LAUSR

As anyone who has spent a night caring for an adolescent with florid anticholinergic symptoms of agitation, hallucinations, delirium, and altered vital signs knows, pediatric patients with acute ingestions oftentimes require a lot of resources to maintain patient safety and stability until the drug finally gets eliminated. Acute intoxications can be challenging, and often many potential risks based on the known side-effect profiles of the ingested drugs require close monitoring. When these risks become critically life threatening, such as progressing to respiratory failure, complex arrthymias, or unrelenting seizures, there is no doubt that early supportive care or PICU interventions (intubation, dialysis, and cardiac support) in the PICU is life saving. Alternatively, resources can be wasted as well. Caring for an alcohol-intoxicated pediatric patient, intubated in the field, admitted to the PICU, who then wakes up, extubates, and takes a PICU bed while managing the early stages of a hangover and awaiting discharge can be challenging for the unit as well. Resources in the PICU are oftentimes limited, and how best to use them is an ongoing challenge. Poisonings remain a significant public health concern and a major cause of injury-related death in pediatrics. Data from the American Academy of Poison Control Centers show that calls to poison centers continue to increase every year since at least 2000 (1). They report over 2.8 million calls in 2015 or a call every 14.5 seconds across the United States. Most of these can be managed at home (67%), but the referrals to hospitals have gone up—particularly in the adolescent age group. Many referred to hospitals also go home from the emergency department (ED), but recent data suggest that up to 39% referred in for ingestions are admitted to the hospital (2, 3). Who gets admitted and where remains highly variable based on an estimation of the real and potential risks of ingestion based on the pharmacology of poisons, the amount of drug taken, toxicology recommendations, capabilities of the ward or observational units, and presence or absence of any toxidrome. If the decision to admit to the PICU is made for any of these reasons, our PICUs obviously take them when at all possible. Despite the fact that poisonings or ingestions have been reported to account for between 3% and 8% of all PICU admissions (4, 5), there are surprisingly little data to drive practice or provide guidance for a busy PICU trying to manage beds effectively and efficiently. What we do know from the literature is that despite the significant number of admissions, most are in the PICU for a day at most and thus are a much smaller percentage of bed usage compared with other diagnoses. We also know that a very wide variety of ingested poisons lead to PICU admission, that usually more than half are in children less than 5 years old with unintentional ingestions, and that intentional ingestions are more common in adolescents, who tend to present sicker and are more likely to be polypharmaceutical intoxications (1–5). Death and morbidity also are very low in this population, but it is unclear how much that relates to appropriate supportive care or to very few patients actually reaching a lethal dose concentration of drug in their body. The important question remains as to what admission criteria to the PICU can be used to be safe and reliable for children with acute intoxications. The article published in this issue of Pediatric Critical Care Medicine by Patel et al (6) presents the first large-scale analysis of this population in the PICU with the main objective to determine whether or not the PICU was the right place for these patients. Their data, gathered from the multiinstitutional Virtual Pediatric Systems (VPS), LLC confirmed previously reported frequency of intoxicated admissions, with similar demographics—though they did have a preponderance of “intentional” intoxications (78%) which may be related to the search criteria in the database that potentially missed a fair number of less than 5-year-olds with unintentional ingestions/ exposures. Using objective criteria of VPS defined mandatorily reported PICU interventions, they should be commended for establishing a clear benchmark of how many children in this cohort were undoubtedly in the right place. How well does this provide a defining view into the acute intoxication population to somehow provide guidance to the ED, ward, toxicology, and PICU attendings for patient placement? What percentage of patients who get admitted to the PICU should be expected to get a PICU intervention? Should it be 100%? Should it be 50%? Is 29% acceptable or agreeable for our standards of PICU utilization? These questions remain. What are PICU interventions that can only be done in the PICU besides the ones captured in the database? Telemetry (particularly QRS morphology), frequent electrocardiograms (ECGs), end-tidal Co 2 , frequent labarotories, 1:1 nursing, narcan drip, high-dose insulin drip, seizure control, and self-harm protection with support staff are just a few other types of interventions that likely are best done in the PICU. The authors admit that they cannot capture all factors that necessitate being in the PICU, but do imply that Copyright © 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000001201 Scot T. Bateman, MD Division of Pediatric Critical Care Department of Pediatrics University of Massachusetts Medical School Worcester, MA