Caring for Critically Ill Adults in PICUs Is Not “Child’s Play”*

Pediatric Critical Care Medicine www.pccmjournal.org 679 In 2011, we led the Pediatric Emergency Mass Critical Care Task Force (1) which recommended that hospitals which provide care exclusively to adults be prepared to provide care for pediatric patients in a pandemic or disaster which impacts children proportionally to adults. In the 2014 Task Force for Mass Critical Care (2), we highlighted the need for a systems-level approach for the provision of critical care in pandemics or disasters where pediatric patients are not considered a “special population” but rather are entitled to an equitable share of critical care resources. These recommendations were driven by the significant lower critical care capacity for pediatric patients within the population compared to that of adults. Although these recommendations remain valid today, we did not envision a pandemic, such as the coronavirus disease 2019 (COVID-19), which so disproportionately affect adults that pediatric intensive care clinicians are being asked to accommodate critically ill adults in their ICUs (3). In this issue of Pediatric Critical Care Medicine, Remy et al (4) comprised dual trained adult and pediatric intensive care physicians provide timely advice primarily aimed at pediatric intensive care physicians regarding key differences in the medical management of critically ill adults. This practical information is timely and much needed by pediatric intensivist caring for adults suffering from COVID-19. However, effective and safe care can only be delivered if a structured framework in place as an enabler. Thus, thoughtful preparation beyond the information provided by Remy et al (4) is necessary to prepare pediatric units to care for adult patients. Issues of ethics, justice, and societal considerations are important in determining whether pediatric critical care beds should be made available for adults. It is widely accepted that there are finite critical care resources and the process to allocate these resources ethically must include considerations of equity of all patients in need (5–7). However, there is very limited practical guidance to assist providers facing the ethical challenges of considering both adults and pediatric patients together vying for a single pool of resources (8). Although there is certainly a strong basis to argue that allowing adults to die while ventilators sit unused in a PICU is unethical, healthcare systems must have a process in place for making decisions regarding the allocation of critical care resources that can address the ethical and medical complexities of allocating resources that takes into account the differences within and between these populations (9). Caring for COVID-19–infected adults in ICUs at pediatric hospitals (which do not normally care for adults) should be considered equivalent to providing adult critical care in an alternate care facility. Commensurate with published recommendations (2, 10–12), this should only occur during a crisis surge response after the strategies for conventional and contingency responses (2, 13), including maximally expanding critical care capacity within adult hospitals such as recruiting pediatric critical care staff and expertise to adult units. In order to successfully provide the care outlined by Remy et al (4) to adults in a pediatric hospital, the enablers of care such as staff, “stuff,” space, and systems must be arranged a priori. Successful delivery of care also depends on a robust “3Cs” (command, control, and communication) system (2, 11, 14).