In this episode of *PICU Doc on Call*, Drs. Monica Gray, Pradip Kamat, and Rahul Damania chat about a 17-year-old girl who ended up with acute liver failure after she intentionally took 22.5 grams of acetaminophen. She came in 48 hours later with really high transaminases and an INR of 5.5, so she was admitted to the PICU. The hosts break down how acetaminophen affects the body, walk through its four clinical stages, and discuss how to manage it—focusing on N-acetylcysteine as the primary antidote. They also touch on other treatments, like fomepizole. Thankfully, this patient recovered without needing a liver transplant, which really shows how important it is to have a team approach with intensivists, hepatologists, toxicologists, and psychiatry all working together.

Show Highlights:

• Clinical case presentation of a 17-year-old girl with acetaminophen ingestion leading to acute liver failure
• Mechanism of acetaminophen toxicity and its metabolic pathways
• Epidemiology of acetaminophen toxicity in pediatric populations
• Pathophysiology of acetaminophen overdose and its effects on liver function
• Clinical manifestations and progression of acetaminophen toxicity through various stages
• Evaluation and diagnostic criteria for assessing acetaminophen toxicity
• Management strategies for acetaminophen overdose, including the use of N-acetylcysteine (NAC).
• Discussion of adjunctive therapies such as fomepizole in severe cases.
• Importance of supportive care in managing complications of acute liver failure
• An interdisciplinary approach to treatment involving various medical specialties

References:

Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.

Reference 1: 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Brooks DE, Dibert KW, Rivers LJ, Pham NPT, Ryan ML. Clin Toxicol (Phila). 2020;58(12):1360.

Reference 2: Pepin L, Matsler N, Fontes A, Heard K, Flaherty BF, Monte AA. Fomepizole Therapy for Acetaminophen-Induced Liver Failure in an Infant. Pediatrics. 2023 Oct 1;152(4):e2022061033. doi:10.1542/peds. 2022-061033. PMID: 37681263.

Reference 3. Chiew AL, Buckley NA. Acetaminophen Poisoning. Crit Care Clin. 2021 Jul;37(3):543-561.

Reference 4. Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr. 2022 Jan 1;74(1):138-158. doi: 10.1097/MPG.0000000000003268. PMID: 34347674.

In this episode of "PICU Doc on Call," Drs. Monica Gray, Pradip Kamat, and Rahul Damania discuss the use of intranasal medications in pediatric intensive care. Using the case of a four-month-old infant needing an MRI, they explore when and why intranasal drugs are preferred over IV access, the science behind nasal drug delivery, safe administration techniques, and common medications used. The episode highlights the benefits of intranasal sedation—such as rapid onset and needle-free delivery—while emphasizing teamwork and careful monitoring for safe, effective pediatric care.

Show Highlights:

• Use of intranasal medications in pediatric intensive care settings
• Case study of a four-month-old infant requiring sedation for an MRI.
• Advantages of intranasal delivery over IV access
• Pharmacokinetics and neuroanatomy related to intranasal drug absorption
• Techniques for safe and effective administration of intranasal medications
• Comparison of intranasal dosing to oral and IV routes
• Common intranasal medications used in the pediatric ICU
• Importance of timing and monitoring during sedation procedures
• Teamwork and communication in administering intranasal medications
• Clinical applications and implications for patient comfort and care delivery

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter ***.
• Reference 1: Tsze DS, Woodward HA, McLaren SH, Leu CS, Venn AMR, Hu NY, Flores-Sanchez PL, Stefan BR, Shen ST, Ekladios MJ, Cravero JP, Dayan PS. Optimal Dose of Intranasal Midazolam for Procedural Sedation in Children: A Randomized Clinical Trial. JAMA Pediatr. 2025 Sep 1;179(9):979-986. doi: 10.1001/jamapediatrics. 2025.2181.
• Reference 2: Prescott MG, Iakovleva E, Simpson MR, Pedersen SA, Munblit D, Vallersnes OM, Austad B. Intranasal analgesia for acute moderate to severe pain in children - a systematic review and meta-analysis. BMC Pediatr. 2023 Aug 18;23(1):405. doi: 10.1186/s12887-023-04203-x.
• Reference 3: Chabowski L, Mahboobi Z, Navolokina A. Intranasal ketamine for procedural sedation in children. Am J Emerg Med. 2023 Jun;68:195. doi: 10.1016/j.ajem.2023.04.013.
• Reference 4: Sulton C, Kamat P, Mallory M, Reynolds J. The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium. Pediatr Emerg Care. 2020 Mar;36(3):138-142. doi: 10.1097/PEC.0000000000001199.

In this special “PICU Doc On Call Shorts” episode, pediatric ICU physicians Dr. Monica Gray, Dr. Pradip Kamat, and Dr. Rahul Damania break down the concept of Mean Arterial Pressure (MAP). Using a case of a six-year-old in septic shock, they discuss how to calculate MAP, normal pediatric values, and the physiological determinants and clinical significance of MAP. The hosts highlight MAP’s role in guiding management of critically ill children, review autonomic and endothelial regulation, and reinforce learning with a board-style question. This episode emphasizes practical bedside application for pediatric interns and ICU providers.

Show Highlights:

1. Overview of Mean Arterial Pressure (MAP) and its clinical significance in pediatric critical care.
2. Introduction of a clinical case involving a 6-year-old child in septic shock.
3. Explanation of the formula for calculating MAP and its application to the clinical case.
4. Discussion of normal reference values for MAP in children and their clinical implications.
5. Physiological determinants of MAP, including cardiac output and systemic vascular resistance.
6. Role of the autonomic nervous system in regulating MAP through baroreceptor reflexes.
7. Importance of maintaining adequate MAP for organ perfusion, particularly in critically ill patients.
8. Clinical applications of MAP monitoring and management strategies in the PICU.
9. Summary of key takeaways regarding MAP calculation, physiological determinants, and clinical relevance.
10. Mention of related topics, such as invasive versus non-invasive blood pressure monitoring.

References:

1. DeMers D, Wachs D. Physiology, Mean Arterial Pressure. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
2. Pediatric Blood Pressure Metrics and Hypotension Thresholds (details the task force data used to derive the 5th and 50th percentile MAP estimation formulas for children)
3. Berlin DA, Bakker J. Starling curves and central venous pressure. Crit Care. 2015 Feb 16;19(1):55.
4. Magder S. Volume and its relationship to cardiac output and venous return. Crit Care. 2016 Sep 10;20(1):271