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PICU Doc On Call

PICU Doc On Call

By: Dr. Pradip Kamat Dr. Rahul Damania Dr. Monica Gray
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PICU Doc On Call is the podcast for current and aspiring Intensivists. This podcast will provide protocols that any Critical Care Physician would use to treat common emergencies and the sudden onset of acute symptoms. Brought to you by Emory University School of Medicine, in conjunction with Dr. Rahul Damania and under the supervision of Dr. Pradip Kamat.Copyright 2026 Dr. Pradip Kamat, Dr. Rahul Damania, Dr. Monica Gray Biological Sciences Hygiene & Healthy Living Physical Illness & Disease Science
Episodes
  • Sweet Dreams: Procedural Sedation in the PICU

    Sweet Dreams: Procedural Sedation in the PICU
    Jun 21 2026
    In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat explore procedural sedation in the pediatric ICU. They cover sedation levels, pre-screening, risk stratification using ASA classifications, and medication selection tailored to each patient's hemodynamic and respiratory status. Through real-world case discussions involving respiratory failure, septic shock, and acute neurological decline, they highlight the importance of end-tidal CO2 monitoring and early adverse event recognition. Key takeaways include avoiding the term "conscious sedation," preparing rescue plans, and prioritizing patient safety through careful assessment and monitoring.Show Highlights:Definitions and levels of sedation (minimal, moderate, deep sedation, and general anesthesia)Importance of terminology in procedural sedationMonitoring sedation levels using scales like the Richmond Agitation-Sedation Scale (RASS)Pre-screening and risk stratification considerations for pediatric patientsASA physical status classification system for assessing patient riskUnique challenges of procedural sedation in critically ill childrenAdverse events associated with pediatric procedural sedation, particularly respiratory complicationsManagement strategies for specific cases requiring sedation (e.g., respiratory failure, septic shock)Importance of end-tidal CO2 monitoring during sedationKey takeaways for safe sedation practices in the pediatric ICU settingReferences: Nir Atlas; Rahul C. Damania; Pradip P. Kamat In Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 135, 1624-1628Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia by Committee on Quality Management and Departmental Administration. Last Amended: October 23, 2024.Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019 Jun;143(6):e20191000. doi: 10.1542/peds.2019-1000. PMID: 31138666.xKrauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006 Mar 4;367(9512):766-80. doi: 10.1016/S0140-6736(06)68230-5. PMID: 16517277.Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth. 2024 Mar;132(3):491-506. doi: 10.1016/j.bja.2023.11.050. Epub 2024 Jan 6. PMID: 38185564.Smith, Heidi A. B. MD, MSCI (Chair)1,2; Besunder, James B. DO, FCCM3,4; Betters, Kristina A. MD1; Johnson, Peter N. PharmD, BCPS, BCPPS, FCCM, FPPA, FASHP5,6; Srinivasan, Vijay MBBS, MD, FCCM7,8; Stormorken, Anne MD9,10; Farrington, Elizabeth PharmD, FCCM11; Golianu, Brenda MD12,13; Godshall, Aaron J. MD14; Acinelli, Larkin CPNP-AC, ACHPN15; Almgren, Christina CPNP16; Bailey, Christine H. MD17; Boyd, Jenny M. MD18,19; Cisco, Michael J. MD20; Damian, Mihaela MD, MPH21,22; deAlmeida, Mary L. MD23,24; Fehr, James MD13,25; Fenton, Kimberly E. MD, FCCM14; Gilliland, Frances DNP, CPNP-AC/PC26,27; Grant, Mary Jo C. CPNP-AC, PhD, FAAN28; Howell, Joy MD29; Ruggles, Cassandra A. PharmD, BCCCP, BCPPS30; Simone, Shari DNP31,32; Su, Felice MD21,22; Sullivan, Janice E. MD33,34; Tegtmeyer, Ken MD, FAAP, FCCM35,36; Traube, Chani MD, FCCM29; Williams, Stacey CPNP-AC37; Berkenbosch, John W. MD, FAAP, FCCM (Chair)33,34. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatric Critical Care Medicine 23(2):p e74-e110, February 2022. | DOI: 10.1097/PCC.0000000000002873Benzoni T, Agarwal A, Cascella M. Procedural Sedation. [Updated 2025 Mar 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551685/Kerson AG, DeMaria R, Mauer E, Joyce C, Gerber LM, Greenwald BM, Silver G, Traube C. Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children. J Intensive Care. 2016 Oct 26;4:65. doi: 10.1186/s40560-016-0189-5. PMID: 27800163; PMCID: PMC5080705.Tel-Dan SF, Shavit D, Nates R, Samuel N, Shavit I. Emergency Physician-Administered Sedation for Thoracostomy in Children With Pleuropneumonia. Pediatr Emerg Care. 2021 Dec 1;37(12):e1209-e1212. doi: 10.1097/PEC.0000000000001975. PMID: 31929389.Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med. 2022 Dec;80(6):485-496. doi: 10.1016/j.annemergmed...
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    34 mins
  • Pink Toes and Blue Brain on VA ECMO (North South Syndrome on ECMO)

    Pink Toes and Blue Brain on VA ECMO (North South Syndrome on ECMO)
    Jun 7 2026

    In this episode of *PICU Doc on Call*, Dr. Monica Gray and Dr. Pradip Kamat are joined by fellow Dr. Hope Vancleve to discuss a complex case of a 12-year-old with MRSA septic shock requiring VA ECMO. The conversation covers sepsis-induced myocardial dysfunction, including its pathophysiology, diagnosis, and management. The hosts also explore differential hypoxia, or Harlequin syndrome, a serious VA ECMO complication causing upper body deoxygenation, and discuss monitoring strategies and circuit reconfiguration to prevent cerebral and myocardial ischemia.

    Show Highlights:

    • Clinical case discussion of a 12-year-old male patient with MRSA septic shock.
    • Complications of sepsis, including sepsis-induced myocardial dysfunction and refractory shock.
    • Management strategies for septic shock, including antibiotic therapy and fluid resuscitation.
    • Use of venoarterial ECMO support in pediatric patients with severe cardiac dysfunction.
    • Pathophysiology of sepsis-induced myocardial dysfunction and its impact on cardiac function.
    • Differential hypoxia (North-South syndrome) in patients on femoral VA ECMO.
    • Diagnostic approaches for sepsis-induced myocardial dysfunction, including echocardiography and biomarkers.
    • Importance of monitoring and managing end-organ function in septic patients.
    • Strategies for addressing differential hypoxia in ECMO patients, including circuit reconfiguration.
    • Discussion of the risks and benefits of various ECMO configurations and management techniques.

    References:

    • Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter
    • Reference 1: Torre DE, Pirri C. Harlequin Syndrome in Venoarterial ECMO and ECPELLA: When ECMO and Native or Impella Circulations Collide - A Comprehensive Review. Rev Cardiovasc Med. 2025 Aug 26;26(8):39992. doi: 10.31083/RCM39992. PMID: 40927093; PMCID: PMC12415751.
    • Reference 2 : Cove ME. Disrupting differential hypoxia in peripheral veno-arterial extracorporeal membrane oxygenation. Crit Care. 2015 Jul 22;19(1):280. doi: 10.1186/s13054-015-0997-3. PMID: 27391473; PMCID: PMC4511033.
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    24 mins
  • Of Rats & Men: Approach to Coumadin Overdose in the PICU

    Of Rats & Men: Approach to Coumadin Overdose in the PICU
    May 24 2026

    In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat discuss a 15-year-old girl who attempted suicide by ingesting rat poison, acetaminophen, ibuprofen, and amlodipine. The episode focuses on long-acting anticoagulant rodenticides (LAARs), such as brodifacoum, which inhibit vitamin K epoxide reductase, causing delayed coagulopathy. Key topics include clinical presentation, diagnostic evaluation, and management, emphasizing vitamin K1 as the primary antidote and prothrombin complex concentrate or fresh-frozen plasma for major bleeding. The patient stabilized with aggressive supportive care, including vasoactive agents and NAC therapy, alongside psychiatric intervention. Listen to learn more!

    Show Highlights

    • Clinical case of a 15-year-old girl who attempted suicide through polypharmacy ingestion
    • Ingestion of multiple substances, including chewable rat poison, acetaminophen, ibuprofen, and amlodipine
    • Discussion of toxicology related to long-acting anticoagulant rodenticides (LAARs) like brodifacoum
    • Symptoms and clinical presentation following acute ingestion, including metabolic acidosis and elevated lactate
    • Diagnostic evaluation and laboratory findings, including coagulation studies and liver function tests
    • Management strategies for LAAR poisoning, including the use of vitamin K and supportive care
    • Importance of monitoring for delayed coagulopathy and serial INR testing
    • Consideration of calcium channel blocker toxicity in the context of the patient's clinical instability
    • Overview of the mechanisms of action of LAARs and their impact on vitamin K-dependent clotting factors
    • Key take-home points regarding the recognition and management of rodenticide ingestion in pediatric patients

    References

    Reference: King N, Tran MH. Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management. Transfus Med Rev. 2015 Oct;29(4):250-8.

    Reference 2: Feinstein DL, Akpa BS, Ayee MA, et al. The emerging threat of superwarfarins: history, detection, mechanisms, and countermeasures. Ann N Y Acad Sci. 2016 Jun;1374(1):111-22.
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    21 mins
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