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Appavu B, Riviello JJ. Multimodal neuromonitoring in the pediatric intensive care unit. Semin Pediatr Neurol 2024; 49:101117. [PMID: 38677796 DOI: 10.1016/j.spen.2024.101117] [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: 11/28/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 04/29/2024]
Abstract
Neuromonitoring is used to assess the central nervous system in the intensive care unit. The purpose of neuromonitoring is to detect neurologic deterioration and intervene to prevent irreversible nervous system dysfunction. Neuromonitoring starts with the standard neurologic examination, which may lag behind the pathophysiologic changes. Additional modalities including continuous electroencephalography (CEEG), multiple physiologic parameters, and structural neuroimaging may detect changes earlier. Multimodal neuromonitoring now refers to an integrated combination and display of non-invasive and invasive modalities, permitting tailored treatment for the individual patient. This chapter reviews the non-invasive and invasive modalities used in pediatric neurocritical care.
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Affiliation(s)
- Brian Appavu
- Clinical Assistant Professor of Child Health and Neurology, University of Arizona School of Medicine-Phoenix, Barrow Neurological Institute at Phoenix Children's, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ 85016, United States.
| | - James J Riviello
- Associate Division Chief for Epilepsy, Neurophysiology, and Neurocritical Care, Division of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Professor of Pediatrics and Neurology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, United States
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2
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Hanalioglu D, Temkit M'H, Hildebrandt K, MackDiaz E, Goldstein Z, Aggarwal S, Appavu B. Neurophysiologic Features Reflecting Brain Injury During Pediatric ECMO Support. Neurocrit Care 2024; 40:759-768. [PMID: 37697125 PMCID: PMC10959789 DOI: 10.1007/s12028-023-01836-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides lifesaving support to critically ill patients who experience refractory cardiopulmonary failure but carries a high risk for acute brain injury. We aimed to identify characteristics reflecting acute brain injury in children requiring ECMO support. METHODS This is a prospective observational study from 2019 to 2022 of pediatric ECMO patients undergoing neuromonitoring, including continuous electroencephalography, cerebral oximetry, and transcranial Doppler ultrasound (TCD). The primary outcome was acute brain injury. Clinical and neuromonitoring characteristics were collected. Multivariate logistic regression was implemented to model odds ratios (ORs) and identify the combined characteristics that best discriminate risk of acute brain injury using the area under the receiver operating characteristic curve. RESULTS Seventy-five pediatric patients requiring ECMO support were enrolled in this study, and 62 underwent neuroimaging or autopsy evaluations. Of these 62 patients, 19 experienced acute brain injury (30.6%), including seven (36.8%) with arterial ischemic stroke, four (21.1%) with hemorrhagic stroke, seven with hypoxic-ischemic brain injury (36.8%), and one (5.3%) with both arterial ischemic stroke and hypoxic-ischemic brain injury. A univariate analysis demonstrated acute brain injury to be associated with maximum hourly seizure burden (p = 0.021), electroencephalographic suppression percentage (p = 0.022), increased interhemispheric differences in electroencephalographic total power (p = 0.023) and amplitude (p = 0.017), and increased differences in TCD Thrombolysis in Brain Ischemia (TIBI) scores between bilateral middle cerebral arteries (p = 0.023). Best subset model selection identified increased seizure burden (OR = 2.07, partial R2 = 0.48, p = 0.013), increased quantitative electroencephalographic interhemispheric amplitude differences (OR = 2.41, partial R2 = 0.48, p = 0.013), and increased interhemispheric TCD TIBI score differences (OR = 4.66, partial R2 = 0.49, p = 0.006) to be independently associated with acute brain injury (area under the receiver operating characteristic curve = 0.92). CONCLUSIONS Increased seizure burden and increased interhemispheric differences in both quantitative electroencephalographic amplitude and TCD MCA TIBI scores are independently associated with acute brain injury in children undergoing ECMO support.
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Affiliation(s)
- Damla Hanalioglu
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - M 'Hamed Temkit
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Kara Hildebrandt
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Elizabeth MackDiaz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Zachary Goldstein
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Shefali Aggarwal
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Brian Appavu
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA.
- Department of Child Health, The University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
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Felling RJ, Kamerkar A, Friedman ML, Said AS, LaRovere KL, Bell MJ, Bembea MM. Neuromonitoring During ECMO Support in Children. Neurocrit Care 2023; 39:701-713. [PMID: 36720837 DOI: 10.1007/s12028-023-01675-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
Extracorporeal membrane oxygenation is a potentially lifesaving intervention for children with severe cardiac or respiratory failure. It is used with increasing frequency and in increasingly more complex and severe diseases. Neurological injuries are important causes of morbidity and mortality in children treated with extracorporeal membrane oxygenation and include ischemic stroke, intracranial hemorrhage, hypoxic-ischemic injury, and seizures. In this review, we discuss the epidemiology and pathophysiology of neurological injury in patients supported with extracorporeal membrane oxygenation, and we review the current state of knowledge for available modalities of monitoring neurological function in these children. These include structural imaging with computed tomography and ultrasound, cerebral blood flow monitoring with near-infrared spectroscopy and transcranial Doppler ultrasound, and physiological monitoring with electroencephalography and plasma biomarkers. We highlight areas of need and emerging advances that will improve our understanding of neurological injury related to extracorporeal membrane oxygenation and help to reduce the burden of neurological sequelae in these children.
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Affiliation(s)
- Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Suite 2158, Baltimore, MD, USA.
| | - Asavari Kamerkar
- Department of Anesthesia Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care, Indiana School of Medicine, Indianapolis, IN, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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4
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Gil LA, Apfeld JC, Gehred A, Walczak AB, Frazier WJ, Seabrook RB, Olutoye OO, Minneci PC. A Systematic Review of Clinical Outcomes After Carotid Artery Ligation Versus Carotid Artery Reconstruction Following Venoarterial Extracorporeal Membrane Oxygenation in Infants and Children. J Surg Res 2023; 291:423-432. [PMID: 37517350 DOI: 10.1016/j.jss.2023.06.046] [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: 03/01/2023] [Revised: 05/24/2023] [Accepted: 06/25/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION In pediatric and neonatal populations, the carotid artery is commonly cannulated for venoarterial (VA) extracorporeal membrane oxygenation (ECMO). The decision to ligate (carotid artery ligation [CAL]) versus reconstruct (carotid artery reconstruction [CAR]) the artery at decannulation remains controversial as long-term neurologic outcomes remain unknown. The objective of this study was to summarize current literature on clinical outcomes following CAL and CAR after Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO). METHODS PubMed (MEDLINE), Embase, Web of Science, and Cochrane databases were searched using keywords from January 1950 to October 2020. Studies examining clinical outcomes following CAL and CAR for VA-ECMO in patients <18 y of age were included. Prospective and retrospective cohort studies, case series, case-control studies, and case reports were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were performed independently by two reviewers. Assessment of risk of bias was performed. RESULTS Eighty studies were included and classified into four categories: noncomparative clinical outcomes after CAL (n = 23, 28.8%), noncomparative clinical outcomes after CAR (n = 12, 15.0%), comparative clinical outcomes after CAL and/or CAR (n = 28, 35.0%), and case reports of clinical outcomes after CAL and/or CAR (n = 17, 21.3%). Follow-up ranged from 0 to 11 y. CAR patency rates ranged from 44 to 100%. There was no substantial evidence supporting an association between CAL versus CAR and short-term neurologic outcomes. CONCLUSIONS Studies evaluating outcomes after CAL versus CAR for VA-ECMO are heterogeneous with limited generalizability. Further studies are needed to evaluate long-term consequences of CAL versus CAR, especially as the first survivors of pediatric/neonatal ECMO approach an age of increased risk of carotid stenosis and stroke.
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Affiliation(s)
- Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Jordan C Apfeld
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Alison Gehred
- Grant Morrow III Library, Nationwide Children's Hospital, Columbus, Ohio
| | - Ashely B Walczak
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - W Joshua Frazier
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ruth B Seabrook
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Oluyinka O Olutoye
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio.
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Pandiyan P, Cvetkovic M, Antonini MV, Shappley RKH, Karmakar SA, Raman L. Clinical Guidelines for Routine Neuromonitoring in Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:895-900. [PMID: 37603797 DOI: 10.1097/mat.0000000000001896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
DISCLAIMER These guidelines for routine neuromonitoring in neonatal and pediatric patients supported on extracorporeal membrane oxygenation (ECMO) are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS and ECMO but these are not necessarily consensus recommendations. The aim of clinical guidelines was to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or being deemed inclusive of all proper methods of care nor exclusive of other methods of care directed at obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient considering all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Poornima Pandiyan
- From the Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Mirjana Cvetkovic
- Cardiac Critical Care Division, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Rebekah K H Shappley
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Swati A Karmakar
- Department of Pediatrics, Baylor College of Medicine, Neurology and Developmental Neuroscience Section, Texas Children's Hospital, Houston, Texas
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Chahine A, Chenouard A, Joram N, Berthomieu L, Du Pont-Thibodeau G, Leclere B, Liet JM, Maminirina P, Leclair-Visonneau L, Breinig S, Bourgoin P. Continuous Amplitude-Integrated Electroencephalography During Neonatal and Pediatric Extracorporeal Membrane Oxygenation. J Clin Neurophysiol 2023; 40:317-324. [PMID: 34387276 DOI: 10.1097/wnp.0000000000000890] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Early prognostication of neurologic outcome in neonates and children supported with extra-corporeal membrane oxygenation (ECMO) is challenging. Amplitude-integrated EEG (aEEG) offers the advantages of continuous monitoring and 24-hours availability at the bedside for intensive care unit providers. The objective of this study was to describe the early electrophysiological background patterns of neonates and children undergoing ECMO and their association with neurologic outcomes. METHODS This was a retrospective review of neonates and children undergoing ECMO and monitored with aEEG. Amplitude-integrated EEG was summarized as an aEEG background score determined within the first 24 hours of ECMO and divided in 3-hour periods. Screening for electrical seizures was performed throughout the full ECMO duration. Neurologic outcome was defined by the Pediatric Cerebral Performance Category score at hospital discharge. RESULTS Seventy-three patients (median age 79 days [8-660], median weight 4.78 kg [3.24-10.02]) were included in the analysis. Thirty-two patients had a favorable neurologic outcome and 41 had an unfavorable neurologic outcome group at hospital discharge. A 24-hour aEEG background score >17 was associated with an unfavorable outcome with a sensitivity of 44%, a specificity of 97%, a positive predictive value of 95%, and a negative predictive value of 57%. In multivariate analysis, 24-hour aEEG background score was associated with unfavorable outcome (hazard ratio, 6.1; p = 0.001; 95% confidence interval, 2.31-16.24). The presence of seizures was not associated with neurologic outcome at hospital discharge. CONCLUSIONS Continuous aEEG provides accurate neurologic prognostication in neonates and children supported with ECMO. Early aEEG monitoring may help intensive care unit providers to guide clinical care and family counseling.
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Affiliation(s)
- Adela Chahine
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Lionel Berthomieu
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | | | - Brice Leclere
- Department of Medical Evaluation and Epidemiology, Nantes University Hospital, Nantes, France
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | | | | | - Sophie Breinig
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit and Pediatric Cardiac Anesthesia, University Hospital, Nantes, France
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Aboul-Nour H, Jumah A, Abdulla H, Sharma A, Howell B, Jayaprakash N, Gardner-Gray J. Neurological monitoring in ECMO patients: current state of practice, challenges and lessons. Acta Neurol Belg 2023; 123:341-350. [PMID: 36701079 PMCID: PMC9878494 DOI: 10.1007/s13760-023-02193-2] [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: 10/06/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) in critically ill patients serves as a management option for end-stage cardiorespiratory failure in medical and surgical conditions. Patients on ECMO are at a high risk of neurologic adverse events including intracranial hemorrhage (ICH), acute ischemic stroke (AIS), seizures, diffuse cerebral edema, and hypoxic brain injury. Standard approaches to neurological monitoring for patients receiving ECMO support can be challenging for multiple reasons, including the severity of critical illness, deep sedation, and/or paralysis. This narrative literature review provides an overview of the current landscape for neurological monitoring in this population. METHODS A literature search using PubMed was used to aid the understanding of the landscape of published literature in the area of neurological monitoring in ECMO patients. RESULTS Review articles, cohort studies, case series, and individual reports were identified. A total of 73 varied manuscripts were summarized and included in this review which presents the challenges and strategies for performing neurological monitoring in this population. CONCLUSION Neurological monitoring in ECMO is an area of interest to many clinicians, however, the literature is limited, heterogenous, and lacks consensus on the best monitoring practices. The evidence for optimal neurological monitoring that could impact clinical decisions and functional outcomes is lacking. Additional studies are needed to identify effective measures of neurological monitoring while on ECMO.
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Affiliation(s)
- Hassan Aboul-Nour
- grid.189967.80000 0001 0941 6502Department of Neurology, Emory University, Atlanta, GA USA ,grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Ammar Jumah
- grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Hafsa Abdulla
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Amreeta Sharma
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Bradley Howell
- grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Namita Jayaprakash
- grid.413103.40000 0001 2160 8953Department of Emergency Medicine, Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Jayna Gardner-Gray
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA ,grid.413103.40000 0001 2160 8953Department of Emergency Medicine, Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
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Characterization of Cerebral Hemodynamics with TCD in Patients Undergoing VA-ECMO and VV-ECMO: a Prospective Observational Study. Neurocrit Care 2022; 38:407-413. [PMID: 36510107 PMCID: PMC9744662 DOI: 10.1007/s12028-022-01653-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation has a high risk of acute brain injury and resultant mortality. Transcranial Doppler characterizes cerebral hemodynamics in real time, but limited data exist on its interpretation in ECMO. Here, we report TCD mean flow velocity and pulsatility index in a large ECMO population. METHODS This was a prospective cohort study at a tertiary care center. The patients were adults on venoarterial ECMO or venovenous ECMO undergoing TCD studies. RESULTS A total of 135 patients underwent a total of 237 TCD studies while on VA-ECMO (n = 95, 70.3%) or VV-ECMO (n = 40, 29.6%). MFVs were captured reliably (approximately 90%) and were similar to a published healthy cohort in all vessels except the internal carotid artery. Presence of a recordable PI was strongly associated with ECMO mode (57% in VA vs. 95% in VV, p < 0.001). Absence of TCD pulsatility was associated with intraparenchymal hemorrhage (14.7 vs. 1.6%, p = 0.03) in VA-ECMO patients. CONCLUSIONS Transcranial Doppler analysis in a single-center cohort of VA-ECMO and VV-ECMO patients demonstrates similar MFVs and PIs. Absence of PIs was associated with a higher frequency of intraparenchymal hemorrhage and a composite bleeding event. However, cautious interpretation and external validation is necessary for these findings with a multicenter study with a larger sample size.
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Tierradentro-Garcia LO, Stern JA, Dennis R, Hwang M. Utility of Cerebral Microvascular Imaging in Infants Undergoing ECMO. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1827. [PMID: 36553271 PMCID: PMC9776869 DOI: 10.3390/children9121827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Infants who require extracorporeal membrane oxygenation (ECMO) therapy have an increased risk of neurological complications and mortality. Microvascular imaging (MVI) is an advanced Doppler technique that allows high-resolution visualization of microvasculature in the brain. We describe the feasibility and utility of MVI for the evaluation of cerebral microvascular perfusion in patients undergoing ECMO. METHODS We retrospectively analyzed brain MVI scans of neonates undergoing ECMO. Two pediatric radiologists qualitatively assessed MVI scans to determine the presence or absence of tortuosity, symmetry, heterogeneity, engorgement, and hypoperfusion of the basal ganglia-thalamus (BGT) region, as well as the presence or absence of white matter vascular engorgement and increased peri-gyral flow in the cortex. We tested the association between the presence of the aforementioned brain MVI features and clinical outcomes. RESULTS We included 30 patients, 14 of which were male (46.7%). The time of ECMO duration was 11.8 ± 6.9 days. The most prevalent microvascular finding in BGT was lenticulostriate vessel tortuosity (26/30, 86.7%), and the most common microvascular finding in the cortex was increased peri-gyral flow (10/24, 41.7%). Cortical white matter vascular engorgement was significantly associated with the presence of any poor outcome as defined by death, seizure, and/or cerebrovascular events on magnetic resonance imaging (p = 0.03). CONCLUSION MVI is a feasible modality to evaluate cerebral perfusion in infants undergoing ECMO. Additionally, evidence of white matter vascular engorgement after ECMO cannulation could serve as a predictor of poor outcomes in this population.
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Affiliation(s)
| | - Joseph A. Stern
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Rebecca Dennis
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Misun Hwang
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Shi X, Gu Q, Li Y, Diao M, Wen X, Hu W, Xi S. A Standardized Multimodal Neurological Monitoring Protocol-Guided Cerebral Protection Therapy for Venoarterial Extracorporeal Membrane Oxygenation Supported Patients. Front Med (Lausanne) 2022; 9:922355. [PMID: 35814786 PMCID: PMC9261463 DOI: 10.3389/fmed.2022.922355] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022] Open
Abstract
Background The main objective of this study was to investigate the role of a multimodal neurological monitoring (MNM)-guided protocol in the precision identification of neural impairment and long-term neurological outcomes in venoarterial extracorporeal membrane oxygenation (VA-ECMO) supported patients. Methods We performed a cohort study that examined adult patients who underwent VA-ECMO support in our center between February 2010 and April 2021. These patients were retrospectively assigned to the “with MNM group” and the “without MNM group” based on the presence or absence of MNM-guided precision management. The differences in ECMO-related characteristics, evaluation indicators (precision, sensitivity, and specificity) of the MNM-guided protocol, and the long-term outcomes of the surviving patients were measured and compared between the two groups. Results A total of 63 patients with VA-ECMO support were retrospectively assigned to the without MNM group (n = 35) and the with MNM group (n = 28). The incidence of neural impairment in the without MNM group was significantly higher than that in the with MNM group (82.1 vs. 54.3%, P = 0.020). The MNM group exhibited older median ages [52.5 (39.5, 65.3) vs. 31 (26.5, 48.0), P = 0.008], a higher success rate of ECMO weaning (92.8 vs. 71.4%, P = 0.047), and a lower median duration of building ECMO [40.0 (35.0, 52.0) vs. 58.0 (48.0, 76.0), P = 0.025] and median ECMO duration days [5.0 (4.0, 6.2) vs. 7.0 (5.0, 10.5), P = 0.018] than the group without MNM. The MNM-guided protocol exhibited a higher precision rate (82.1 vs. 60.0%), sensitivity (95.7 vs. 78.9%), and specificity (83.3 vs. 37.5%) in identifying neural impairment in VA-ECMO support patients. There were significant differences in the long-term outcomes of survivors at 1, 3 and 6 months after discharge between the two groups (P < 0.05). However, the results showed no significant differences in ICU length of stay (LOS), hospital LOS, survival to discharge, or 28-day mortality between the two groups (P > 0.05). Conclusion The MNM-guided protocol is conducive to guiding intensivists in the improvement of cerebral protection therapy for ECMO-supported patients to detect and treat potential neurologic impairment promptly, and then improving long-term neurological outcomes after discharge.
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Affiliation(s)
- Xiaobei Shi
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiao Gu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiwei Li
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mengyuan Diao
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Wen
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Wei Hu
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Shaosong Xi
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Transcranial Doppler Ultrasound, a Review for the Pediatric Intensivist. CHILDREN 2022; 9:children9050727. [PMID: 35626904 PMCID: PMC9171581 DOI: 10.3390/children9050727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 12/04/2022]
Abstract
The use of transcranial Doppler ultrasound (TCD) is increasing in frequency in the pediatric intensive care unit. This review highlights some of the pertinent TCD applications for the pediatric intensivist, including evaluation of cerebral hemodynamics, autoregulation, non-invasive cerebral perfusion pressure/intracranial pressure estimation, vasospasm screening, and cerebral emboli detection.
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12
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Laws JC, Jordan LC, Pagano LM, Wellons JC, Wolf MS. Multimodal Neurologic Monitoring in Children With Acute Brain Injury. Pediatr Neurol 2022; 129:62-71. [PMID: 35240364 PMCID: PMC8940706 DOI: 10.1016/j.pediatrneurol.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 01/04/2022] [Accepted: 01/25/2022] [Indexed: 12/26/2022]
Abstract
Children with acute neurologic illness are at high risk of mortality and long-term neurologic disability. Severe traumatic brain injury, cardiac arrest, stroke, and central nervous system infection are often complicated by cerebral hypoxia, hypoperfusion, and edema, leading to secondary neurologic injury and worse outcome. Owing to the paucity of targeted neuroprotective therapies for these conditions, management emphasizes close physiologic monitoring and supportive care. In this review, we will discuss advanced neurologic monitoring strategies in pediatric acute neurologic illness, emphasizing the physiologic concepts underlying each tool. We will also highlight recent innovations including novel monitoring modalities, and the application of neurologic monitoring in critically ill patients at risk of developing neurologic sequelae.
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Affiliation(s)
- Jennifer C Laws
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lindsay M Pagano
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael S Wolf
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
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Yu SH, Mao DH, Ju R, Fu YY, Zhang LB, Yue G. ECMO in neonates: The association between cerebral hemodynamics with neurological function. Front Pediatr 2022; 10:908861. [PMID: 36147805 PMCID: PMC9485612 DOI: 10.3389/fped.2022.908861] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/25/2022] [Indexed: 11/20/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a superior life support technology, commonly employed in critical patients with severe respiratory or hemodynamic failure to provide effective respiratory and circulatory support, which is especially recommended for the treatment of critical neonates. However, the vascular management of neonates with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is still under controversy. Reconstruction or ligation for the right common carotid artery (RCCA) after ECMO is inconclusive. This review summarized the existed studies on hemodynamics and neurological function after vascular ligation or reconstruction hoping to provide better strategies for vessel management in newborns after ECMO. After reconstruction, the right cerebral blood flow can increase immediately, and the normal blood supply can be restored rapidly. But the reconstructed vessel may be occluded and stenotic in long-term follow-ups. Ligation may cause lateralization damage, but there could be no significant effect owing to the establishment of collateral circulation. The completion of the circle of Willis, the congenital anomalies of cerebral or cervical vasculature, the duration of ECMO, and the vascular condition at the site of arterial catheterization should be assessed carefully before making the decision. It is also necessary to follow up on the reconstructed vessel sustainability, and the association between cerebral hemodynamics and neurological function requires further large-scale multi-center studies.
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Affiliation(s)
- Shu-Han Yu
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Dan-Hua Mao
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Rong Ju
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yi-Yong Fu
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li-Bing Zhang
- Department of Pediatric Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Guang Yue
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Millet A, Evain JN, Desrumaux A, Francony G, Bouzat P, Mortamet G. Clinical applications of transcranial Doppler in non-trauma critically ill children: a scoping review. Childs Nerv Syst 2021; 37:2759-2768. [PMID: 34244843 DOI: 10.1007/s00381-021-05282-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/29/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Many applications of transcranial Doppler (TCD) as a diagnosis or monitoring tool have raised interest in the last decades. It is important that clinicians know when and how to perform TCD in this population, what parameter to assess and monitor and how to interpret it. OBJECTIVE This review aims to describe the emerging clinical applications of TCD in critically ill children excluding those suffering from trauma. METHODS Databases Web of Science, Cochrane and PubMed were searched in May 2020. We considered all publications since the year 2000 addressing the use of TCD as a prognostic, diagnostic or follow-up tool in children aged 0 to 15 years admitted to intensive care or emergency units, excluding neonatology and traumatic brain injury. Two independent reviewers selected 82 abstracts and full-text articles from the 2011 unique citations identified at the outset. RESULTS TCD provides crucial additional information at bedside about cerebrovascular hemodynamics. Many clinical applications include the diagnosis and management of various medical and surgical neurologic conditions (central nervous system infections, arterial ischemic stroke, subarachnoid hemorrhage and vasospasm, brain death, seizures, metabolic disease, hydrocephalus) as well as monitoring the impact systemic conditions on brain perfusion (hemodynamic instability, circulatory assistance). CONCLUSION To conclude, TCD has become an invaluable asset for non-invasive neuromonitoring in critically ill children excluding those suffering from trauma. However, the scope of TCD remains unclearly defined yet and reference values in critically ill children are still lacking.
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Affiliation(s)
- Anne Millet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Jean-Noël Evain
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Amélie Desrumaux
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| | - Gilles Francony
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre Bouzat
- Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France.
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Abstract
The goal of neurocritical care (NCC) is to improve the outcome of patients with neurologic insults. NCC includes the management of the primary brain injury and prevention of secondary brain injury; this is achieved with standardized clinical care for specific disorders along with neuromonitoring. Neuromonitoring uses multiple modalities, with certain modalities better suited to certain disorders. The term "multimodality monitoring" refers to using multiple modalities at the same time. This article reviews pediatric NCC, the various physiologic parameters used, especially continuous electroencephalographic monitoring.
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Affiliation(s)
- James J Riviello
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA.
| | - Jennifer Erklauer
- Section of Pediatric Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA; Section of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1250, Houston, TX 77030, USA
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16
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O'Brien NF, Reuter-Rice K, Wainwright MS, Kaplan SL, Appavu B, Erklauer JC, Ghosh S, Kirschen M, Kozak B, Lidsky K, Lovett ME, Mehollin-Ray AR, Miles DK, Press CA, Simon DW, Tasker RC, LaRovere KL. Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement. J Pediatr Intensive Care 2021; 10:133-142. [PMID: 33884214 PMCID: PMC8052112 DOI: 10.1055/s-0040-1715128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 12/16/2022] Open
Abstract
Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.
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Affiliation(s)
- Nicole Fortier O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Karin Reuter-Rice
- Department of Pediatrics, Division of Pediatric Critical Care, School of Medicine, School of Nursing, Duke University, Duke Institute for Brain Sciences, North Carolina, United States
| | - Mark S. Wainwright
- Department of Neurology, University of Washington, Seattle Children's Hospital, Washington, United States
| | - Summer L. Kaplan
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brian Appavu
- Department of Pediatrics, Division of Critical Care Medicine, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine—Phoenix, Arizona, United States
| | - Jennifer C. Erklauer
- Department of Pediatrics, Division of Critical Care Medicine and Neurology, Baylor College of Medicine, Texas Children's Hospital, Texas, United States
| | - Suman Ghosh
- Department of Pediatrics, Division of Pediatric Neurology, University of Florida, College of Medicine, Florida, United States
| | - Matthew Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brandi Kozak
- Department of Radiology, Ultrasound Division, Center for Pediatric Contrast Ultrasound, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Karen Lidsky
- Department of Pediatrics, Division of Pediatric Critical Care, Wolfson Children's Hospital, University of Florida, Florida, United States
| | - Marlina Elizabeth Lovett
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Amy R. Mehollin-Ray
- Department of Radiology, Baylor College of Medicine, E.B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Texas, United States
| | - Darryl K. Miles
- Department of Pediatrics/Division of Critical Care, UT Southwestern Medical Center, Texas, United States
| | - Craig A. Press
- Department of Pediatrics, Section of Child Neurology, University of Colorado, Children's Hospital Colorado, Colorado, United States
| | - Dennis W. Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pennsylvania, United States
| | - Robert C. Tasker
- Departments of Neurology & Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
| | - Kerri Lynn LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
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17
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Aboul Nour H, Poyiadji N, Mohamed G, Alsrouji OK, Ramadan AR, Griffith B, Marin H, Chebl AB. Challenges of acute phase neuroimaging in VA-ECMO, pitfalls and alternative imaging options. Interv Neuroradiol 2021; 27:434-439. [PMID: 32990105 PMCID: PMC8190935 DOI: 10.1177/1591019920962881] [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: 08/21/2020] [Accepted: 09/08/2020] [Indexed: 11/17/2022] Open
Abstract
Large vessel occlusion in patients on ECMO is challenging to appreciate clinically secondary to sedation or induced paralysis, thus placing more emphasis on neurovascular imaging. However, emergent CTA and CTP are both inaccurate and unreliable in ECMO patients due to altered circuitry and interference with normal physiologic hemodynamics. In this review, the utility of DSA is discussed in evaluating the altered hemodynamics of VA-ECMO circuits and patency of major vasculature. In addition, the potential use of TCD in ECMO patients is discussed.
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Affiliation(s)
| | - Neo Poyiadji
- Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | - Ghada Mohamed
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | | | | | - Brent Griffith
- Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | - Horia Marin
- Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | - Alex Bou Chebl
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
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Rollet-Cohen V, Sachs P, Léger PL, Merchaoui Z, Rambaud J, Berteloot L, Kossorotoff M, Mortamet G, Dauger S, Tissieres P, Renolleau S, Oualha M. Transcranial Doppler Use in Non-traumatic Critically Ill Children: A Multicentre Descriptive Study. Front Pediatr 2021; 9:609175. [PMID: 34277513 PMCID: PMC8282928 DOI: 10.3389/fped.2021.609175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 05/31/2021] [Indexed: 01/08/2023] Open
Abstract
Background: The use and perceived value of transcranial Doppler (TCD) scope in paediatric critical care medicine has not been extensively documented. Objective: To describe the use of TCD to assess non-traumatic brain injury in patients admitted to four paediatric intensive care units (PICUs) in France. Methods: We prospectively included all children (aged under 18) assessed with inpatient TCD between November 2014 and October 2015 at one of the four PICUs. The physicians completed a questionnaire within 4 h of performing TCD. Results: 152 children were included. The primary diagnosis was neurological disease in 106 patients (70%), including post ischemic-anoxic brain insult (n = 42, 28%), status epilepticus (n = 19, 13%), and central nervous system infection/inflammation (n = 15, 10%). TCD was the first-line neuromonitoring assessment in 110 patients (72%) and was performed within 24 h of admission in 112 patients (74%). The most common indications for TCD were the routine monitoring of neurological disorders (n = 85, 56%) and the detection of asymptomatic neurological disorders (n = 37, 24). Concordance between the operator's interpretation of TCD and the published normative values was observed for 21 of the 75 (28%) TCD abnormal findings according to the published normative values. The physicians considered that TCD was of value for the ongoing clinical management of 131 (86%) of the 152 patients. Conclusion: TCD is commonly used in French PICUs and tends to be performed early after admission on patients with a broad range of diseases. The physicians reported that the TCD findings often helped their clinical decision making. In view of the subjectivity of bedside interpretation, true TCD contribution to clinical care remains to be determined. Objective studies of the impact of TCD on patient management and clinical outcomes are therefore warranted.
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Affiliation(s)
- Virginie Rollet-Cohen
- Paediatric Intensive Care Unit, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Philippe Sachs
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Pierre-Louis Léger
- Paediatric and Neonatal Intensive Care Unit, Trousseau University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Zied Merchaoui
- Pediatric Intensive Care, Paris South University Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
| | - Jérôme Rambaud
- Paediatric and Neonatal Intensive Care Unit, Trousseau University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Laureline Berteloot
- Paediatric Radiology Department, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Manoëlle Kossorotoff
- Paediatric Neurology Department, French Centre for Paediatric Stroke, Necker-Enfants-Malades University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Guillaume Mortamet
- Paediatric Intensive Care Unit, Grenoble University Hospital, Grenoble, France
| | - Stéphane Dauger
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Pierre Tissieres
- Pediatric Intensive Care, Paris South University Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
| | - Sylvain Renolleau
- Paediatric Intensive Care Unit, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Mehdi Oualha
- Paediatric Intensive Care Unit, Necker-Enfants Malades University Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
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19
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Neurological Monitoring and Complications of Pediatric Extracorporeal Membrane Oxygenation Support. Pediatr Neurol 2020; 108:31-39. [PMID: 32299748 PMCID: PMC7698354 DOI: 10.1016/j.pediatrneurol.2020.03.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/17/2022]
Abstract
Extracorporeal membrane oxygenation is extracorporeal life support for life-threatening cardiopulmonary failure. Since its introduction, the use of extracorporeal membrane oxygenation has expanded to patients with more complex comorbidities without change in patient mortality rates. Although many patients survive, significant neurological complications like seizures, ischemic strokes, and intracranial hemorrhage can occur during extracorporeal membrane oxygenation care. The risks of these complications often add to the complexity of decision-making surrounding extracorporeal membrane oxygenation support. In this review, we discuss the pathophysiology and incidence of neurological complications in children supported on extracorporeal membrane oxygenation, factors influencing the incidence of these complications, commonly used neurological monitoring modalities, and outcomes for this complex patient population. We discuss the current literature on the use of electroencephalography for both seizure detection and monitoring of background electroencephalographic changes, in addition to the use of less commonly used imaging modalities like transcranial Doppler. We summarize the knowledge gaps and the lack of clinical consensus guidelines for managing these potentially life-changing neurological complications. Finally, we discuss future work to further understand the pathophysiology of extracorporeal membrane oxygenation-related neurological complications.
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20
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Transcranial Doppler Ultrasound During Critical Illness in Children: Survey of Practices in Pediatric Neurocritical Care Centers. Pediatr Crit Care Med 2020; 21:67-74. [PMID: 31568242 DOI: 10.1097/pcc.0000000000002118] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The scope of transcranial Doppler ultrasound in the practice of pediatric neurocritical care is unknown. We have surveyed pediatric neurocritical care centers on their use of transcranial Doppler and analyzed clinical management practices. DESIGN Electronic-mail recruitment with survey of expert centers using web-based questionnaire. SETTING Survey of 43 hospitals (31 United States, 12 international) belonging to the Pediatric Neurocritical Care Research Group. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A 67% (29/43) hospital-response rate. Of these centers, 27 reported using transcranial Doppler in the PICU; two hospitals opted out due to lack of transcranial Doppler availability/use. The most common diagnoses for using transcranial Doppler in clinical care were intracranial/subarachnoid hemorrhage (20 hospitals), arterial ischemic stroke (14 hospitals), and traumatic brain injury (10 hospitals). Clinical studies were carried out and interpreted by credentialed individuals in 93% (25/27) and 78% (21/27) of the centers, respectively. A written protocol for performance of transcranial Doppler in the PICU was available in 30% (8/27 hospitals); of these, two of eight hospitals routinely performed correlation studies to validate results. In 74% of the centers (20/27), transcranial Doppler results were used to guide clinical care: that is, when to obtain a neuroimaging study (18 hospitals); how to manipulate cerebral perfusion pressure with fluids/vasopressors (13 hospitals); and whether to perform a surgical intervention (six hospitals). Research studies were also commonly performed for a range of diagnoses. CONCLUSIONS At least 27 pediatric neurocritical care centers use transcranial Doppler during clinical care. In the majority of centers, studies are performed and interpreted by credentialed personnel, and findings are used to guide clinical management. Further studies are needed to standardize these practices.
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21
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O’Brien NF, Lovett ME, Chung M, Maa T. Non-invasive estimation of cerebral perfusion pressure using transcranial Doppler ultrasonography in children with severe traumatic brain injury. Childs Nerv Syst 2020; 36:2063-2071. [PMID: 31996979 PMCID: PMC7223617 DOI: 10.1007/s00381-020-04524-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/25/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To identify if cerebral perfusion pressure (CPP) can be non-invasively estimated by either of two methods calculated using transcranial Doppler ultrasound (TCD) parameters. DESIGN Retrospective review of previously prospectively gathered data. SETTING Pediatric intensive care unit in a tertiary care referral hospital. PATIENTS Twenty-three children with severe traumatic brain injury (TBI) and invasive intracranial pressure (ICP) monitoring in place. INTERVENTIONS TCD evaluation of the middle cerebral arteries was performed daily. CPP at the time of the TCD examination was recorded. For method 1, estimated cerebral perfusion pressure (CPPe) was calculated as: CPPe = MAP × (diastolic flow (Vd)/mean flow (Vm)) + 14. For method 2, critical closing pressure (CrCP) was identified as the intercept point on the x-axis of the linear regression line of blood pressure and flow velocity parameters. CrCP/CPPe was then calculated as MAP-CrCP. MEASUREMENTS AND MAIN RESULTS One hundred eight paired measurements were available. Using patient averaged data, correlation between CPP and CPPe was significant (r = 0.78, p = < 0.001). However, on Bland-Altman plots, bias was 3.7 mmHg with 95% limits of agreement of - 17 to + 25 for CPPe. Using patient averaged data, correlation between CPP and CrCP/CPPe was significant (r = 0.59, p = < 0.001), but again bias was high at 11 mmHg with wide 95% limits of agreement of - 15 to + 38 mmHg. CONCLUSIONS CPPe and CrCP/CPPe do not have clinical value to estimate the absolute CPP in pediatric patients with TBI.
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Affiliation(s)
- Nicole F O’Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Marlina E. Lovett
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Melissa Chung
- Division of Neurology, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Tensing Maa
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, 700 Children’s Drive, Columbus, OH 43205 USA
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22
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Outcomes of Infants Supported With Extracorporeal Membrane Oxygenation Using Centrifugal Versus Roller Pumps: An Analysis From the Extracorporeal Life Support Organization Registry. Pediatr Crit Care Med 2019; 20:1177-1184. [PMID: 31567621 PMCID: PMC7175473 DOI: 10.1097/pcc.0000000000002103] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine whether mortality differs between roller and centrifugal pumps used during extracorporeal membrane oxygenation in infants weighing less than 10 kg. DESIGN Retrospective propensity-matched cohort study. SETTING All extracorporeal membrane oxygenation centers reporting to the Extracorporeal Life Support Organization. PATIENTS All patients less than 10 kg supported on extracorporeal membrane oxygenation during 2011-2016 within Extracorporeal Life Support Organization Registry. INTERVENTIONS Centrifugal and roller pump recipients were propensity matched (1:1) based on predicted probability of receiving a centrifugal pump using demographic variables, indication for extracorporeal membrane oxygenation, central versus peripheral cannulation, and pre-extracorporeal membrane oxygenation patient management. MEASUREMENTS AND MAIN RESULTS A total of 12,890 patients less than 10 kg were supported with extracorporeal membrane oxygenation within the Extracorporeal Life Support Organization registry during 2011-2016. Patients were propensity matched into a cohort of 8,366. Venoarterial and venovenous extracorporeal membrane oxygenation runs were propensity matched separately. The propensity-matched cohorts were similar except earlier year of extracorporeal membrane oxygenation (standardized mean difference, 0.49) in the roller pump group. Within the propensity-matched cohort, survival to discharge was lower in the centrifugal pump group (57% vs 59%; odds ratio, 0.91; 95% CI, 0.83-0.99; p = 0.04). Hemolytic, infectious, limb injury, mechanical, metabolic, neurologic, pulmonary, and renal complications were more frequent in the centrifugal pump group. Hemorrhagic complications were similar between groups. Hemolysis mediated the relationship between centrifugal pumps and mortality (indirect effect, 0.023; p < 0.001). CONCLUSIONS In this propensity score-matched cohort study of 8,366 extracorporeal membrane oxygenation recipients weighing less than 10 kg, those supported with centrifugal pumps had increased mortality and extracorporeal membrane oxygenation complications. Hemolysis was evaluated as a potential mediator of the relationship between centrifugal pump use and mortality and met criteria for full mediation.
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Cerebrovascular Physiology During Pediatric Extracorporeal Membrane Oxygenation: A Multicenter Study Using Transcranial Doppler Ultrasonography. Pediatr Crit Care Med 2019; 20:178-186. [PMID: 30395027 DOI: 10.1097/pcc.0000000000001778] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To explore changes to expected, age-related transcranial Doppler ultrasound variables during pediatric extracorporeal membrane oxygenation. DESIGN Prospective, observational, multicenter study. SETTING Tertiary care PICUs. PATIENTS Children 1 day to 18 years old requiring veno arterial extracorporeal membrane oxygenation. METHODS Participants underwent daily transcranial Doppler ultrasound measurement of bilateral middle cerebral artery flow velocities. Acute neurologic injury was diagnosed if seizures, cerebral hemorrhage, or diffuse cerebral ischemia was detected. MEASUREMENTS AND MAIN RESULTS Fifty-two children were enrolled and analyzed. In the 44 children without acute neurologic injury, there was a significant reduction in systolic flow velocity and mean flow velocity compared with predicted values over time (F [8, 434] = 60.44; p ≤ 0.0001, and F [8, 434] = 17.61; p ≤ 0.0001). Middle cerebral artery systolic flow velocity was lower than predicted on extracorporeal membrane oxygenation days 1-5, and mean flow velocity was lower than predicted on extracorporeal membrane oxygenation days 1-3. In the six infants less than 90 days old suffering diffuse cerebral ischemia, middle cerebral artery systolic flow velocity, mean flow velocity, and diastolic flow velocity from extracorporeal membrane oxygenation days 1-9 were not significantly different when compared with children of similar age in the cohort that did not suffer acute neurologic injury (systolic flow velocity F [8, 52] = 0.6659; p = 0.07 and diastolic flow velocity F [8, 52] = 1.4; p = 0.21 and mean flow velocity F [8, 52] = 1.93; p = 0.07). Pulsatility index was higher in these infants over time than children of similar age in the cohort on extracorporeal membrane oxygenation that did not suffer acute neurologic injury (F [8, 52] = 3.1; p = 0.006). No patient in the study experienced cerebral hemorrhage. CONCLUSIONS Flow velocities in the middle cerebral arteries of children requiring extracorporeal membrane oxygenation are significantly lower than published normative values for critically ill, mechanically ventilated, sedated children. Significant differences in measured systolic flow velocity, diastolic flow velocity, and mean flow velocity were not identified in children suffering ischemic injury compared with those who did not. However, increased pulsatility index may be a marker for ischemic injury in young infants on extracorporeal membrane oxygenation.
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