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.

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.

In this episode of PICU Doc on Call, Dr. Monica Gray and Dr. Pradip Kamat chat about flexible fiberoptic bronchoscopy (FFB) in the pediatric ICU. They walk through a case involving an eight-year-old who’s dealing with respiratory failure after a stem cell transplant. Along the way, they talk about when and why you might use bronchoscopy both for diagnosis and treatment—plus how to approach sedation and what effects the procedure can have on the heart and lungs. They also dive into important topics like managing hypoxia, handling increased airway and pulmonary vascular resistance, and what to keep in mind if your patient has a traumatic brain injury. The episode wraps up with tips for managing fever after the procedure and a quick look at how rigid bronchoscopy compares.

Show Highlights:

• Use of flexible fiberoptic bronchoscopy (FFB) in the pediatric ICU (PICU)
• Indications for performing bronchoscopy (diagnostic and therapeutic)
• Management of sedation and analgesia during bronchoscopy
• Cardiovascular effects associated with bronchoscopy procedures
• Respiratory effects and complications during bronchoscopy
• Special considerations for bronchoscopy in patients with traumatic brain injury (TBI)
• Post-procedure complications, including fever and its management
• Overview of rigid bronchoscopy and its indications
• Importance of understanding physiological changes during bronchoscopy
• Educational focus on acute pediatric care for current and aspiring PICU interns

References:

Reference 1: Sachdev A, Chhawchharia R. Flexible Fiberoptic Bronchoscopy in Pediatric Practice. Indian Pediatr. 2019 Jul 15;56(7):587-593. PMID: 31333214.

Reference 2: Li SX, Tao XF, Wu HJ, Jin F, Zhu GH, Wang YS, Tang LF, Chen ZM, Wu L. Advances in pediatric flexible bronchoscopy. World J Pediatr. 2025 Oct;21(10):945-956. doi: 10.1007/s12519-025-00967-7. Epub 2025 Oct 4. PMID: 41045338; PMCID: PMC12578761.

Reference 3: Truitt BA, Kasi AS, Kamat PP, Fundora MP, Simon DM, Guglani L. Cryoextraction via flexible bronchoscopy in children with tracheobronchial obstruction. Pediatr Pulmonol. 2023 Sep;58(9):2527-2534. doi: 10.1002/ppul.26540. Epub 2023 Jun 23. PMID: 37350368.