1
|
Younger DS. Critical illness-associated weakness and related motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:707-777. [PMID: 37562893 DOI: 10.1016/b978-0-323-98818-6.00031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.
Collapse
Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
| |
Collapse
|
2
|
Outcomes and impact of multidisciplinary team care on immunologic and hemato-oncologic pediatric patients. Allergol Immunopathol (Madr) 2023; 51:154-158. [PMID: 36617835 DOI: 10.15586/aei.v51i1.627] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/15/2022] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Immunologic and hemato-oncologic disorders in the pediatric population represent an interrelated and complex group of conditions whose approach, diagnosis, and management could be difficult. Multidisciplinary teams have been proved beneficial in treating such complexities. METHODS We conducted a retrospective observational study at a tertiary hospital in Madrid, Spain, which is a pediatric immunology and onco-hematology referral center. We included all patients of multidisciplinary outpatient consultation, comprising a working group of pediatric oncohematologists and immunologists, between April 2016 and December 2019. Epidemiologic, clinical, and laboratory data were collected. We analyzed these data and established a relationship between age and findings of final diagnosis as well as variance on diagnoses prior to their multidisciplinary assessment and number of visits to the consultation. RESULTS In all, 93 children and adolescents were included in this study. Laboratory abnormalities were the most frequent reason for being referred to our unit (87.2%); 78% of children had a previously diagnosed comorbidity. Before starting follow-up in the multidisciplinary consultation, 14% of patients were diagnosed, and after the study by the multidisciplinary team, the final diagnosis was reached in 58.1% of patients. No correlation was discovered between final diagnosis and gender (P = 0.29), age (biserial correlation coefficient, r = 0.036, P = 0.70), and number of visits (P = 0.07). CONCLUSION A multidisciplinary approach to immunologic, hematologic, and oncologic pediatric diseases is feasible. It can be a powerful and useful tool for diagnosis and treatment, especially in complex pediatric patients.
Collapse
|
3
|
Abstract
Brain injury in children is a major public health problem, causing substantial morbidity and mortality. Cause of pediatric brain injury varies widely and can be from a primary neurologic cause or as a sequela of multisystem illness. This review discusses the emerging field of pediatric neurocritical care (PNCC), including current techniques of imaging, treatment, and monitoring. Future directions of PNCC include further expansion of evidence-based practice guidelines and establishment of multidisciplinary PNCC services within institutions.
Collapse
Affiliation(s)
- Ajit A Sarnaik
- Central Michigan University College of Medicine, Carls Building, Pediatric Critical Care, Children's Hospital of Michigan, 3901 Beaubien Avenue, Detroit, MI 48201, USA.
| |
Collapse
|
4
|
Madurga-Revilla P, López-Pisón J, Samper-Villagrasa P, Garcés-Gómez R, García-Íñiguez JP, Domínguez-Cajal M, Gil-Hernández I, Viscor-Zárate S. Functional assessment of a series of paediatric patients receiving neurointensive treatment: New Functional status scale. Neurologia 2020; 35:311-317. [PMID: 29102527 DOI: 10.1016/j.nrl.2017.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 08/12/2017] [Accepted: 08/16/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Functional health, a reliable parameter of the impact of disease, should be used systematically to assess prognosis in paediatric intensive care units (PICU). Developing scales for the assessment of functional health is therefore essential. The Paediatric Overall and Cerebral Performance Category (POPC, PCPC) scales have traditionally been used in paediatric studies. The new Functional Status Scale (FSS) was designed to provide more objective results. This study aims to confirm the validity of the FSS compared to the classic POPC and PCPC scales, and to evaluate whether it may also be superior to the latter in assessing of neurological function. PATIENTS AND METHOD We conducted a retrospective descriptive study of 266 children with neurological diseases admitted to intensive care between 2012 and 2014. Functional health at discharge and at one year after discharge was evaluated using the PCPC and POPC scales and the new FSS. RESULTS Global FSS scores were found to be well correlated with all POPC scores (P<.001), except in category 5 (coma/vegetative state). Global FSS score dispersion increases with POPC category. The neurological versions of both scales show a similar correlation. DISCUSSION Comparison with classic POPC and PCPC categories suggests that the new FSS scale is a useful method for evaluating functional health in our setting. The dispersion of FSS values underlines the poor accuracy of POPC-PCPC compared to the new FSS scale, which is more disaggregated and objective.
Collapse
Affiliation(s)
- P Madurga-Revilla
- UCI Pediátrica, Hospital Infantil Universitario Miguel Servet, Zaragoza, España.
| | - J López-Pisón
- Unidad de Neurometabolismo, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - P Samper-Villagrasa
- Servicio de Pediatría, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - R Garcés-Gómez
- Unidad de Urgencias Pediátricas, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - J P García-Íñiguez
- UCI Pediátrica, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - M Domínguez-Cajal
- UCI Pediátrica, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - I Gil-Hernández
- UCI Pediátrica, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - S Viscor-Zárate
- Pediatría de Atención Primaria, Centro de Atención Primaria, Tudela, Navarra, España
| |
Collapse
|
5
|
Functional progression of patients with neurological diseases in a tertiary paediatric intensive care unit: our experience. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2017.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
6
|
Madurga-Revilla P, López-Pisón J, Samper-Villagrasa P, Garcés-Gómez R, García-Íñiguez J, Domínguez-Cajal M, Gil-Hernández I, Viscor-Zárate S. Functional assessment of a series of paediatric patients receiving neurointensive treatment: the new Functional Status Scale. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2017.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
7
|
Big problems in little patients: Nationwide blunt cerebrovascular injury outcomes in the pediatric population. J Trauma Acute Care Surg 2019; 87:1088-1095. [DOI: 10.1097/ta.0000000000002428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
8
|
Howard SW, Zhang Z, Buchanan P, Bernell SL, Williams C, Pearson L, Huetsch M, Gill J, Pineda JA. The cost of a pediatric neurocritical care program for traumatic brain injury: a retrospective cohort study. BMC Health Serv Res 2018; 18:20. [PMID: 29329548 PMCID: PMC5766987 DOI: 10.1186/s12913-017-2768-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 11/24/2017] [Indexed: 12/20/2022] Open
Abstract
Background Inpatient care for children with severe traumatic brain injury (sTBI) is expensive, with inpatient charges averaging over $70,000 per case (Hospital Inpatient, Children Only, National Statistics. Diagnoses– clinical classification software (CCS) principal diagnosis category 85 coma, stupor, and brain damage, and 233 intracranial injury. Diagnoses by Aggregate charges [https://hcupnet.ahrq.gov/#setup]). This ranks sTBI in the top quartile of pediatric conditions with the greatest inpatient costs (Hospital Inpatient, Children Only, National Statistics. Diagnoses– clinical classification software (CCS) principal diagnosis category 85 coma, stupor, and brain damage, and 233 intracranial injury. Diagnoses by Aggregate charges [https://hcupnet.ahrq.gov/#setup]). The Brain Trauma Foundation developed sTBI intensive care guidelines in 2003, with revisions in 2012 (Kochanek, Carney, et. al. PCCM 3:S1-S2, 2012). These guidelines have been widely disseminated, and are associated with improved health outcomes (Pineda, Leonard. et. al. LN 12:45-52, 2013), yet research on the cost of associated hospital care is limited. The objective of this study was to assess the costs of providing hospital care to sTBI patients through a guideline-based Pediatric Neurocritical Care Program (PNCP) implemented at St. Louis Children’s Hospital, a pediatric academic medical center in the Midwest United States. Methods This is a retrospective cohort study. We used multi-level regression to estimate pre−/post−implementation effects of the PNCP program on inflation adjusted total cost of in-hospital sTBI care. The study population included 58 pediatric patient discharges in the pre-PNCP implementation group (July 15, 1999 - September 17, 2005), and 59 post-implementation patient discharges (September 18, 2005 - January 15, 2012). Results Implementation of the PNCP was associated with a non-significant difference in the cost of care between the pre- and post-implementation periods (eβ = 1.028, p = 0.687). Conclusions Implementation of the PNCP to support delivery of guideline-based care for children with sTBI did not change the total per-patient cost of in-hospital care. A key strength of this study was its use of hospital cost data rather than charges. Future research should consider the longitudinal post-hospitalization costs of this approach to sTBI care.
Collapse
Affiliation(s)
- Steven W Howard
- Saint Louis University, Health Management and Policy, Salus Center 374, 3545 Lafayette Ave., St. Louis, MO, 63104, USA.
| | - Zidong Zhang
- Saint Louis University, School of Medicine, St. Louis, MO, USA
| | - Paula Buchanan
- Saint Louis University, Center for Outcomes Research, St. Louis, MO, USA
| | - Stephanie L Bernell
- Oregon State University, School of Social and Behavioral Health Sciences, Corvallis, OR, USA
| | | | | | - Michael Huetsch
- Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, MO, USA
| | - Jeff Gill
- Division of Biostatistics, Washington University in St. Louis, School of Medicine, St. Louis, MO, USA.,Department of Government, American University, Washington DC, USA
| | - Jose A Pineda
- Washington University in St. Louis, School of Medicine, St. Louis, MO, USA
| |
Collapse
|
9
|
Madurga Revilla P, López Pisón J, Samper Villagrasa P, García Íñiguez JP, Garcés Gómez R, Domínguez Cajal M, Gil Hernández I. Functional progression of patients with neurological diseases in a tertiary paediatric intensive care unit: Our experience. Neurologia 2017; 35:381-394. [PMID: 29174722 DOI: 10.1016/j.nrl.2017.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 08/12/2017] [Accepted: 09/08/2017] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Neurological diseases explain a considerable proportion of admissions to paediatric intensive care units (PICU), and are a significant cause of morbidity and mortality. This study aims to analyse the functional progression of children with critical neurological conditions. MATERIAL AND METHODS Retrospective descriptive study of children admitted to PICU with neurological diseases over a period of 3 years (2012-2014), assessing vital and functional prognosis at PICU discharge and at one year according to the Pediatric Cerebral and Overall Performance Category scales (PCPC-POPC) and the Functional Status Scale (FSS). The results are compared with our previous data (1990-1999), and those of the international multicentre PANGEA study. RESULTS A total of 266 children were studied. The mortality rate was 3%; the PRISM-III and PIM2 models did not show predictive ability. Clinically significant worsening was observed in functional health at discharge in 30% of the sample, according to POPC, 15% according to PCPC, and 5% according to FSS. After one year, functional performance improved according to PCPC-POPC, but not according to FSS. Children with no underlying neurological disease had a higher degree of functional impairment; this was prolonged over time. We observed a decrease in overall and neurocritical mortality compared with our previous data (5.60 vs. 2.1%, P=.0003, and 8.44 vs. 2.63%, P=.0014, respectively). Compared with the PANGEA study, both mortality and cerebral functional impairment in neurocritical children were lower in our study (1.05 vs. 13.32%, P<.0001, and 10.47% vs. 23.79%, P<.0001, respectively). CONCLUSIONS Nearly one-third of critically ill children have neurological diseases. A significant percentage, mainly children without underlying neurological diseases, had a clinically significant functional impact at PICU discharge and after a year. Neuromonitoring and neuroprotection measures and the evaluation of functional progression are necessary to improve critical child care.
Collapse
Affiliation(s)
- P Madurga Revilla
- Unidad de Cuidados Intensivos Pediátrica, Hospital Infantil Universitario Miguel Servet, Zaragoza, España.
| | - J López Pisón
- Unidad de Neurometabolismo, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - P Samper Villagrasa
- Servicio de Pediatría, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J P García Íñiguez
- Unidad de Cuidados Intensivos Pediátrica, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - R Garcés Gómez
- Unidad de Urgencias Pediátricas, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - M Domínguez Cajal
- Unidad de Cuidados Intensivos Pediátrica, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| | - I Gil Hernández
- Unidad de Cuidados Intensivos Pediátrica, Hospital Infantil Universitario Miguel Servet, Zaragoza, España
| |
Collapse
|
10
|
Abstract
BACKGROUND Acute neurological emergencies (ANEs) in children are common life-threatening illnesses and are associated with high mortality and severe neurological disability in survivors, if not recognized early and treated appropriately. We describe our experience of teaching a short, novel course "Pediatric Neurologic Emergency Life Support" to pediatricians and trainees in a resource-limited country. METHODS This course was conducted at 5 academic hospitals from November 2013 to December 2014. It is a hybrid of pediatric advance life support and emergency neurologic life support. This course is designed to increase knowledge and impart practical training on early recognition and timely appropriate treatment in the first hour of children with ANEs. Neuroresuscitation and neuroprotective strategies are key components of this course to prevent and treat secondary injuries. Four cases of ANEs (status epilepticus, nontraumatic coma, raised intracranial pressure, and severe traumatic brain injury) were taught as a case simulation in a stepped-care, protocolized approach based on best clinical practices with emphasis on key points of managements in the first hour. RESULTS Eleven courses were conducted during the study period. One hundred ninety-six physicians including 19 consultants and 171 residents participated in these courses. The mean (SD) score was 65.15 (13.87%). Seventy percent (132) of participants were passed (passing score > 60%). The overall satisfaction rate was 85%. CONCLUSIONS Pediatric Neurologic Emergency Life Support was the first-time delivered educational tool to improve outcome of children with ANEs with good achievement and high satisfaction rate of participants. Large number courses are required for future validation.
Collapse
|
11
|
Abstract
Neonatal neurocritical care is an emerging subspecialty that combines the expertise of critical care medicine and neurology with that of nursing and other providers in an interprofessional team approach to care. Neurocritical care of the neonate has roots in adult and pediatric practice. It has been demonstrated that adults with acute neurologic conditions who are treated in a specialized neurocritical care unit have reduced morbidity and mortality, as well as decreased length of stay, lower costs, and reduced need for neurosurgical procedures. In pediatrics, neurocritical care has focused on various primary and secondary neurologic conditions complicating critical care that also contribute to mortality, morbidity, and duration of hospitalization. However, the concept of neurocritical care as a subspecialty in pediatric practice is still evolving, and evidence demonstrating improved outcomes is lacking. In the neonatal intensive care nursery, neurocritical care is also evolving as a subspecialty concept to address both supportive and preventive care and optimize neurologic outcomes for an at-risk neonatal patient population. To enhance effectiveness of this care approach, nurses must be prepared to appropriately recognize acute changes in neurologic status, implement protocols that specifically address neurologic conditions, and carefully monitor neurologic status to help prevent secondary injury. The complexity of this team approach to brain-focused care has led to the development of a specialized role: the neurocritical care nurse (neonatal intensive care nursery [NICN] nurse). This article will review key concepts related to neonatal neurocritical care and the essential role of nursing. It will also explore the emerging role of the NICN nurse in supporting early recognition and management of at-risk infants in this neonatal subspecialty practice.
Collapse
|
12
|
Abstract
PURPOSE OF REVIEW Approximately one in five children admitted to a pediatric ICU have a new central nervous system injury or a neurological complication of their critical illness. The spectrum of neurologic insults in children is diverse and clinical practice is largely empirical, as few randomized, controlled trials have been reported. This lack of data poses a substantial challenge to the practice of pediatric neurocritical care (PNCC). PNCC has emerged as a novel subspecialty, and its presence is expanding within tertiary care centers. This review highlights the recent advances in the field, with a focus on traumatic brain injury (TBI), cardiac arrest, and stroke as disease models. RECENT FINDINGS Variable approaches to the structure of a PNCC service have been reported, comprising multidisciplinary teams from neurology, critical care, neurosurgery, neuroradiology, and anesthesia. Neurologic morbidity is substantial in critically ill children and the increased use of continuous electroencephalography monitoring has highlighted this burden. Therapeutic hypothermia has not proven effective for treatment of children with severe TBI or out-of-hospital cardiac arrest. However, results of studies of severe TBI suggest that multidisciplinary care in the ICU and adherence to guidelines for care can reduce mortality and improve outcome. SUMMARY There is an unmet need for clinicians with expertise in the practice of brain-directed critical care for children. Although much of the practice of PNCC may remain empiric, a focus on the regionalization of care, creating defined training paths, practice within multidisciplinary teams, protocol-directed care, and improved measures of long-term outcome to quantify the impact of such care can provide evidence to direct the maturation of this field.
Collapse
|
13
|
Dixon RR, Nocera M, Zolotor AJ, Keenan HT. Intracranial Pressure Monitoring in Infants and Young Children With Traumatic Brain Injury. Pediatr Crit Care Med 2016; 17:1064-1072. [PMID: 27632060 PMCID: PMC5257177 DOI: 10.1097/pcc.0000000000000937] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001. DESIGN Prospective, observational cohort study. SETTING Twelve PICUs in North Carolina. PATIENTS All children 24 months old or younger with traumatic brain injury, admitted to an included PICU. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies. CONCLUSION Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old or younger with traumatic brain injury and a need for better evidence to support treatment recommendations for this group of children.
Collapse
Affiliation(s)
- Rebecca R. Dixon
- Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - Maryalice Nocera
- University of North Carolina Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Adam J. Zolotor
- University of North Carolina Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Heather T. Keenan
- Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| |
Collapse
|
14
|
Grinspan ZM, Eldar YC, Gopher D, Gottlieb A, Lammfromm R, Mangat HS, Peleg N, Pon S, Rozenberg I, Schiff ND, Stark DE, Yan P, Pratt H, Kosofsky BE. Guiding Principles for a Pediatric Neurology ICU (neuroPICU) Bedside Multimodal Monitor: Findings from an International Working Group. Appl Clin Inform 2016; 7:380-98. [PMID: 27437048 DOI: 10.4338/aci-2015-12-ra-0177] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 02/29/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Physicians caring for children with serious acute neurologic disease must process overwhelming amounts of physiological and medical information. Strategies to optimize real time display of this information are understudied. OBJECTIVES Our goal was to engage clinical and engineering experts to develop guiding principles for creating a pediatric neurology intensive care unit (neuroPICU) monitor that integrates and displays data from multiple sources in an intuitive and informative manner. METHODS To accomplish this goal, an international group of physicians and engineers communicated regularly for one year. We integrated findings from clinical observations, interviews, a survey, signal processing, and visualization exercises to develop a concept for a neuroPICU display. RESULTS Key conclusions from our efforts include: (1) A neuroPICU display should support (a) rapid review of retrospective time series (i.e. cardiac, pulmonary, and neurologic physiology data), (b) rapidly modifiable formats for viewing that data according to the specialty of the reviewer, and (c) communication of the degree of risk of clinical decline. (2) Specialized visualizations of physiologic parameters can highlight abnormalities in multivariable temporal data. Examples include 3-D stacked spider plots and color coded time series plots. (3) Visual summaries of EEG with spectral tools (i.e. hemispheric asymmetry and median power) can highlight seizures via patient-specific "fingerprints." (4) Intuitive displays should emphasize subsets of physiology and processed EEG data to provide a rapid gestalt of the current status and medical stability of a patient. CONCLUSIONS A well-designed neuroPICU display must present multiple datasets in dynamic, flexible, and informative views to accommodate clinicians from multiple disciplines in a variety of clinical scenarios.
Collapse
Affiliation(s)
- Zachary M Grinspan
- Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, NY; Department of Pediatrics, Weill Cornell Medicine, New York, NY; New York-Presbyterian Hospital, New York, NY
| | - Yonina C Eldar
- Faculty of Electrical Engineering, Technion Israel Institute of Technology , Haifa, Israel
| | - Daniel Gopher
- Faculty of Industrial Engineering and Management, Technion Israel Institute of Technology , Haifa, Israel
| | - Amihai Gottlieb
- Faculty of Industrial Engineering and Management, Technion Israel Institute of Technology , Haifa, Israel
| | - Rotem Lammfromm
- Faculty of Industrial Engineering and Management, Technion Israel Institute of Technology , Haifa, Israel
| | - Halinder S Mangat
- New York-Presbyterian Hospital, New York, NY; Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Nimrod Peleg
- Faculty of Electrical Engineering, Technion Israel Institute of Technology , Haifa, Israel
| | - Steven Pon
- Department of Pediatrics, Weill Cornell Medicine, New York, NY; New York-Presbyterian Hospital, New York, NY
| | - Igal Rozenberg
- Faculty of Electrical Engineering, Technion Israel Institute of Technology , Haifa, Israel
| | - Nicholas D Schiff
- New York-Presbyterian Hospital, New York, NY; Department of Neurology, Weill Cornell Medicine, New York, NY; Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY
| | - David E Stark
- Departments of Medicine and Bioengineering, Stanford University , Stanford, CA
| | - Peter Yan
- New York-Presbyterian Hospital, New York, NY; Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Hillel Pratt
- Faculties of Medicine and Biomedical Engineering, Technion Israel Institute of Technology , Haifa, Israel
| | - Barry E Kosofsky
- Department of Pediatrics, Weill Cornell Medicine, New York, NY; New York-Presbyterian Hospital, New York, NY; Department of Neurology, Weill Cornell Medicine, New York, NY; Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY
| |
Collapse
|
15
|
Wainwright MS, Grimason M, Goldstein J, Smith CM, Amlie-Lefond C, Revivo G, Noah ZL, Harris ZL, Epstein LG. Building a pediatric neurocritical care program: a multidisciplinary approach to clinical practice and education from the intensive care unit to the outpatient clinic. Semin Pediatr Neurol 2014; 21:248-54. [PMID: 25727506 DOI: 10.1016/j.spen.2014.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We describe our 10-year experience developing the Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program at Northwestern University Feinberg School of Medicine. The neurocritical care team includes intensivists, neurologists, and an advanced practice nurse who have expertise in critical care neurology and who continue care in long-term follow-up of intensive care unit patients in a dedicated neurocritical care outpatient clinic. Brain-directed critical care requires collaboration between intensivists and neurologists with specific expertise in neurocritical care, using protocol-directed consistent care, and physiological measures to protect brain function. The heterogeneity of neurologic disorders in the pediatric intensive care unit requires a background in the relevant basic science and pathophysiology that is beyond the scope of standard neurology or critical care fellowships. To address this need, we also created a fellowship in neurocritical care for intensivists, neurologists, and advanced practice nurses. Last, we discuss the implications for pediatric neurocritical care from the experience of management of pediatric stroke and the development of stroke centers.
Collapse
Affiliation(s)
- Mark S Wainwright
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neurology, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Critical Care, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Michele Grimason
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joshua Goldstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neurology, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Craig M Smith
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Critical Care, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Gadi Revivo
- The Rehabilitation Institute of Chicago, Chicago, IL
| | - Zehava L Noah
- Division of Critical Care, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Zena L Harris
- Division of Critical Care, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Leon G Epstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Department of Pediatrics, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neurology, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
16
|
Abbas Q, Shabbir A, Siddiqui NR, Kumar R, Haque A. Burden of neurological illnesses in a pediatric intensive care unit of developing country. Pak J Med Sci 2014; 30:1223-7. [PMID: 25674112 PMCID: PMC4320704 DOI: 10.12669/pjms.306.5671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/10/2014] [Accepted: 08/03/2014] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To assess the burden and spectrum of neurological illness in a pediatric intensive care unit and review the associated mortality. METHODS Retrospective review of medical records of children (1 mo-16 years) with acute neurological diagnosis admitted in PICU in Aga Khan University hospital from January 2008 to December 2011 was done. Basic demographic, diagnosis, neuro diagnostic procedures performed, therapies and outcomes were done on a structured datasheet. RESULTS During study period, 231 (19.3%) patients were admitted with acute neurological illnesses in PICU. The mean age was 67 ±50 months, 54% (n=125) was under-five and 138 (59.7%) were males. Out of total, 144 (62.3%) had neurological illness and 87 (37.7%) had neurosurgical diagnosis. In acute neurological illness, 51.5% (n=119) had non-traumatic-coma (NTC) and 10.8% (n=25) had neuromuscular illness. CNS infection (26%, n=60) in structural cause and status epilepticus (10%, n=23) were the most common cause of structural and metabolic type of NTC respectively. Severe traumatic brain injury (21.2%, n=49) and postoperative neurosurgical illness (16.5%, n=38) were common neurosurgical cases in our cohort. The intensive care resources were utilized as mechanical ventilation in 78% (n=180), inotropic support in 29.4% (n=67) and therapeutic hypothermia in 33% (n=76). Fifty children (21.6%) required PICU care for observation only. More than 500 neurodiagnostic tests/procedures were performed in this cohort of children with acute neurological disorders in PICU. The mortality rate in neurological cases was 18% (42/231) as compared to the overall mortality rate was 12% in PICU. CONCLUSION Acute neurological disorders were common in PICU, and were associated with higher mortality. CNS infections, status epilepticus and severe traumatic brain injuries were the most common acute neurological illnesses in our cohort.
Collapse
Affiliation(s)
- Qalab Abbas
- Qalab Abbas, MBBS, Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Amber Shabbir
- Amber Shabbir, MBBS, Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Naveedur Rehman Siddiqui
- Naveedur Rehman Siddiqui, FCPS, Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Raman Kumar
- Raman Kumar, MBBS, Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Anwarul Haque
- Anwarul Haque, MBBS, Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| |
Collapse
|
17
|
Serum amyloid A is increased in children with abusive head trauma: a gel-based proteomic analysis. Pediatr Res 2014; 76:280-6. [PMID: 24941216 DOI: 10.1038/pr.2014.86] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 03/08/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Abusive head trauma (AHT) is the leading cause of death from traumatic brain injury in infants and young children. Identification of mild AHT (Glasgow Coma Scale score: 13-15) is difficult because children can present with nonspecific symptoms and with no history of trauma. METHODS Two-dimensional difference gel electrophoresis combined with mass spectrometry was used to compare the serum protein profile of children with mild AHT and age-matched controls. Protein changes were confirmed by western blots. Western blots were performed using serum from children with mild, moderate, and severe AHT to assess the effect of injury severity on protein intensity. The protein identified--serum amyloid A (SAA)--was then measured by enzyme-linked immunosorbent assay. RESULTS Using serum from 18 mild AHT cases and 20 controls, there were ~1,000 protein spots; 2 were significantly different between groups. Both spots were identified as SAA. There was no relationship between protein levels and injury severity. SAA concentrations measured by enzyme-linked immunosorbent assay were increased in cases vs. controls. CONCLUSION SAA may be a potential biomarker to identify children with mild AHT who present for medical care without a history of trauma and who might otherwise not be recognized as needing a head computed tomography.
Collapse
|
18
|
Abstract
Because pediatric intensive care units (PICUs) improve survival for a range of acute diseases, attention has turned toward ensuring the best possible functional outcomes after critical illness. The neurocritical care of children is of increasing interest. However, the pediatric population encompasses a heterogeneous set of neurologic conditions, with several possible models of how best to address them. This article reviews the special challenges faced by PICUs with regards to diseases, technologies, and skills and the progress that has been made in treatment, monitoring, and prognostication. Recent advances in translational research expected to modify the field in the near-term are described.
Collapse
Affiliation(s)
- Joshua Cappell
- Pediatric Critical Care Medicine, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | | |
Collapse
|
19
|
Abstract
The past 50 years have witnessed the emergence and evolution of the modern pediatric ICU and the specialty of pediatric critical care medicine. ICUs have become key in the delivery of health care services. The patient population within pediatric ICUs is diverse. An assortment of providers, including intensivists, trainees, physician assistants, nurse practitioners, and hospitalists, perform a variety of roles. The evolution of critical care medicine also has seen the rise of critical care nursing and other critical care staff collaborating in multidisciplinary teams. Delivery of optimal critical care requires standardized, reliable, and evidence-based processes, such as bundles, checklists, and formalized communication processes.
Collapse
|