We cannot solve our problems with the same thinking we used when we created them. – Albert Einstein

The practice of pediatric cardiac critical care has undergone incredible advances over the past 50 years (1), with an evolution that has come through the constant seeking of scientific and medical truth (2). These efforts have improved clinical practice across the entire spectrum of congenital heart lesions. Along with innovations in support strategies for acute cardiogenic shock and proven neurologic protection during and after surgery using cardiopulmonary bypass, there has been a decrease in overall mortality and morbidity. As a result, many children who previously would not have even been offered cardiac surgical and medical interventions are now expected to have a good outcome. This practice, however, does lead to seeing a new population of patients who are at risk of adverse events, more so than ever before, and it establishes a work cycle of improving quality of care within the specialty. That is, advancements demand even more advancement. Each iteration in progress reinforces the need for: 1) continued high quality research in our field, 2) translation of new knowledge into education and training, and 3) ongoing professional and organizational development to ensure excellence in patient care (3–5).

In this context, cardiac critical care clinical research constantly needs to focus on new ideas, quality improvement, education, and sustainability. Maintaining these core research priorities will overcome uncertainties in therapies for our patients. As a journal dedicated to the field, Pediatric Critical Care Medicine (PCCM) has established itself as a premier source of literature for all these focus areas. This month–and for the first time ever in PCCM’s 24-year history–we are privileged in being able to present a whole issue focused on cardiac critical care topics. Of course, all the content is worthy of your time, but here are two themes of linked articles that will be a good place to start your reading.

THEME 1: CLINICAL CARDIAC PHARMACOLOGY AND PHYSIOLOGY

In the PCCM Trials section there is a report about acute hemodynamics in the Fontan circulation during an open-label study of vasopressin (6). This report has an accompanying editorial (7). Unlike our usual editorials this one is extended and contains illustrative physiology using the cardiovascular system (CVS) simulator of pressure volume loops. Third, in case you missed the June 2022 PCCM Concise Clinical Physiology Review on the CVS in severe sepsis (8), the same authors now present another installment about the CVS in cardiogenic shock (9).

In conjunction, these three articles demonstrate a core spectrum of clinical intervention, observation, and physiology. PCCM will continue to bring connected material to the field because such articles support our understanding of perioperative cardiac care and give us evidence that will question habits or institutional bias.

THEME 2: AIRWAY MANAGEMENT THROUGH THE LENS OF COHORT REVIEW AND EPIDEMIOLOGY

How we manage the patient’s airway during pediatric cardiac intensive care is central to perioperative practice. Three reports in this issue of PCCM provide a range of experiences about short- and long-term airway care. First, a single-center, retrospective study of failed extubation in neonates after cardiac surgery, between 2015 and 2018 (10), which adds more detailed information to what we learned about unplanned extubation from the Pediatric Cardiac Critical Care Consortium (PC4) dataset (11), and about time to extubation in postoperative cardiac patients in the Virtual Pediatric Systems (VPS) database (12). Two other reports this month focus on airway management with tracheostomy. There is a Pediatric Health Information System (PHIS) dataset report of tracheostomy and gastrostomy in infants undergoing truncus arteriosus repair, 2004−2019 (13). There is also a single-center, retrospective report of cardiac intensive care patients undergoing tracheostomy, 2011−2020 (14). These data–along with what we recently learned about tracheostomy timing in pulmonary hypertension (15,16)–broadly cover the most contemporary information about this topic. These are a must-read.

This collection of articles with a focus on airway management also illustrates the usefulness of broad picture database epidemiology (e.g., PC4, VPS, and PHIS) alongside single-center detailed review. PCCM remains committed to such approaches from our cardiac intensive care community. However, as we seek to improve post-critical illness outcomes, we should now be asking “what follows next?” and “how do we improve patient safety?” Some answers can be found in this month’s Special Article about the new field of Implementation Science (17). This item is a practical position paper and call to action by the Excellence in Pediatric Implementation Science (ECLIPSE) group of the Pediatric Acute Lung Injury and Sepsis Investigators network (18).

PCCM AND THE NEXT ERA OF CARDIAC INTENSIVE CARE RESEARCH

Findings such as these two themes covered in this month’s issue of PCCM allow us to reflect on who we are as a specialty and, importantly, how we will support the development of the next generation of practitioners. Ultimately, we must provide the data necessary to maintain our academic and clinical service mission. The journal has an important role in this entire endeavor. It serves as the academic home for meaningful results from important questions. However, we must also demand more of ourselves. The quality of evidence must continue to improve. To paraphrase the Einstein quote that headlines this Foreword, we cannot solve the next generation of problems with last generation of thinking.

Therefore, PCCM has had to change with the times. We have adapted to the increased volume of competitive research submissions and, by necessity, developed a more stringent acceptance rate of 7% to 11% (19,20). Our readers demand structure to the academic clinical writing that they are presented, and the journal has responded with detailed outlines for authors (21,22), as well as a new approach to engaging with citations to references in the Chatbot Generative Pre-Trained Transformer era (23). Finally, we have also had to prepare for the future with a robust system of high-quality, peer review that–ultimately–is there to elevate the quality of our research efforts and the quality of reading material. To this end, in the September 2023 issue of Critical Care Medicine you will find material about the “Reviewer Academy” of the Society of Critical Care Medicine (24).

In conclusion, pediatric cardiac critical care has made, and continues to make, significant strides in advancing the clinical research needed for patient care. The future outcomes of children with critical cardiac disease will require us to challenge and build on our past research successes. We must ask ourselves the more difficult questions that will make marked improvements in our care. This November 2023 issue of PCCM is devoted to cardiac critical care topics; it is a start, so let’s work to establish this development as a regular feature for our community.

REFERENCES 1. Checchia PA, Brown KL, Wernovsky G, et al.: The evolution of pediatric cardiac critical care. Crit Care Med. 2021; 49:545–557 2. Checchia PA: The ongoing evolution of the truth. Pediatr Crit Care Med. 2018; 19:584–585 3. Werho DK, DeWitt AG, Owens ST, et al.: Establishing entrustable professional activities in pediatric cardiac critical care. Pediatr Crit Care Med. 2022; 23:54–59 4. Tabbutt S, Krawczeski C, McBride M, et al.: Standardized training for physicians practicing pediatric cardiac critical care. Pediatr Crit Care Med. 2022; 23:60–64 5. Checchia PA: It is time to raise the bar with a board. Pediatr Crit Care Med. 2022; 23:74–75 6. Adamson GT, Yu J, Ramamoorthy C, et al.: Acute hemodynamics in the Fontan circulation: Open-label study of vasopressin. Pediatr Crit Care Med. 2023; 24:952–960 7. Ahmed M, Bronicki RA: The Fontan circulation holds water: The impact of arginine vasopressin on the Fontan circulation. Pediatr Crit Care Med. 2023; 24:972–974 8. Bronicki RA, Tume SC, Flores S, et al.: The cardiovascular system in severe sepsis: Insight from a cardiovascular simulator. Pediatr Crit Care Med. 2022; 23:464–472 9. Bronicki RA, Tume SC, Flores S, et al.: The cardiovascular system in cardiogenic shock: Insight from a cardiovascular simulator. Pediatr Crit Care Med. 2023; 24:937–942 10. Wilson HC, Gunsaulus ME, Owens GE, et al.: Failed extubation in neonates after cardiac surgery: A single-center, retrospective study. Pediatr Crit Care Med. 2023; 24:e547–e555 11. Perry T, Klugman D, Schumacher K, et al.: Unplanned extubation during pediatric cardiac intensive care: US multicenter registry study of prevalence and outcomes. Pediatr Crit Care Med. 2023; 24:551–562 12. Epstein R, Ohliger SJ, Cheifetz IM, et al.: Trends in time to extuabtion for pediatric postoperative cardiac patients and its correlation with changes in clinical outcomes: A virtual PICU database study. Pediatr Crit Care Med. 2022; 23:544–554 13. Hook JE, Delany DR, Buckley JR, et al.: Outcomes of gastrostomy and tracheostomy in infants undergoing truncus arteriosus repair: database study using the Pediatric Health Information System. Pediatr Crit Care Med. 2023; 24:e540–e546 14. Fox MT, Meyer-Macaulay C, Roberts H, et al.: Tracheostomy timing during pediatric cardiac intensive care: Single referral center retrospective cohort. Pediatr Crit Care Med. 2023; 24:e556–e567 15. Perez JM, Melvin PR, Berry JG, et al.: Outcomes for children with pulmonary hypertension undergoing tracheostomy placement: A multi-institutional analysis. Pediatr Crit Care Med. 2022; 23:717–726 16. Villafranco N, Chartan C, Varghese NP, et al.: Tracheostomy in pulmonary hypertension: Not for the faint of heart. Pediatr Crit Care Med. 2022; 23:754–756 17. Woods-Hill CZ, Wolfe H, Malone S, et al.; Excellence in Pediatric Implementation Science (ECLIPSE) for the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Implementation science research in pediatric critical care medicine. Pediatr Crit Care Med. 2023; 24:943–951 18. Randolph AG, Bembea MM, Cheifetz IM, et al.; Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Pediatric Acute Lung Injury and Sepsis Investigators (PALISI): Evolution of an investigator-initiated research network. Pediatr Crit Care Med. 2022; 23:1056–1066 19. Tasker RC: 2021 in review. Pediatr Crit Care Med. 2021; 22:1009–1010 20. Tasker RC: 2022 in review. Pediatr Crit Care Med. 2022; 23:961–963 21. Tasker RC: Writing for PCCM: The 3,000-word structured clinical research report. Pediatr Crit Care Med. 2021; 22:312–317 22. Tasker RC: Writing for PCCM: Instructions for authors. Pediatr Crit Care Med. 2022; 23:651–655 23. Tasker RC: Writing for Pediatric Critical Care Medicine: Engaging with citations to references in the Chatbot generative pre-trained transformer era. Pediatr Crit Care Med. 2023; 24:890–892 24. Alexander PMA, Aslakson RA, Barreto EF, et al.: The reviewer academy of the Society of Critical Care Medicine: Key principles and strategic plan. Crit Care Med. 2023; 51:1111–1123