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Caring for Critically Ill Children

NEW YORK (May 1, 2013)

"Isn't caring for the very sick children in the pediatric critical care unit terribly depressing?" people ask Steven Kernie, M.D. Since the kids he and his colleagues care for in the intensive care unit usually have really good outcomes with really productive lives ahead of them, his answer is, "Not at all." And he should know: He has headed up Critical Care Division at NewYork-Presbyterian/Morgan Stanley Children's Hospital for the past year after a 20-year career as a pediatric critical care specialist in Texas.

Steven Kernie, M.D.
Steven Kernie, M.D.

"The mortality rate in pediatric critical care is quite low," he adds, "under 5 percent in general and in our unit it's just 2 to 3 percent, compared to 15 to 20 percent on an adult unit."

Kids end up in the ICU for a variety of reasons: problems arising from congenital heart disease, organ transplantation, spine surgery, pneumonia, asthma, seizures, meningitis, or encephalitis. "In addition, probably about half of the kids in the ICU have some neurologic issue that's going to impair how they recover from their underlying disease, and up to a quarter of them have a primary brain injury, meaning that's the reason they're in the ICU," says Dr. Kernie, who is Associate Professor of Pediatrics, Pathology and Cell Biology and Director, Pediatric Critical Care Medicine. Because improvements in the care of brain injuries could help a lot of children in ICU Dr. Kernie has directed his basic science research at understanding how the brain recovers after an injury.

"Twenty years ago we didn't really know what was going on in brain injuries and we could only offer supportive care," he says, which consisted of providing nutrition and maintaining normal oxygen and blood pressure. But neuroscientists have learned more about the brain since then. "During my training in a neuroscience lab I got interested in a very particular part of the mouse brain, the hippocampus, where memory and learning reside," Dr. Kernie says. "It has a population of stem cells that regenerate throughout life, and we've learned that the human brain also has this population of cells. People with brain injuries recover spontaneously, and we determined that if we could learn how the brain self-recovers we should be able to manipulate the process and make it more robust."

Research by Dr. Kernie and colleagues has showed that some of that self-recovery happens because neural stem cells in the hippocampus can regenerate neurons, and he is now working on ways to enhance that response, he says. FDA-approved drugs, including antidepressants and the diabetes drug metformin, are known to enhance neurogenesis. "Antidepressants rev up the stem cell population in animals, and metformin has been shown to increase neurogenesis and to make the animal smarter," says Dr. Kernie. "I think we know enough about how some of the self-repair occurs that we can start testing various drugs in our animal models."

In addition to the basic science research he conducts in his lab, Dr. Kernie's job as division chief includes patient care and administrative duties in the academic division. As an administrator Dr. Kernie is charged with ensuring that the three distinct pediatric ICUs all run smoothly and provide great care, and that all of the subspecialists involved in a child's care communicate well with each other.

"Intensivists are a little bit like air traffic controllers," he says. "The kids in the ICU are really sick and they always have a number of medical subspecialists and surgeons helping take care of them. Ultimately we're the ones who are responsible for coordinating all of the aspects of their care. So overseeing that is a major piece of what I do." Dr. Kernie is helped in this job by Arthur J. Smerling, M.D., Medical Director of the Cardiac Unit, and Katherine V. Biagas, M.D., who directs the other two mixed medical/surgical units, which each have 5 to 14 patients on any given day.

Another part of Dr. Kernie's job is managing the division's educational program that includes medical students, residents, and nine pediatric critical care fellows. "We've got far and away the most robust pediatric critical care fellowship program in the New York area, and one of the most robust in the country. I've been extremely impressed by the quality of the fellows and the depth of number of applicants we get for very few positions – it's really pretty spectacular," he says. Fellows are there to learn, but because they are fairly far along in their careers and have a fair amount of experience, "they can add a lot to helping how the patients are cared for providing novel perspectives and challenging us about our managements styles and things like that," Dr. Kernie adds. "It's a two-way street."

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