Pathophysiology for the Pediatric Critical Care Fellow: Three Representative Simulation Cases.

Introduction: During the course of fellowship training, pediatric critical care fellows are expected to develop a broad and in-depth understanding of the pathophysiology of multiple disease processes. The simulation-based pediatric critical care pathophysiology curriculum we present uses scenarios created by pediatric critical care fellows to teach complex pathophysiology. Methods: Each of the three representative cases presented covered a specific pathophysiologic process and required participants to acutely manage (1) an 18-year-old patient with altered mental status in the setting of hepatic encephalopathy; (2) an 8-year-old patient with sepsis, coagulopathy, and acute kidney injury; or (3) a 12-year-old patient with status epilepticus. Each case could be conducted in a simulation suite or an acute care unit bed. We assessed learners' knowledge and attitudes at the end of these simulations with a structured debriefing session and via completion of an evaluation form. The simulations were then followed by a 30-minute interactive didactic session on the topic. Results: Each scenario had six fellow participants who completed evaluations. After completing each of the three case scenarios presented, the majority of participating pediatric critical care fellows indicated that the content was relevant and sufficiently challenging. They also indicated that these simulation scenarios would improve their clinical practice. Discussion: This fellow-developed simulation curriculum is novel, highlighting the relevance for critical care fellows' understanding of realistic clinical scenarios while promoting advanced management skills with a pathophysiology focus.

Randomized clinical trial of high concentration versus titrated oxygen use in pediatric asthma.

OBJECTIVE: To compare the effects of high concentration to titrated oxygen therapy (HCOT) on transcutaneous carbon dioxide (PtCO2 ) level in pediatric asthma exacerbation. Titrated oxygen therapy (TOT) in acute asthma will avoid a rise in PtCO 2 in the pediatric population. METHOD: The study design is a prospective, randomized, clinical trial comparing HCOT (maintain SpO2 92-95%) while being treated for asthma exacerbation in the emergency department (ED). INCLUSION CRITERIA: 2 to 18 years, previously diagnosed asthma with acute exacerbation (asthma score >5). PtCO2 and asthma scores were measured at 0, 20, 40, 60 minutes and then every 30 minutes until disposition decision. The primary outcome was a change in PtCO 2 . Secondary outcomes were admission rate and change in asthma score. RESULTS: A total of 96 patients were enrolled in the study with a mean age of 8.27 years; 49 in HCOT and 47 in the TOT group. The 0 minute PtCO2 was similar (35.33 + 3.88 HCOT vs 36.66 + 4.69 TOT, P = 0.13); whereas, the 60 minutes PtCO 2 was higher in the HCOT (38.08 + 5.11 HCOT vs 35.51 + 4.57 TOT, P = 0.01). The asthma score was similar at 0 minute (7.55 + 1.34 HCOT vs 7.30 + 1.18 TOT, P = 0.33); whereas, the 60 minutes asthma score was lower in the TOT (4.71 + 1.38 HCOT vs 3.57 + 1.25 TOT, P = 0.0001). The rate of admission to the hospital was 40.5% in HCOT vs 25.5% in the TOT (P = 0.088). CONCLUSIONS: HCOT in pediatric asthma exacerbation leads to significantly higher carbon dioxide levels, which increases asthma scores and trends towards the increasing rate of admission. Larger studies are needed to explore this association.