Discover and read the best of Twitter Threads about #WFPICCS20

Sharon Y Irving on ‘early enteral #nutrition: timing is more important than initial volume’

Starting with what is early enteral nutrition... definitions are vague 👇 but generally within 24hrs is recommended

#PedsICU #WFPICCS20

Need to consider the metabolic response of critical illness on #nutrition - this is multi factorial

But it’s key to remember that this response is not predictable, will vary with the illness and hard to assess

#PedsICU #WFPICCS20

The blood flow to the splanchnic & GI tract circulation can be varied during resuscitation and critical illness - all this can lead to impact to the ability to tolerate enteral #nutrition

#PedsICU #WFPICCS20

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Suchitra Ranjit discusses multimodal monitoring during #sepsis to help decode the physiological diagnosis and personalise therapy

Opening message is that cardiac output is difficult to assess at the bedside

#PedsICU #WFPICCS20

MAP is often used as a proxy of CO - is this reasonable?

There is not a strong relationship between them in post-cardiac surgical children

#PedsICU #WFPICCS20

What happens when fluid is given in #sepsis?

Again: v weak correlation between CI & MAP

Interestingly almost 50% of patients did not respond to fluid & significant % of patients had a fall in BO/CI!

48% of children needed more inotrope after the fluid

#PedsICU #WFPICCS20

Hector Wong discusses the clinical application of biomarkers in #sepsis

Starts with how can biomarkers help us...

#PedsICU #WFPICCS20

A great picture showing how the aim of biomarkers is to allow precision medicine - but you need to understand the concept of enrichment first!

#PedsICU #WFPICCS20 #Sepsis

The development of AKI is independently associated with morbidity and mortality in #sepsis

Combining this with additional biomarker activity is helpful

#PedsICU #WFPICCS20

Joe Carcillo discusses clinical phenotypes & outcomes of #sepsis

He says mortality was reduced in the emergency department by protocols using early antibiotics/fluids

Yet some children who end up on #PedsICU develop multiorgan failure despite following protocols

#WFPICCS20

Four clinical phenotypes have been associated with progressive multiorgan failure in #sepsis

All of these phenotypes end with macrophage activation syndrome.

Research is going on to target therapies against each phenotype (eg, TAMOF with plasma exchange)

#PedsICU #WFPICCS20

Children can have one or more of these phenotypes and some are more common than others.

This data is important when planning #research trials for targeted #sepsis therapies

But also this data has implications for clinical outcomes...

#PedsICU #WFPICCS20

Steven E. Wolf now talks about #PedsICU #airway #burns

Airway burns is something I always worry about. Looking forward to his insights in this topic

#WFPICCS20 #PedsAnes

Airway probs can occur from:
- direct burns
- inhalation injury (10-20% of all burns pts)
- trauma from other injuries
- 3rd spacing oedema during fluid resuscitation
- long term intubation (eg subglottic stenosis)

#PedsICU #PedsAnes #WFPICCS20

Don’t forget carbon monoxide poisoning in airway burns!

#PedsICU #PedsAnes #WFPICCS20

Prof. Bettina Vom Dessauer now talks about the #burns patient as a critically ill patient with systemic problems.

#PedsICU #WFPICCS20

Outcomes in #burns patient associated with:
- early admission to hospital
- care in a specialised burns unit
- control of infections
- early nutrition

These children are often healthy before the injury and this results in the whole homeostasis being altered

#PedsICU #WFPICCS20

The pathophysiology of #burns patients is multi systemic and occur at a cellular level

What we see clinically is distributive shock.

#PedsICU #WFPICCS20 #physiology

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Catching up on #burns patients on the #PedsICU - first up Steven E. Wolf discussing specialised burns care by the surgical team

He starts by discussing the ultimate goals of paediatric burn care:
- no deaths
- no scars
- no pain

We are improving but not there yet

#WFPICCS20

‘Burns are as bad as they are going to get at the start; they can only get better - burns are different to chronic diseases’ - Steven E. Wolf, burns surgeon/Intensivist

#PedsICU #WFPICCS20

What are the strategies for management of the #burn wound?

The key is fix and heal the wound. Then de-intensify the patient as soon as possible.

Remember: #burns wounds will have organisms cultured - but are they causing infection?

#PedsICU #WFPICCS

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Watching Dr Trung Nguyen discussing the indications and outcomes of therapeutic plasma exchange in #PedsICU #WFPICCS20

A thread to follow....

Within plasma there can be molecules that are harmful/toxic that you may want to remove, without removing the rest of the blood molecules...

Three options exist to purify blood 👇

#PedsICU #WFPICCS20

First is haemofiltration: the limit here is the size of the molecules you want to remove vs the size of the filter membrane...

But it is a technique many #PICU are familiar with for #CRRT

#PedsICU #WFPICCS20

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Allan Doctor discusses the functional assessment of haemostasis and anticoagulation therapy during critical illness

#PedsICU #WFPICCS20

let’s look at normal #coagulation system #physiology...

New ways of thinking at a cellular level moves from the classic intrinsic and extrinsic a pathway to a cell based process consisting of:
- Initiation
- amplification phase
- propagation phase

#PedsICU #WFPICCS20

And fibrinolysis is an important part of #coagulation #physiology to prevent excess clot growth and clot break down after healing...

It is this process we accelerate with thrombolysis

#PedsICU #WFPICCS20

@DrOliverKaram

@DrOliverKaram moves on to talk about #platelet transfusion in the #PedsICU

He starts by telling us platelets are stored at room temperature for 5-7 days and this means they are a risk of infection source

#WFPICCS20

When are platelet transfusions indicated? Expert recommendations exist... but do we follow them?

#PedsICU #WFPICCS20

Each 10ml/kg platelet transfusion is associated with a 2% increase in #PedsICU mortality

Ask: do they really need that transfusion?

#WFPICCS20

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@DrOliverKaram

@DrOliverKaram talks to us about plasma products @WFPICCS #wfpiccs20 #PedsICU

Not all plasma products are created equally: some still have residual cells, and some are better than others...

When is plasma indicated?

Major trauma is a clear indiction.

But use in prophylactic head injuries seems to worsen development of lesions

Use of plasma products in children is associated with multiorgan dysfunction - do you really need to give this?

#PedsICU #WFPICCS20

So why are #plasma products given?

You can see some children given just to correct INR - not that big a change obtained overall, but the higher the INR at transfusion the bigger the effect.

#PedsICU #WFPICCS20

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@PedCritCareMed

Next up: social media in #PedsICU - delivered by @PedCritCareMed #SoMe editor @SapnaKmd

This really is important - it is a huge tool for medical education!

#WFPICCS20

@SapnaKmd

#SoMe allows us to have a network of people - for me, it’s opened my eyes about the #PedsICU world and educated me huge amounts and made so many international connections

#WFPICCS20 @SapnaKmd

@PedCritCareMed

I’m still really proud to be part of @PedCritCareMed #SoMe panel.... and please do follow each and everyone on this picture as you will see so much #PedsICU content

#WFPICCS20 @SCCM @WFPICCS

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