Neurological critical care

Pediatric neurocritical care: is it time to come of age?

PURPOSE OF REVIEW

Neurocritical care in adults with life-threatening neurological disease is a distinct discipline that has developed out of critical care medicine and neurology. This review considers whether it is time for such a specialized service to be developed in pediatrics.

RECENT FINDINGS

Recent reports describe how some institutions and pediatric professional bodies have set about transferring the specialist neurocritical care experience in adults to pediatric practice. The issue, now, is whether such a development would improve pediatric healthcare, medical education and training in the newly defined field. Adult neurocritical care did not develop in a void. The historical influences were the polio epidemics and the investment in experimental neuroprotection. These traditions provided a foundation for success in recent clinical trials, patient outcomes and healthcare research. Pediatric neurocritical care does not have the equivalent parallels and track record in healthcare research. Size of practice and casemix is also significantly different, with one-third of potential beneficiaries of the new field having a primary medical, rather than neurological, disorder. Three types of development for pediatric neurocritical services are, therefore, suggested by the literature and the implications of these on cross-discipline staffing and education are discussed.

SUMMARY

Pediatric neurocritical care is the new frontier for pediatric critical care medicine and pediatric neurology. There is sufficient specialist interest and momentum for the development of a multidisciplinary collaboration that has the aim of improving patient care.

Pediatric neurologic emergencies

Neuroemergencies are life-threatening situations in which, whatever the cause, common pathologic phenomena result in secondary brain lesions. The goal of critical care management is to stop these self-aggravating processes as soon as possible. Initial resuscitation is devoted to control of the airway and hemodynamic and hydroelectrolytic stabilization. With mass lesions, minimal computed tomographic exploration immediately precedes surgical decompression. Further critical care adapted to the child's needs requires multimodal monitoring. Normoventilation, deep sedation, osmotherapy with mannitol or hypertonic saline solutions, and optimization of mean arterial pressure are the basis of management. A purely pressure-driven approach aimed at controlling cerebral perfusion pressure could be potentially harmful, and associated measurement of blood flow velocity with transcranial Doppler and jugular bulb oxygen saturation monitoring allows an approach to cerebral blood flow and metabolism. Outcome can be improved in dangerous situations such as severe brain injuries, cerebral arteriovenous malformation rupture, status epilepticus, and acute hydrocephalus, provided that emergency management could be applied efficiently.