan, our study which included a larger provincial population found the mean diagnostic delay was 16.6 months. CONCLUSIONS: This study did not uncover differences in diagnostic delay or ALS care between urban and rural dwellers. Further study is required to determine reproducibility of results.

Utilizing Pediatric Scoring Systems to Predict Disposition During Interfacility Transport.

OBJECTIVE: Determining care disposition for pediatric patients during interfacility transport is often challenging. Severity of illness scoring can assist with this process. The purpose of this retrospective study was to compare currently utilized scoring systems and their ability to reliably match pediatric transport patients' severity of illness with the level of care necessary. METHODS: The retrospective transport registry review for our region included 209 patients <18 years, transported between 2015 and 2016 and admitted to tertiary care. The Pediatric RISk of Mortality III (PRISM III); Canadian Pediatric Triage and Acuity Scale (PedCTAS); Transport Pediatric Early Warning Scores (TPEWS); and Transport Risk Assessment in Pediatrics (TRAP) scores were calculated. Descriptive statistics and binomial logistic regression were utilized to compare the scoring tools. Interrater reliability was calculated using kappa statistics. All analyses were computed using IBM SPSS Statistics for Windows, version 24. RESULTS: Patients were more likely to be admitted to pediatric intensive care unit (PICU) with PedCTAS = 1 (odds ratio [OR] = 37.2; 95% confidence interval [CI], 12.4, 111.4; p < 0.0001), TPEWS = 3 in one category or total score ≥6 (OR = 42.2; 95% CI, 17.0, 104.9; p < 0.0001), and TRAP ≥4 (OR = 7.2; 95% CI, 3.8, 13.5; p < 0.0001). PRISM scores were not predictive for PICU admissions. CONCLUSION: Elevated PedCTAS, TPEWS, and TRAP scores are strongly associated with PICU admission within the interfacility transport setting.

Pediatric early warning score and deteriorating ward patients on high-flow therapy.

BACKGROUND: Delivery of non-invasive ventilation commonly occurs in the pediatric intensive care unit (PICU). With the advent of high-flow nasal cannula (HFNC), patients with respiratory distress may be rescued on the ward without a PICU admission. We evaluated our ward HFNC algorithm to determine its safety profile and independent predictors for non-responders, defined as requiring subsequent PICU admission. METHODS: A retrospective chart review of patients <17 years of age admitted with respiratory distress between 2016 and 2017 was carried out. Pediatric Early Warning System (PEWS) respiratory score was used to assess the clinical response of patients requiring HFNC. Variables associated with non-responders were evaluated, and their PICU admission was studied for escalation of care and criticality. RESULTS: Patients with comorbidities (P = 0.02) were more likely to require HFNC. Of the 18 patients initiated on HFNC, 44% (n = 8) remained on the ward. Non-responders (n = 10; 56%) had higher (2.7 vs 1.8; P = 0.03) and worsening (-0.1 vs 0.3; P = 0.05) PEWS respiratory scores 90 min after HFNC initiation. Eighty percent (n = 8) of non-responders required escalation to continuous positive airway pressure or bilevel positive airway pressure in the PICU. For both HFNC responders and non-responders, there were no requirements for intubation, evidence of air leak or difference in days of respiratory support. CONCLUSIONS: High and worsening PEWS scores 90 min after HFNC initiation may indicate non-response when coupled with a standardized ward HFNC algorithm for respiratory distress. Further improvements may be seen with an earlier initiation of HFNC in the emergency department and more aggressive flow escalation on the ward.

Survey of Nutrition Practice in Patients with Severe Sepsis among Canadian Registered Dietitians.

PURPOSE: The purpose of this study was to determine the opinions and reported nutrition practices of Canadian Registered Dietitians (RDs) with regard to feeding patients with severe sepsis. METHODS: In 2017, surveys were sent to 112 eligible Canadian RDs in 10 provinces who were practicing in an intensive care environment. The survey included embedded branching logic questions developed to address major facets of sepsis, critical illness, and nutrition. The survey instrument assimilated all data in an anonymous manner, so respondents could not be linked to their answers. RESULTS: Of the 64 RDs who responded (57% response rate), the majority practiced in adult intensive care (81%), within an academic center (59%), and in a mixed unit (73%). A wide variability of Canadian RDs' opinions and practice was reported in determining energy requirements, enteral nutrition (EN) practice, EN with vasoactive agents, parenteral nutrition (PN), and supplemental micronutrients. CONCLUSIONS: Practice variability of Canadian RDs likely reflects gaps in both evidence and guidelines for severe sepsis. Further research efforts are needed to customize nutritional requirements in the patient with evolving sepsis, EN with patients at high risk for gastrointestinal dysfunction, optimizing PN, and the role of micronutrients.

Brain Death Criteria: Medical Dogma and Outliers.

The diagnosis of brain death (BD) is legally and medically accepted. Recently, several high-profile cases have led to discussions regarding the integrity of current criteria, and many physiologic problems have been identified to support the necessity for their reevaluation. These include a global variability of the criteria, the suggestion of a clinical "hierarchy," and the resultant approximation of BD. Further ambiguity has been exposed through case reports of reversible BD, and an inconsistent understanding from physicians who are viewed as experts in this domain. Meeting BD criteria clearly does not equate to a physiologic "death" of the brain, and a greater community perspective should be considered as the dialogue moves forward.

Pre-Trauma Center Management of Intracranial Pressure in Severe Pediatric Traumatic Brain Injury.

OBJECTIVES: Pre-trauma center care is a critical component in severe pediatric traumatic brain injury (TBI). For geographically large trauma catchment areas, optimizing increased intracranial pressure (ICP) management may potentially improve outcomes. This retrospective study examined ICP management in nontrauma centers and during interfacility transport to the trauma center. METHODS: Charts from a pediatric level I trauma center were reviewed for admissions between 2008 and 2013. Patients with a Glasgow Coma Scale score of 8 or less, head Abbreviated Injury Scale score of 3 or higher, and requiring intubation at a nontrauma center were included. Exclusion criteria included head injury secondary to drowning, stroke, obstetrical complications, asphyxia, and afflicted head trauma (younger than 5 years). Trauma center charts contained coalesced data from first responders, nontrauma centers, and transport. RESULTS: Twenty-five patients (74%) had increased ICP upon admission at trauma center, 48% experienced ICPs greater than 20 cm H2O within 12 hours of admission, 12% required an urgent craniotomy, and 16% had herniation syndromes on neuroimaging. Pre-trauma center ICP management included osmotherapy and head-of-bed elevation. Sixty-four percent of patients with increased ICP at trauma center admission received pre-trauma center ICP management. CONCLUSIONS: Early increased ICP is a common presentation of severe pediatric TBI during pre-trauma center management. However, what constitutes optimal care remains unknown. Given the difficulties of diagnosing early increased ICP in this setting, prophylactic raising ICP-lowering strategies may be considered.

Mechanical ventilation guided by electrical impedance tomography in pediatric acute respiratory distress syndrome.

Mechanical ventilation strategies in pediatric acute respiratory distress syndrome (pARDS) continue to advance. Optimizing positive end expiratory pressure (PEEP) and ventilation to recruitable lung can be difficult to clinically achieve. This is in part, due to disease evolution, unpredictable changes in lung compliance, and the inability to assess regional tidal volumes in real time at the bedside. Here we report the utilization of thoracic electrical impedance tomography to guide daily PEEP settings and recruitment maneuvers in a child with pARDS.

Remote Presence Robotic Technology Reduces Need for Pediatric Interfacility Transportation from an Isolated Northern Community.

BACKGROUND: Providing acutely ill children in isolated communities access to specialized care is challenging. This study aimed to evaluate remote presence robotic technology (RPRT) for enhancing pediatric remote assessments, expediting initiation of treatment, refining triaging, and reducing the need for transport. METHODS: We conducted a pilot prospective observational study at a primary/urgent care clinic in an isolated northern community. Participants (n = 38) were acutely ill children <17 years presenting to the clinic, whom local healthcare professionals had considered for interfacility transportation (IFT). Participants were assessed and managed by a tertiary center pediatric intensivist through a remote presence robot. The intensivist triaged participants to either remain at the clinic or be transported to regional/tertiary care. Controls from a pre-existing local transport database were matched using propensity scoring. The primary outcome was the number of IFTs among participants versus controls. RESULTS: Fourteen of 38 (37%) participants required transport, whereas all controls were transported (p < 0.0001). Six of 14 (43%) transported participants were triaged to a nearby regional hospital, while no controls were regionalized (p = 0.0001). All participants who remained at the clinic stayed <24 h, and were matched to controls who stayed 4.9 days in tertiary care (p < 0.001). There was no statistically significant difference in hospital length of stay between transported participants and controls (6.0 vs. 5.7 days). CONCLUSIONS: RPRT reduced the need for specialized pediatric IFT, while enabling regionalization when appropriate. This study may have implications for the broader implementation of RPRT, while reducing costs to the healthcare system.

Mobile emergency simulation training for rural health providers.

INTRODUCTION: Mobile emergency simulation offers innovative continuing medical educational support to regions that may lack access to such opportunities. Furthermore, satisfaction is a critical element for active learning. Together, the authors evaluated Canadian rural healthcare providers' satisfaction from high fidelity emergency simulation training using a modified motorhome as a mobile education unit (MEU). METHODS: Over a 5-month period, data was collected during 14 educational sessions in nine different southern Manitoban communities. Groups of up to five rural healthcare providers managed emergency simulation cases including polytrauma, severe sepsis, and inferior myocardial infarction with right ventricular involvement, followed by a debrief. Participants anonymously completed a feedback form that contained 11 questions on a five-point Likert scale and six short-answer questions. RESULTS: Data from 131 respondents were analyzed, for a response rate of 75.6%. Respondents included nurses (27.5%), medical residents (26.7%), medical first responders (16.0%), and physicians (12.2%). The median response was 5 for overall quality of learning, development of clinical reasoning skills and decision-making ability, recognition of patient deterioration, and self-reflection. The post-simulation debrief median response was also 5 for summarizing important issues, constructive criticism, and feedback to learn. Respondents also reported that the MEU provided a believable working environment (87.0%, n=114), they had limited or no previous access to high fidelity mannequins (82.7%, n=107), and they had no specific training in crisis resource management or were unfamiliar with the term (92%, n=118). CONCLUSIONS: A high level of satisfaction was reported in rural health providers with mobile emergency simulation. Access to and experience with high fidelity mannequins was limited, suggesting areas for potential educational growth.

Pediatric neurocritical care in the 21st century: from empiricism to evidence.

PURPOSE OF REVIEW: Approximately one in five children admitted to a pediatric ICU have a new central nervous system injury or a neurological complication of their critical illness. The spectrum of neurologic insults in children is diverse and clinical practice is largely empirical, as few randomized, controlled trials have been reported. This lack of data poses a substantial challenge to the practice of pediatric neurocritical care (PNCC). PNCC has emerged as a novel subspecialty, and its presence is expanding within tertiary care centers. This review highlights the recent advances in the field, with a focus on traumatic brain injury (TBI), cardiac arrest, and stroke as disease models. RECENT FINDINGS: Variable approaches to the structure of a PNCC service have been reported, comprising multidisciplinary teams from neurology, critical care, neurosurgery, neuroradiology, and anesthesia. Neurologic morbidity is substantial in critically ill children and the increased use of continuous electroencephalography monitoring has highlighted this burden. Therapeutic hypothermia has not proven effective for treatment of children with severe TBI or out-of-hospital cardiac arrest. However, results of studies of severe TBI suggest that multidisciplinary care in the ICU and adherence to guidelines for care can reduce mortality and improve outcome. SUMMARY: There is an unmet need for clinicians with expertise in the practice of brain-directed critical care for children. Although much of the practice of PNCC may remain empiric, a focus on the regionalization of care, creating defined training paths, practice within multidisciplinary teams, protocol-directed care, and improved measures of long-term outcome to quantify the impact of such care can provide evidence to direct the maturation of this field.

Ventilation Monitoring in Severe Pediatric Traumatic Brain Injury at Nontrauma Centers.

OBJECTIVE: Pediatric traumatic brain injury (TBI) guidelines should direct patient management. This retrospective study compared ventilation monitoring practices of nontrauma center (NTC) personnel and air medical crews (AMCs) in pediatric patients with severe TBI at NTCs after endotracheal intubation. METHODS: Pediatric patient charts for level I trauma center admissions between 2008 and 2013 with severe TBI were screened. Inclusion criteria included admission Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score of ≥ 3, and secure airway initiated or managed at an NTC. RESULTS: A total of 30 patients were evaluated. The median head Abbreviated Injury Scale score was 4, and the trauma center mortality rate was 30%. NTC personnel and AMCs intubated 22 and 8 patients, respectively. AMCs monitored ventilation with much greater regularity (100 vs. 41%, P = .004), used continuous waveform capnography more often (75 vs. 14%, P = .003), and also initiated it quicker (17 vs. 37 minutes, = .001) after intubation. Unmonitored patients from NTC intubations waited on average 72.3 minutes before interfacility transport to the trauma center. CONCLUSIONS: AMCs showed superior ventilation monitoring after intubation in pediatric patients with severe TBI. Ventilation monitoring was not routinely conducted by NTC personnel, signifying areas to improve patient care.

Anatomic repair of the distal biceps tendon cannot be consistently performed through a classic single-incision suture anchor technique.

BACKGROUND: Distal biceps tendon ruptures commonly occur in active men, and surgical repair through a single-incision technique using suture anchors has become common. The current study assessed whether an anatomic repair of the biceps to the radial tuberosity can be consistently achieved through a single-incision technique. METHODS: Acute distal biceps tendon repairs using the single-incision technique were retrospectively reviewed. Computed tomography (CT) scans were obtained to investigate tuberosity dimensions and the position of the suture anchors. An isokinetic dynamometer was used to obtain flexion and supination strength. Disabilities of the Arm, Shoulder and Hand (DASH) scores were collected. RESULTS: CT scans were performed in 27 patients, of which, 21 underwent strength testing. The suture anchor placement averaged 50° radial to the apex of the tuberosity. Strength testing showed flexion strength of the repaired side was equal (97%-106%) to the normal side. Supination strength (80%-86%) and work (66%-75%) performed were both weaker on the repaired side (66%-75%; P < .05). The average DASH score was 10.7. CONCLUSIONS: Ideal suture anchor placement, in the ulnar aspect of the tuberosity, could not be reliably achieved through this single-incision technique. This could have clinical importance because supination strength was not fully restored in this group of patients.

ALS Health care provider wellness.

BACKGROUND: Interest in health care provider (HCP) wellness and burnout is increasing; however, minimal literature explores HCP wellness in the context of Amyotrophic Lateral Sclerosis (ALS) care. OBJECTIVES: We sought to determine rates of burnout and resiliency, as well as challenges and rewards in the provision of ALS care. METHODS: A survey link was sent to physicians at all Canadian ALS centers for distribution to ALS HCPs in their network. The survey included demographics questions, and validated measures for resiliency and burnout; the Brief Resilient Coping Scale (BRCS) and the Single Item Burnout Score (SIBS). Participants were asked to describe challenges and rewards of ALS care, impact of COVID-19 pandemic, and how their workplace could better support them. RESULTS: There were 85 respondents across multiple disciplines. The rate of burnout was 47%. Burnout for female respondents was significantly higher (p = 0.007), but not for age, role, or years in ALS clinic. Most participants were medium resilient copers n = 48 (56.5%), but resiliency was not related to burnout. Challenges included feeling helpless while patients relentlessly progressed to death, and emotionally charged interactions. Participants found fulfillment in providing care, and through relationships with patients and colleagues. There was a strongly expressed desire for increased resources, team building/debriefing, and formal training in emotional exhaustion and burnout. CONCLUSIONS: The high rate of burnout and challenges of ALS care highlight the need for additional resources, team-building, and formal education around wellness.

Cell-free preparation of functional and triggerable giant proteoliposomes.

Heat, we leak: We express a membrane protein outside well-defined giant liposomes obtained by gravity-transferred sucrose-in-oil droplets into a cell-free, reconstituted expression system. We show that the presence of the liposome is necessary during expression for efficient protein insertion into the membrane and that temperature can trigger the resulting membrane function.

Safety of Berlin Heart EXCOR pump changes in the PICU.

OBJECTIVE: To describe whether Berlin Heart EXCOR Pediatric pump changes in the ICU are associated with infection, hemodynamic and ventilatory instability, and neurologic injury. DESIGN: Retrospective, descriptive chart review. SETTING: PICU in a quaternary care children's hospital. PATIENTS: Eight patients were supported on Berlin Heart EXCOR Pediatric pumps due to cardiomyopathy or cardiogenic shock. Two patients were supported with left ventricular assist devices, five had biventricular assist devices, and one required a univentricular assist device. INTERVENTIONS: A team of cardiac surgeons, pediatric intensivists, and operating room nurses conducted sixteen pump changes in the pediatric intensive care unit. Patients were monitored for deleterious effects for 5 days following the change. MEASUREMENT AND MAIN RESULTS: For the first 48 hrs following the EXCOR pump change, no patients exhibited acute neurologic deficits or escalation of hemodynamic or ventilatory support. Over the first 5 days, no blood cultures were positive for microbes. CONCLUSIONS: Berlin Heart EXCOR Pediatric pump changes in the pediatric intensive care unit appear to be a safe procedure when conducted by a highly specialized team.

Canadian Pediatric Intensive Care Adaptations for Critically Ill Adults During the COVID-19 Pandemic: Survey Study.

BACKGROUND: The COVID-19 pandemic overwhelmed Canadian hospitals with adult admissions. A large number of adult patients required critical care therapies, placing significant strain on hospital resources. In order to decompress adult intensive care units, pediatric intensive care units (PICUs) introduced adapted models of traditional care to lessen these burdens. OBJECTIVE: We aimed to evaluate how PICUs across Canada adapted care for the high volumes of critically ill adults. METHODS: A survey containing 40 questions was sent to the medical directors of 14 Canadian PICUs where English was the primary clinical language. The survey was designed to gain perspective on the various adaptations that PICUs instituted during the COVID-19 pandemic. RESULTS: Of the 13 PICUs that returned survey responses (response rate: 13/14, 93%), 10 (77%) participated in at least one adaptation to support the influx of admitted adults with COVID-19. The key challenges included disorganization, loss of autonomy, and compromised patient care. The significant advantages of these adaptations included a sense of learning and comradery. CONCLUSIONS: Our study highlighted an unpreparedness in critical care surge capacity. During the COVID-19 pandemic, adaptations rapidly emerged in Canada that involved PICUs with adult care. In the future, preplanned adaptations for optimizing robust critical care services should be developed based on what has been learned from the COVID-19 pandemic.