Critical Care

The Division of Pediatric Critical Care is dedicated to the delivery of state-of-the-art child and family centered care for critically ill and injured children.

The division’s mission is accomplished by a collaborative group that champions a multidisciplinary approach to care, the incorporation of best available evidence into clinical practice, and acquisition of new knowledge through clinical research. Attention to patient safety, continuous performance improvement, and education of physicians, nurses, and other care team members is paramount.

The Pediatric Intensive Care Unit staff faced the challenge and uncertainty of Covid-19 and took their responsibilities professionally and without wavering. The PICU team embraced the challenge and was integrated into all aspects of systems improvement to provide high quality care for children with Covid-19, while maintaining the safety of all our team members. The PICU quickly created and implemented clinical management pathways for delivery of respiratory therapies, processes for managing patients with acute deterioration, and maintained a continuous flow of education and updates as needed for a rapidly changing management schema. It is through these efforts that children suffering from Covid-19 received prompt high quality care without a child dying from Covid-19 and with no staff member acquiring infection from a patient.

Despite the challenges of Covid-19, the PICU faculty has been successful academically and professionally. Major awards and academic accomplishments among the division members include important contributions to several national societies and both internal and external collaborations:

Christopher Carroll, MD, continues many clinical and translational research activities and collaborations. He is recognized as an international leader and lectures frequently at international conferences about topics including asthma and other respiratory diseases, critical care, and digital media. He continues in leadership roles in major medical organizations including Chest® (the American College of Chest Physicians) Covid Task Force, deputy editor of multimedia for the journal Chest, and chair of the Critical Care NetWork and chair of the program committee of Chest. Dr. Carroll also received a distinguished educator award from Chest, the Presidential Citation from the Society of Critical Care Medicine, and Hartford Business Journal’s 2020 Health Care Hero Award.

Adam Silverman, MD, as director of the Center for Global Health (CGH), leads efforts to increase appreciation for diversity, equity and inclusion amongst learners, staff and faculty at Connecticut Children’s while leveraging the skills and talents of our institution to improve the health of children living in resourcelimited settings. Despite travel restrictions created by the Covid-19 pandemic, Dr. Silverman partnered remotely with pediatric providers in Haiti and Rwanda and assisted in the education of future pediatricians and with quality improvement activities in countries with some of the most compelling health care inequalities. He continues to organize an annual Global Health Symposium and the Global Health Film Festival. Locally, he has collaborated with other faculty to further refine and improve the Global Health Care Pathway for pediatric residents, organized a Global Health Boot Camp and mentored staff members who travel to developing countries to help improve the health care of children around the world.

Heather Schlott, MD, continues as medical director of the hospital’s Extracorporeal Membrane Oxygenation (ECMO) program. This technology provides state-ofthe-art heart and lung support for our most critically ill patients. The program has grown and, in fact, Connecticut Children’s received a Silver Award from the national Extracorporeal Life Support Organization for excellent outcomes. The award spans 2018 through 2021. Dr. Schlott also leads the continuous renal replacement therapy (CRRT) program. This collaboration with Neonatology, Nephrology, Hepatology, and Pediatric Surgery continues its efforts to expand the services available to a growing population of neonates and infants that might benefit from CRRT. Lastly, Dr. Schlott continues as a champion of sepsis care, including acting as the clinical expert for Connecticut Children’s in the Children’s Hospital Association’s “Improving Pediatric Sepsis Outcomes” Collaborative, which has achieved a 30 percent increase in timely sepsis recognition, a 6 percent decrease in hospital days per sepsis episode, and a 19 percent decrease in sepsis mortality.

Kenneth Banasiak, MD, continues to lead as the medical director of cardiac critical care with a multidisciplinary collaboration with Cardiology and Cardiothoracic Surgery to standardize the care of postoperative patients, resulting in improved inter-service communications, patient safety, staff competency, and patient outcomes. Our benchmarked cardiac surgery outcomes are superb and either exceed or match that of larger cardiac intensive care programs. Dr. Banasiak also created and implemented a continuing education curriculum on “Applied Critical Care Physiology,” which focuses primarily on the education of residents who intend to go on to careers in acute care subspecialties. He is revamping this program to provide this education virtually, which will allow for expansion beyond Connecticut Children’s.

Daniel Fisher, MD, in collaboration with the Simulation Center, continues to oversee the interdisciplinary educational program with focus on in-hospital resuscitation of patients in emergency situations. Using a high-fidelity simulation manikin, care team learners are presented with a patient in a life-threatening scenario and are called upon to resuscitate the patient. Sessions focus on medical decision-making, critical task completion, and interdisciplinary communication during high risk situations. This program has elevated the quality of care provided. Dr. Fisher also continues to chair the Medication Safety Management Committee, which evaluates the safety of the institution’s medications practices and works to decrease medical errors. In addition, he continues his participation in the refinement of the hospital’s comprehensive electronic medical record. All of these activities have huge impacts on the quality and safety of patient care and translate to improved outcomes.

Leonard Comeau, MD, continues his activities to improve the comfort and quality of care for our patients, both in the PICU and hospital-wide. He participates in care delivered by the Sedation Service, and also serves as the leader of the quality and safety oversight activities of the Sedation and Analgesia Committee. He also serves as the chair of the hospital Clinical Ethics Committee, which addresses issues related to the appropriateness and decision-making regarding health care for some of our most complicated patients. In addition, Dr. Comeau leads Schwartz Rounds, a series of discussions for all Connecticut Children’s staff where they can openly and honestly discuss the social and emotional dimensions of providing patient care. The goal is to foster empathy, collaboration, and compassionate support for the self and others, including our patients, their families, and all members of the health care team.

Allison Cowl, MD, serves as a member of the steering committee of the Pediatric NetWork for the American College of Chest Physicians. She continues her clinical research collaborations with the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) international network, focusing on various aspects of the care of critically ill patients and is a key site director for these multi-institutional research collaboratives. She participates in clinical research protocols evaluating platelet transfusion algorithms as well as early mobilization practices in the PICU. Dr. Cowl serves as the site PI in a large international trial that is evaluating ventilation strategies, as well as the use of prone positioning, in the treatment of patients with severe acute respiratory failure. In addition, Dr. Cowl has implemented a new care paradigm for all patients within the PICU with an eye on ensuring the best possible functional outcome for our patients and minimizing post-intensive care syndrome. As leader of our comprehensive multidisciplinary program (“BLOOM”), she is working with the care team to develop the expertise to minimize, recognize and manage delirium, promote early mobilization of patients, and liberate them as early as possible from mechanical ventilation support. In addition, Dr. Cowl serves as the core faculty leader for student, resident, and fellow education in the PICU. She has mentored many residents in clinical studies; specifically, the role of ECMO in the treatment of asthma, the utilization of two modes of non-invasive pressurized respiratory support devices for treatment of patients with bronchiolitis, and the feasibility of providing enteral nutrition.

Rosanne Salonia, MD, continues her work in improving the quality of care and safety for children with acute deterioration and in reducing the incidence of hospital acquired conditions. Specifically, she continues her work as a member of the Emergency Response Committee, which oversees the use of the Pediatric Early Warning Score system (PEWS/MET) in focusing attention on patients at risk for clinical deterioration. She manages the associated database and coordinates the ongoing evaluation of the MET data. She is also co-leader of the Code Blue Committee, reviewing activations across the institution with a multidisciplinary team to improve patient outcomes and system-related issues. She continues her clinical research collaboration with the Pediatric Neuro-critical Care Research Group (PNCRG), which addresses various aspects of care of patients with severe brain injuries (such as management of sedation and delirium and most recently Covidrelated neurologic complications). She is involved in a collaboration with the National Children’s Hospitals’ Solutions for Patient Safety group, which works to eliminate serious safety events in children’s hospitals with specific work focused on reducing unplanned extubations. Dr. Salonia also continues her work with the simulation program to improve team communication during high-risk clinical scenarios.

Robert Parker, DO, is interested in medical simulation and education. He has presented and lectured internationally and brings this expertise to Connecticut Children’s. His research is focused on clinician stress and burnout. Using wearable technology, he is able to capture data about how a clinician’s body responds to stressful situations. With these biometrics, he can gain a better understanding of provider stress and educate the medical team about potential ways to offload it and increase personal wellness, which can also improve patient care and clinical outcomes.

The year 2020 marked the retirement of Aaron Zucker, MD, FCCM. Connecticut Children’s, in general, and the PICU, in particular, are indebted to him for leadership for over a decade. Dr. Zucker leaves a legacy of critical care growth and excellence. In October 2020, Connecticut Children’s welcomed Elliot Melendez, MD, as the new head of the division of critical care. He grew up in the Bronx and though his early education was characterized by being a high school dropout, he was able, through mentorship and determination, to obtain his high school equivalency diploma and attend the City of New York, Lehman College. He went on to graduate cum laude from Harvard Medical School. He did his General Pediatrics residency and Pediatric Emergency Medicine fellowship at Boston Children’s Hospital, and a Pediatric Critical Care fellowship at the Massachusetts General Hospital. His career focus has been on quality improvement, specifically in the field of pediatric severe sepsis and shock. He was a member of the national executive advisory committee of the Children’s Hospital Association, which eventually created the Improving Pediatric Sepsis Outcomes collaborative. His vision for the department is one that fosters and maintains a model of continuous improvement, which puts our patients and families in the center of all conversations.

PUBLICATIONS

Acquaviva K, Mugele J, Abadilla N, Adamson T, Bernstein SL, Bhayani RK, Büchi AE, Burbage D, Carroll CL, et al. Documenting social media engagement as scholarship: a new model for assessing academic accomplishment for the health professions. J Med Internet Res. 2020; 22(12): e25070.

Kaul V, Szakmany T, Peters JI, Stukus D, Sala KA, Dangayach N, Simpson SQ, Carroll CL. Quality of the discussion of asthma on Twitter. J Asthma. 2020. doi: 10.1080/02770903.2020.1847933.

Carroll CL, Szakmany T, Dangayach NS, DePriest A, Duprey MS, Kaul V, Kleinpell R, Tegtmeyer K, Kudchadkar SR. Growth of the digital footprint of the Society of Critical Care Medicine Annual Congress. Crit Care Explor. 2020; 2(11): e0252.

López-Fernández YM, Smith LS, Kohne JG, Weinman JP, Modesto-Alapont V, Reyes-Dominguez SB, Medina A, Piñeres-Olave BE, Mahieu N, Klein MJ, Flori HR, Jouvet P, Khemani RG for the Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) Investigators. Prognostic relevance and inter-observer reliability of chest-imaging in pediatric ARDS: a pediatric acute respiratory distress incidence and epidemiology (PARDIE) study. Int Care Med. 2020; 46(7):1382-1393.

Weiss SL, Peters MJ, Agus MSD, Alhazzani W, Choong K, Flori HR, Inwald DP, Nadel S, Nunnally MR, Schlapbach LJ, Tasker RC, Tissieres P, Kissoon N on behalf of the Children’s Surviving Sepsis Campaign Taskforce. Perspective of the surviving sepsis campaign on the management of pediatric sepsis in the era of coronavirus disease 2019. Pediatr Crit Care Med. 2020; 21(11): e1031-e1037.

Corsello D, Gotur DB, Masud FN, Carroll CL, Simpson SQ. Impact of small-n studies in the face of a pandemic. Chest. 2020;158(4):1338-1340. Siuba MT, Carroll CL, Farkas JD, Olusanya S, Baker K, Gaijic O. The Zentensivist manifesto: defining the art of critical care. ATS Scholar 2020; 1(3):225-232.

Gallo de Moraes A, Carroll CL, Schmidt GA, Pendleton KM. All that glitters isn’t gold: critical care in the time of Covid. Chest. 2020;158(3):877-878.

Carroll CL. Not just little ARDS? Pediatric critical care and biomarkers for pediatric acute respiratory distress syndrome. Chest. 2020; 158(3):850-851.

Kudchadkar SR, Carroll CL. Utilizing social media for rapid knowledge dissemination in a pandemic: #PedsICU and Covid-19. Pediatr Crit Care Med. 2020; 21(8):e538-546.

Feldshein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MBF, Newburger JW, Kleinman LC, Heidimann SM, Marton AA, Singh AR, Li S, Tarquinio KM, Jaggi P, Oster M, Zackai SP, Ratner AJ, Walsh RF, Fitzgerald JC, Keenaghan MA, Alharash H, Doymaz S, Clouser KN, Giuliano JS, Gupta A, Parker RM, Maddux AB, Havalad V, Ramsingh A, Bukulmez H, Bradford TT, Smith LS, Tenforde MW, Carroll CL, Riggs BJ. Getz SJ, Daube A, Lansell A, Munoz AC, Hobbs CV, Marohn KL, Halasa NB, Patel MM, Randoplf AG for the Overcoming Covid-19 Investigators. Multisystem inflammatory syndrome in United States children and adolescents. N Engl J Med. 2020; 383:334-346.

Camporesi A, Díaz-Rubio F, Carroll CL, GonzálezDambrauskas S. Protecting children from iatrogenic harm during Covid-19 pandemic. J Paediatr Child Health. 2020; 56(7):1010–1012.

Baker AK, Carroll CL, Grindle C, Sala KA, Cowl AS. Assessing frequency of respiratory complications in children undergoing adenotonsillectomy. Pediatr Crit Care Med. 2020; 21(7):e426-430.

Carroll CL. SCAMP-ering toward improved quality of care in children with status asthmaticus. Pediatr Crit Care Med. 2020; 21(5):499-500. Hymel KP, Lee G, Boos S, Karst WA, Sirotnak A, Haney SB, Laskey A, Wang M for the PediBIRN lnvestigators. Estimating the relevance of historical red flags in the diagnosis of abusive head trauma. J Pediatr. 2020; 218:178-183.

Sneller H, Carroll CL, Welch K, Sturm J. Differentiating non-responders from responders in children with moderate and severe asthma exacerbations. J Asthma. 2020; 57(4):405-409.

Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, et al, (Carroll CL, 14/51). Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med. 2020; 21(2): e52-106.

Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, et al. (Carroll CL, 14/51). Executive summary: surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med. 2020;21(2):186-195.

Carroll CL, Kaul V, Sala KA, Dangayach NS. Describing the digital footprints or “sociomes” of asthma for stakeholder groups on Twitter. ATS Scholar. 2020; 1(1):55-66.

Dahmer MK, Flori H, Sapru A, Kohne J, Weeks HM, Curley MAQ, Matthay MA, Quasney MW, Bateman ST, Berg MD, Borasino S, Bysani GK, Cowl AS, et al. Surfactant protein D is associated with severe pediatric ARDS, prolonged ventilation, and death in children with acute respiratory failure. Chest. 2020; 158(3);1027-1035.

Kudchadkar SR, Nelliot A, Awojoodu R, Vaidya D, Traube C, Walker T, Needham DM, for the Prevalence of Acute Rehabilitation for Kids in the PICU (PARKPICU) Investigators and the Pediatric Acute Lung Injury and Sepsis Investigators (PALASI) Network. Physical rehabilitation in critically ill children: a multicenter point

prevalence study in the United States. Crit Care Med. 2020 May;48(5): 634-644.

Baker AK, Carroll CL, Grindle CR, Sala KA, Cowl AS. Assessing frequency of respiratory complications in children undergoing adenotonsillectomy. Ped Crit Care Med. 2020 Jul;21(7):e-426-e430.

Creedon JK, Vargas S, Asaro LA, Wypij D, Paul R, Melendez E. Timing of antibiotic administration in pediatric sepsis. Pediatr Emer Care. 2020 Oct;36(10):464-467.

Melendez E, Dwyer D, Donelly D, Currier D, Nachreiner D, Miller DM, Hurlbut J, Pepin MJ, Agus MSD, Wong J. Standardized protocol is associated with a decrease in continuous albuterol use and length of stay in critical status asthmaticus. Pediatr Crit Care Med. 2020 May;21(5):451-460. doi: 10.1097/ PCC.0000000000002239.

Baiu I, Melendez E. Periorbital and orbital cellulitis. JAMA. 2020; 323(2):196. doi:10.1001/ jama.2019.18211.

STAFF

Elliot Melendez, MD, Division Chief Kenneth Banasiak, MD Christopher Carroll, MD Leonard Comeau, MD Allison Cowl, MD Daniel Fisher, MD Robert Parker, DO Rosanne Salonia, MD Heather Schlott, MD Adam Silverman, MD

Petronella Stoltz, APRN