The care of critically ill adults with COVID-19 in Ontario pediatric intensive care units.

PURPOSE: To describe and review the experience of two pediatric intensive care units (PICUs) in Ontario, Canada, adapting and providing care to critically ill adults during the COVID-19 pandemic. CLINICAL FEATURES: At a time of extreme pressure to adult intensive care unit (ICU) capacity, two PICUs provided care to critically ill adults with COVID-19 pneumonia. Substantial yet rapid planning was required to facilitate safe delivery of critical care to adult patients while maintaining PICU services, including thoughtful development of care pathways and patient selection. To prepare clinical staff, several communication strategies, knowledge translation, skill consolidation, and system-adaptation mechanisms were developed. There was iterative adaptation of operational processes, including staffing models, specialist consultation, and the pharmacy. Care provided by the interprofessional teams was reoriented as appropriate to the needs of critically ill adults in close collaboration with adult ICU teams. Forty-one adults were admitted to the two PICUs over a 12-week period. In total, 36 patients (88%) received invasive ventilation, eight patients (20%) were supported with venovenous extracorporeal membrane oxygenation, and six patients (15%) received continuous renal replacement therapy. Four died in the PICU during this period. Feedback from staff included anxiety around reorienting practice to the care of critically ill adults, physical exhaustion, and psychological distress. Importantly, staff also reported a renewed sense of purpose with participation in the program. CONCLUSION: Though challenging, the experience has provided opportunity to enhance collaboration with partner institutions and improve the care of older children and adolescents in the PICU.

RéSUMé: OBJECTIF: Nous avions pour objectif de décrire et examiner l'expérience de deux unités de soins intensifs pédiatriques (USIP) en Ontario, au Canada, qui se sont adaptées et ont fourni des soins aux adultes gravement malades pendant la pandémie de COVID-19. CARACTéRISTIQUES CLINIQUES: À l'époque où la capacité des unités de soins intensifs (USI) pour adultes était extrêmement sollicitée, deux USIP ont prodigué des soins à des adultes gravement malades souffrant de pneumonie liée à la COVID-19. Une planification substantielle mais rapide a été nécessaire pour faciliter la prestation sécuritaire de soins intensifs à une patientèle adulte tout en maintenant les services de l'USIP, y compris l'élaboration réfléchie des trajectoires de soins et la sélection de la patientèle. Pour préparer le personnel clinique, plusieurs stratégies de communication, d'application des connaissances, de consolidation des compétences et de mécanismes d'adaptation du système ont été élaborées. Il y a eu une adaptation progressive des processus opérationnels, y compris des modèles de dotation, des consultations de spécialistes et de la pharmacie. Les soins fournis par les équipes interprofessionnelles ont été réorientés en fonction des besoins des adultes gravement malades en étroite collaboration avec les équipes adultes de soins intensifs. Quarante et une personnes adultes ont été admises dans les deux unités de soins intensifs pédiatriques sur une période de 12 semaines. Au total, 36 adultes (88 %) ont bénéficié d'une ventilation invasive, huit personnes (20 %) ont reçu une oxygénation par membrane extracorporelle veino-veineuse, et six (15 %) ont reçu un traitement substitutif de l'insuffisance rénale en continu. Quatre personnes sont décédées à l'USIP au cours de cette période. Les commentaires du personnel comprenaient de l'anxiété liée à la réorientation de leur pratique vers des soins à des adultes gravement malades, l'épuisement physique et la détresse psychologique. Fait important, le personnel a également signalé un regain de motivation lié à la participation de leur USIP à ce programme. CONCLUSION: Bien que difficile, l'expérience a permis d'améliorer la collaboration avec les établissements partenaires et d'améliorer les soins aux enfants plus âgé·es et aux adolescent·es de l'USIP.

Moral distress: Developing strategies from experience.

BACKGROUND: Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress. OBJECTIVES: We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience. RESEARCH DESIGN: An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers. PARTICIPANTS: Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital. RESEARCH CONTEXT: This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies. ETHICAL CONSIDERATIONS: The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project. FINDINGS: Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports. DISCUSSION: Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting. CONCLUSION: This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice.

Choice of maintenance intravenous fluids among paediatric residents in Canada.

BACKGROUND: Recent literature and guidelines support routine use of isotonic intravenous (IV) fluids for maintenance therapy in hospitalized infants and children. Current prescribing practices are unknown. OBJECTIVE: To elicit paediatric residents' choice of maintenance IV fluids, particularly with regard to tonicity, in a variety of clinical scenarios and patient ages. We hypothesized that residents would choose isotonic fluids in most cases, but there would be substantially more variability in fluid choice in the neonatal age group. METHODS: An Internet-based survey was e-mailed to trainees in the 17 paediatric residency programs across Canada, via the Canadian Paediatric Program Directors. The survey instrument included questions related to training, followed by a series of questions eliciting choice of IV fluid in a variety of clinical situations. RESULTS: A total of 147 survey responses were submitted (22% response rate). Isotonic solutions were selected by >75% across all clinical scenarios involving infants and children. Very hypotonic fluids were seldom chosen. There was more variability in fluid choice in neonates, with evidence of significant differences in fluid tonicity based on senior versus junior resident status and geographical location. CONCLUSIONS: Results imply a predominance of isotonic fluid use in infants and children, suggesting that clinical practice has changed in response to risk of hyponatremia with hypotonic IV fluids. As hypothesized, there was more variability with respect to choice of maintenance fluids in neonates. This likely reflects a paucity of guidance in an age group with unique physiologic factors affecting fluid and electrolyte status.

Through the looking glass: qualitative study of critical care clinicians engaging in humanities.

PURPOSE: Critical care medicine is facing an epidemic of burnout and consequent attrition. Interventions are needed to re-establish the medical field as a place of professional growth, resilience, and personal well-being. Humanities facilitate creation, reflection, and meaning-making, holding the promise of personal and community transformation. This study aimed to explore how clinicians engage with a humanities program, and what role and impact do the humanities play in their individual and collective journey. METHODS: This is a qualitative study employing a phenomenological approach. Participants were faculty and trainees who participated in the program. Data consisted of (a) 60-h observations of humanities evenings, (b) more than 200 humanities artifacts brought by participants, and (c) 15 in-depth participant interviews. Data were analyzed inductively and reflectively by a team of researchers. RESULTS: Participants were motivated to engage with the humanities curriculum because of past experiences with art, identifying a desire to re-explore their creativity to make meaning from their clinical experiences and a wish to socialize with and understand their colleagues through a different lens. The evenings facilitated self-expression, and inspired and empowered participants to create art pieces and re-engage with art in their daily lives. More importantly, they found a community where they could be vulnerable and supported, where shared experiences were discussed, emotions were validated, and relationships were deepened between colleagues. CONCLUSIONS: Humanities may impact resilience and personal and community well-being by facilitating reflection and meaning-making of challenging clinical work and building bonds between colleagues.

Invasive Group A Streptococcal Infections in Pediatric Critical Care: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVE: The reported rising global rates of invasive group A Streptococcus (iGAS) infection raise concern for disease related increase in critical illness and fatalities. An enhanced understanding of various presentations to health care and clinical course could improve early recognition and therapy in children with iGAS. The objective of this study was to describe the epidemiology of iGAS infections among children admitted to critical care. METHODS: A retrospective cohort study of children admitted to the PICU at The Hospital for Sick Children, in Toronto, Canada, between March 2022 and June 2023. Eligible patients were 0 to 18 years, with a diagnosis of iGAS infection. We describe the proportion of children admitted to the PICU with iGAS over the study period, their clinical characteristics, the frequency and timing of therapies, discharge versus baseline function, and PICU mortality. RESULTS: Among the 1820 children admitted to the PICU, 29 (1.6%) patients had iGAS infection. Of these 29 patients, 80% (n = 23) survived to hospital discharge. Patients who survived generally had favorable functional outcomes. Despite the high severity of illness and mortality described in this cohort, 61% returned to their baseline functional status by hospital discharge. CONCLUSIONS: This is the first report of critically ill children with iGAS in Canada during the increased incidence reported worldwide. We describe the clinical course of iGAS infection in children admitted to PICU with access to advanced extracorporeal interventions. Though there is a high mortality rate in this cohort, those who survive have favorable outcomes.

CD36 and TLR interactions in inflammation and phagocytosis: implications for malaria.

CD36 participates in macrophage internalization of a variety of particles, and has been implicated in inflammatory responses to many of these ligands. To what extent CD36 cooperates with other receptors in mediating these processes remains unclear. Because CD36 has been shown to cooperate with TLR2, we investigated the roles and interactions of CD36 and TLRs in inflammation and phagocytosis. Using Ab-induced endocytosis of CD36 and phagocytosis of erythrocytes displaying Abs to CD36, we show that selective engagement and internalization of this receptor did not lead to proinflammatory cytokine production by primary human and murine macrophages. In addition, CD36-mediated phagocytosis of Plasmodium falciparum malaria-parasitized erythrocytes (PEs), which contain parasite components that activate TLRs, also failed to induce cytokine secretion from primary macrophages. Furthermore, we demonstrate that CD36-mediated internalization did not require TLR2 or the TLR-signaling molecule IRAK4. However, macrophage pretreatment with TLR agonists markedly stimulated particle uptake via CD36. Similarly, PE uptake was unaffected by TLR deficiency, but in wild-type cells was increased by pretreatment with purified P. falciparum glycosylphosphatidylinositols, which activate TLR2. Our findings indicate that CD36 must cooperate with other receptors such as TLRs to participate in cytokine responses. Although purified P. falciparum components activate TLRs, CD36-mediated internalization of intact PEs is not inflammatory. Further, CD36 mediates internalization of particles, including PEs, independently of TLR signaling, but can functionally cooperate with TLRs to enhance internalization.

Who am I? Narratives as a window to transformative moments in critical care.

Critical care clinicians practice a liminal medicine at the border between life and death, witnessing suffering and tragedy which cannot fail to impact the clinicians themselves. Clinicians' professional identity is predicated upon their iterative efforts to articulate and contextualize these experiences, while a failure to do so may lead to burnout. This journey of self-discovery is illuminated by clinician narratives which capture key moments in building their professional identity. We analyzed a collection of narratives by critical care clinicians to determine which experiences most profoundly impacted their professional identity formation. After surveying 30 critical care journals, we identified one journal that published 84 clinician narratives since 2013; these constituted our data source. A clinician educator, an art historian, and an anthropologist analyzed these pieces using a narrative analysis technique identifying major themes and subthemes. Once the research team agreed on a thematic structure, a clinician-ethicist and a trainee read all the pieces for analytic validation. The main theme that emerged across all these pieces was the experience of existing at the heart of the dynamic tension between life and death. We identified three further sub-themes: the experience of bridging the existential divide between dissimilar worlds and contexts, fulfilling divergent roles, and the concurrent experience of feeling dissonant emotions. Our study constitutes a novel exploration of transformative clinical experiences within Critical Care, introducing a methodology that equips medical educators in Critical Care and beyond to better understand and support clinicians in their professional identity formation. As clinician burnout soars amidst increasing stressors on our healthcare systems, a healthy professional identity formation is an invaluable asset for personal growth and moral resilience. Our study paves the way for post-graduate and continuing education interventions that foster mindful personal growth within the medical subspecialties.

Statins fail to improve outcome in experimental cerebral malaria and potentiate Toll-like receptor-mediated cytokine production by murine macrophages.

Cerebral malaria is responsible for a large proportion of the estimated one million deaths caused by Plasmodium falciparum malaria annually. This disease is associated with excessive pro-inflammatory cytokine production resulting from dysregulated host responses to infection. On the basis of reports indicating potent activity against host-mediated inflammatory disorders such as sepsis, we examined the activity of statins (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors) on malaria-associated inflammation in vivo and in vitro. Simvastatin failed to improve survival or alter parasitemia in C57BL/6 mice infected with Plasmodium berghei ANKA, an experimental model of cerebral malaria. In vitro statin treatment potentiated production of tumor necrosis factor and interleukin-6 by murine peritoneal macrophages in response to P. falciparum glycosylphosphatidyl inositol, a Toll-like receptor 2 (TLR2) ligand. Statin treatment also potentiated pro-inflammatory cytokine production stimulated by a panel of TLR2 and TLR4 ligands. Our results indicate that statins fail to confer protection in experimental cerebral malaria and potentiate TLR-mediated pro-inflammatory cytokine production by primary murine macrophages.

Failure of two distinct anti-apoptotic approaches to reduce mortality in experimental cerebral malaria.

Cerebral malaria is responsible for a high proportion of mortality in human Plasmodium falciparum infection. Previous studies have reported the presence of apoptosis in endothelial cells, astrocytes, neurons, and glial cells in experimental murine cerebral malaria caused by infection with Plasmodium berghei ANKA. Using this model, we tested two strategies, which have been shown to improve survival in murine models of sepsis: 1) treatment with z-VAD, a pancaspase inhibitor; and 2) overexpression of Bcl-2 using transgenic mice expressing human Bcl-2 (which prevents the release of apoptotic mediators from the mitochondria) from a myeloid cell promoter. Neither of these anti-apoptotic strategies, previously shown to provide therapeutic benefit in sepsis, improved survival in experimental cerebral malaria.