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Letters to the Editor

The Role of the Pediatric Intensivist in the Coronavirus Disease 2019 Pandemic

Rodriguez-Rubio, Miguel MD; Camporesi, Anna MD; de la Oliva, Pedro MD, PhD

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Pediatric Critical Care Medicine: October 2020 - Volume 21 - Issue 10 - p 928-930
doi: 10.1097/PCC.0000000000002433
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To the Editor:

The outbreak of infections by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) was officially declared a Public Health Emergency of International Concern by the World Health Organization (WHO) on January 30, 2020, after the initial cases in China continued to rise and new cases started to be reported from several other countries in Asia and Europe. On March 12, 2020, with over 20,000 cases and almost 1,000 deaths in the European region, the WHO declared the outbreak a pandemic (1). To this day, the number of SARS-CoV2 infections (coronavirus disease 2019 [COVID-19]) continues to rise worldwide bringing along an alarming number of deaths.

The Global Preparedness Monitoring Board of the WHO, in its 2019 “A World At Risk Report,” stated that although progress had been made, worldwide efforts to face a health emergency remained “grossly insufficient” (2). Although ICUs have had to prepare for pandemic situations in the past and guidance has been provided by professional societies (3), the current unprecedented situation continues to overwhelm healthcare systems and economies around the world. Governments are facing socioeconomic, logistic, and organizational challenges that may change the way our societies and healthcare systems function forever.

THE ICU CONUNDRUM

The availability of ICU beds varies greatly among countries (4) and depends on several factors such as the number of beds per 100,000 habitants, the socioeconomic status, the prevalence of chronic illnesses, and overall health status of the population and management choices (i.e., different admission and discharge criteria).

During the current pandemic, special attention has been paid to ICU bed and ventilator availability. Many hospitals in Italy, Spain, the United Kingdom, or the United States have been forced to expand their ICUs outside of their regular spaces using nonconventional locations like operating theaters, wards, or postoperative care units as ICUs. These ad hoc spaces commonly lack the complex architecture and resources of a conventional ICU making logistics challenging.

Although healthcare systems around the world have been able to expand their capacity in terms of ICU beds, ventilator availability has been a major problem. With a saturated global market that cannot meet the demand of these high-tech devices, physicians and respiratory therapists have turned to alternative management strategies including careful selection of the patients who will benefit the most from invasive ventilatory support, extended use of noninvasive support, off-label use of noninvasive ventilation devices, or anesthesia machines for invasive mechanical ventilation or even ventilator splitting (i.e., using one ventilator to support two or more different patients) (5). Likewise, governments, academic institutions, private companies, and individuals have made an enormous effort to increase the offer of ventilators including, in some cases, homemade devices.

With an increased ICU bed capacity and ventilator availability, the next challenge arises: critically ill adults with COVID-19 are highly complex patients who have important requirements of specialized ICU management, including nursing, respiratory support, and supportive care. The increased complexity along with the elevated number of patients requiring intensive care adds up to the high number of healthcare workers affected by COVID-19 in creating severe staffing problems among institutions worldwide.

PEDIATRIC CRITICAL CARE MEDICINE

Although Goran Haglund established the first ever PICU in Gothenburg, Sweden, in 1955, Pediatric Critical Care Medicine is a relatively young subspecialty (e.g., the pediatric section of the Society of Critical Care Medicine was created in 1981) that has rapidly evolved into a highly complex field (6). Pediatric intensivists are highly skilled, highly specialized physicians who treat, on a day-to-day basis, severely ill children with life-threatening diseases such as congenital heart disease, trauma, and infectious diseases. PICUs are high-acuity units where children in a wide range of ages receive state of the art care around the clock, including invasive mechanical ventilation, extracorporeal life support, or continuous renal replacement therapies.

HOW CAN WE HELP?

COVID-19 seems to somewhat spare children with those who show symptoms rarely evolving to need PICU admission (7). This situation leaves pediatric critical care teams relatively unexposed to the infection and with a maintained or decreased workload.

In an unprecedented situation for ICUs around the world and with healthcare systems suffering severe shortages of equipment and staff, pediatric critical care physicians can be of great value in providing temporary support to adult ICUs (8). With advanced knowledge in physiology and, specifically, respiratory support, pediatric intensivist can be integrated into ICU teams and under the constant supervision of adult ICU consultants can exceptionally perform fellow-level tasks that may help alleviate the burden these teams are suffering.

Pediatric teams have been providing resources and logistic support to adult ICUs in our regions for the last month and a half. This process has been driven by institution-wide protocols and well-meaning improvisation with very little specific guidance, leading to significant heterogeneity in practice. Questions remain as to whether admitting adult patients to PICUs or deploying pediatric intensivists to adult ICUs should be the preferred model. We encourage professional societies from the critical care field, both adult and pediatric, to develop and distribute consensus statements that at a national level may provide help and support on how to integrate mixed teams in which pediatric intensivists can have clearly defined roles and responsibilities.

ACKNOWLEDGMENTS

We thank all of our colleagues in adult and pediatric critical care around the world for the inspiring high-quality care they continue to provide during this pandemic.

Miguel Rodriguez-Rubio, MD
Pediatric Intensive Care Department, La Paz University Hospital, Madrid, Spain, Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain;
Anna Camporesi, MD
Division of Pediatric Anesthesia and Intensive Care Unit, Department of Pediatrics, Children’s Hospital Vittore Buzzi, Milan, Italy;
Pedro de la Oliva, MD, PhD
Pediatric Intensive Care Department, La Paz University Hospital, Madrid, Spain, Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain

REFERENCES

1. World Health Organization. WHO announces COVID-19 outbreak a pandemic. 2020. Available at: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2020/3/who-announces-covid-19-outbreak-a-pandemic. Accessed April 1, 2020
2. Global Preparedness Monitoring Board. A world at risk: Annual report on global preparedness for health emergencies. 2019. Available at: https://apps.who.int/gpmb/annual_report.html. Accessed April 1, 2020
3. Christian MD, Devereaux AV, Dichter JR, et al. Introduction and executive summary: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. CHEST. 2014. 146:8S–34S
4. Prin M, Wunsch H. International comparisons of intensive care: Informing outcomes and improving standards. Curr Opin Crit Care. 2012. 18:700–706
5. Clarke AL, Stephens AF, Liao S, et al. Coping with COVID-19: Ventilator splitting with differential driving pressures using standard hospital equipment. Anaesthesia. 2020. Apr 9. [online ahead of print]
6. Epstein D, Brill JE. A history of pediatric critical care medicine. Pediatr Res. 2005. 58:987996
7. Ong JSM, Tosoni A, Kim Y, et al. Coronavirus disease 2019 in critically ill children: A narrative review of the literature. Pediatr Crit Care Med. 2020 Apr 7. [online ahead of print]
8. Remy KE, Verhoef PA, Malone JR, et al. Caring for critically ill adults with coronavirus disease 2019 in a PICU: Recommendations by dual trained intensivists. Pediatr Crit Care Med. 2020 April 29. [online ahead of print]
Copyright © 2020 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies