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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Lovett ME, MacDonald JM, Mir M, Ghosh S, O'Brien NF, LaRovere KL. Noninvasive Neuromonitoring Modalities in Children Part I: Pupillometry, Near-Infrared Spectroscopy, and Transcranial Doppler Ultrasonography. Neurocrit Care 2024; 40:130-146. [PMID: 37160846 DOI: 10.1007/s12028-023-01730-4] [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: 05/20/2022] [Accepted: 04/03/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Noninvasive neuromonitoring in critically ill children includes multiple modalities that all intend to improve our understanding of acute and ongoing brain injury. METHODS In this article, we review basic methods and devices, applications in clinical care and research, and explore potential future directions for three noninvasive neuromonitoring modalities in the pediatric intensive care unit: automated pupillometry, near-infrared spectroscopy, and transcranial Doppler ultrasonography. RESULTS All three technologies are noninvasive, portable, and easily repeatable to allow for serial measurements and trending of data over time. However, a paucity of high-quality data supporting the clinical utility of any of these technologies in critically ill children is currently a major limitation to their widespread application in the pediatric intensive care unit. CONCLUSIONS Future prospective multicenter work addressing major knowledge gaps is necessary to advance the field of pediatric noninvasive neuromonitoring.
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Affiliation(s)
- Marlina E Lovett
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Jennifer M MacDonald
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Marina Mir
- Division of Pediatric Critical Care, Montreal Children's Hospital and McGill University, Montreal, Canada
| | - Suman Ghosh
- Department of Neurology, State University of New York Downstate College of Medicine, Brooklyn, NY, USA
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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Agrawal S, Abecasis F, Jalloh I. Neuromonitoring in Children with Traumatic Brain Injury. Neurocrit Care 2024; 40:147-158. [PMID: 37386341 PMCID: PMC10861621 DOI: 10.1007/s12028-023-01779-1] [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: 05/19/2022] [Accepted: 06/05/2023] [Indexed: 07/01/2023]
Abstract
Traumatic brain injury remains a major cause of mortality and morbidity in children across the world. Current management based on international guidelines focuses on a fixed therapeutic target of less than 20 mm Hg for managing intracranial pressure and 40-50 mm Hg for cerebral perfusion pressure across the pediatric age group. To improve outcome from this complex disease, it is essential to understand the pathophysiological mechanisms responsible for disease evolution by using different monitoring tools. In this narrative review, we discuss the neuromonitoring tools available for use to help guide management of severe traumatic brain injury in children and some of the techniques that can in future help with individualizing treatment targets based on advanced cerebral physiology monitoring.
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Affiliation(s)
- Shruti Agrawal
- Department of Paediatric Intensive Care, Cambridge University Hospitals National Health Service Foundation Trust, Level 3, Box 7, Addenbrookes Hospital Hills Road, Cambridge, UK.
- University of Cambridge, Cambridge, UK.
| | - Francisco Abecasis
- Paediatric Intensive Care Unit, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ibrahim Jalloh
- University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
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Riggs BJ, Carpenter JL. Pediatric Neurocritical Care: Maximizing Neurodevelopmental Outcomes Through Specialty Care. Pediatr Neurol 2023; 149:187-198. [PMID: 37748977 DOI: 10.1016/j.pediatrneurol.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023]
Abstract
The field of pediatric neurocritical care (PNCC) has expanded and evolved over the last three decades. As mortality from pediatric critical care illness has declined, morbidity from neurodevelopmental disorders has expanded. PNCC clinicians have adopted a multidisciplinary approach to rapidly identify neurological injury, implement neuroprotective therapies, minimize secondary neurological insults, and establish transitions of care, all with the goal of improving neurocognitive outcomes for their patients. Although there are many aspects of PNCC and adult neurocritical care (NCC) medicine that are similar, elemental difference between adult and pediatric medicine has contributed to a divergent evolution of the respective fields. The low incidence of pediatric critical care illness, the heterogeneity of neurological insults, and the limited availability of resources all shape the need for a PNCC clinical care model that is distinct from the established paradigm adopted by the adult neurocritical care community at large. Considerations of neurodevelopment are fundamental in pediatrics. When neurological injury occurs in a child, the neurodevelopmental stage at the time of insult alters the impact of the neurological disease. Developmental variables contribute to a range of outcomes for seemingly similar injuries. Despite the relative infancy of the field of PNCC, early reports have shown that implementation of a specialized PNCC service elevates the quality and safety of care, promotes education and communication, and improves outcomes for children with acute neurological injuries. The multidisciplinary approach of PNCC clinicians and researchers also promotes a culture that emphasizes the importance of quality improvement and education initiatives, as well as development of and adherence to evidence-based guidelines and family-focused care models.
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Affiliation(s)
- Becky J Riggs
- Division of Pediatric Critical Care Medicine, Oregon Health & Science University, Portland, Oregon.
| | - Jessica L Carpenter
- Division of Pediatric Neurology, University of Maryland Medical Center, Baltimore, Maryland
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Jiang J, Sari H, Goldman R, Huff E, Hanna A, Samraj R, Gourabathini H, Bhalala U. Neurological Pupillary Index (NPi) Measurement Using Pupillometry and Outcomes in Critically Ill Children. Cureus 2023; 15:e46480. [PMID: 37927706 PMCID: PMC10624239 DOI: 10.7759/cureus.46480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Aim/objective Neurological Pupil Index (NPi), measured by automated pupillometry (AP), allows the objective assessment of pupillary light reflex (PLR). NPi ranges from 0 (non-reactive) to 5 (normal). In this study, we aimed to compare neurologic and functional outcomes in children admitted for neurologic injury with normal (≥3) versus abnormal (<3) NPi measured during their pediatric intensive care unit (PICU) stay. Materials and methods We conducted a retrospective chart review of children between one month and 18 years admitted to our PICU with a diagnosis of neurologic injury between January 2019 and June 2022. We collected demographic, clinical, pupillometer, and outcome data, including mortality, Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and Functional Status Score (FSS) at admission, at discharge, and at the three to six-month follow-up. We defined abnormal pupil response as any NPi <3 at any point during the PICU stay. Using the student's t-test and chi-square test, we compared the short-term and long-term outcomes of children with abnormal NPi (<3) versus those with normal NPi (≥3). Results There were 49 children who met the inclusion criteria and who had pupillometry data available for analysis. The mean (SD) Glasgow Coma Scale (GCS) in the study cohort was 5.6 (4.3), and 61% had low (<3) NPi during ICU stay. Mortality was significantly higher among patients with an abnormal NPi as compared to those with normal NPi. Children with abnormal NPi exhibited significant worsening of neurologic and functional status (ΔPCPC, ΔPOPC, and ΔFSS) from admission to discharge (mean (SD): 3.55(1.5), 3.45(1.43), 16.75(7.85), p<0.001) as compared to those with normal NPi (mean (SD): 1.45(0.93), 1.73(0.90), 3.55(2.07), p>0.05). The significant difference in neurologic and functional status persisted at the three to six-month follow-up between the two groups - children with abnormal NPi (mean (SD): 2.0(1.41), 2.08(1.38), 6.92(6.83), p<0.01) and children with normal NPi (mean (SD): 0.82(1.01), 0.94(1.03), 1.53(1.70), p>0.05). Conclusion In our retrospective cohort study, children admitted to the PICU for a neuro injury and with abnormal NPi (< 3) have higher mortality, and worse short-term and long-term neurologic and functional outcomes as compared to those with normal NPi (≥ 3) measured during the PICU course. AP provides an objective assessment of PLR and has potential applications for neuro-prognostication. More research needs to be done to elucidate the prognostic value of NPi in pediatrics.
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Affiliation(s)
- Jessie Jiang
- Medicine, Texas A&M College of Medicine, Round Rock, USA
| | - Halil Sari
- Statistics, Texas A&M College of Medicine, Round Rock, USA
| | - Rachelle Goldman
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | - Erionne Huff
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | - Ashley Hanna
- Pediatric Neurosurgery, Driscoll Children's Hospital, Corpus Christi, USA
| | - Ravi Samraj
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | | | - Utpal Bhalala
- Pediatrics, Texas A&M College of Medicine, College Station, USA
- Anesthesiology and Critical Care, Driscoll Children's Hospital, Corpus Christi, USA
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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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R M, Bansal A. Multimodal Neuromonitoring in Pediatric Neurocritical Care: Current Perspectives. Indian J Pediatr 2023; 90:261-271. [PMID: 36607512 DOI: 10.1007/s12098-022-04415-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/28/2022] [Indexed: 01/07/2023]
Abstract
Children with neurological illness in the critical care unit are always at higher risk of developing secondary brain injury (SBI). Brain insult can lead to changes in cerebral autoregulation, intracranial pressure (ICP), cerebral oxygenation, and metabolism. This can cause a raised ICP, cerebral ischemia, hypoxia, excitotoxicity, cellular energy failure, and nonconvulsive status epilepticus. Simultaneous and continuous assessment of these parameters will help to improve patient care and neurological outcomes. Even though clinical examination and neuroimaging can help in the initial diagnosis of the neurological illness, they may not be helpful in continuous monitoring of cerebral pathophysiological changes. The ideal single neuromonitoring device to detect these real-time changes is currently unavailable. However, a range of invasive and noninvasive monitors are available to monitor these cerebral functional parameters. Invasive monitoring techniques include invasive ICP monitoring, cerebral autoregulation monitoring, brain tissue partial oxygen pressure, and cerebral microdialysis. Noninvasive-monitoring techniques include pupillometry, brain and ocular ultrasonography, near-infrared spectroscopy, and electrophysiological monitoring. Multimodal (MM) neuromonitoring involves incorporating these techniques and tools for the early identification and treatment of primary and secondary brain insults. The utility and feasibility of most of these techniques are well described in adult neurocritical care. Even though the evidence on their usage in children is primarily available in pediatric traumatic brain injury, the emerging data help to further expand their utility in pediatric nontraumatic coma. MM neuromonitoring aims to provide clinical and pathophysiological information to the intensivists to improve their understanding of the child's neurological status and to formulate patient-specific treatment approaches.
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Affiliation(s)
- Muthuvel R
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Arun Bansal
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
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Brown KL, Agrawal S, Kirschen MP, Traube C, Topjian A, Pressler R, Hahn CD, Scholefield BR, Kanthimathinathan HK, Hoskote A, D'Arco F, Bembea M, Manning JC, Hunfeld M, Buysse C, Tasker RC. The brain in pediatric critical care: unique aspects of assessment, monitoring, investigations, and follow-up. Intensive Care Med 2022; 48:535-547. [PMID: 35445823 PMCID: PMC10082392 DOI: 10.1007/s00134-022-06683-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/15/2022] [Indexed: 02/05/2023]
Abstract
As survival after pediatric intensive care unit (PICU) admission has improved over recent years, a key focus now is the reduction of morbidities and optimization of quality of life for survivors. Neurologic disorders and direct brain injuries are the reason for 11-16% of admissions to PICU. In addition, many critically ill children are at heightened risk of brain injury and neurodevelopmental difficulties affecting later life, e.g., complex heart disease and premature birth. Hence, assessment, monitoring and protection of the brain, using fundamental principles of neurocritical care, are crucial to the practice of pediatric intensive care medicine. The assessment of brain function, necessary to direct appropriate care, is uniquely challenging amongst children admitted to the PICU. Challenges in assessment arise in children who are unstable, or pharmacologically sedated and muscle relaxed, or who have premorbid abnormality in development. Moreover, the heterogeneity of diseases and ages in PICU patients, means that high caliber evidence is harder to accrue than in adult practice, nonetheless, great progress has been made over recent years. In this 'state of the art' paper about critically ill children, we discuss (1) patient types at risk of brain injury, (2) new standardized clinical assessment tools for age-appropriate, clinical evaluation of brain function, (3) latest evidence related to cranial imaging, non-invasive and invasive monitoring of the brain, (4) the concept of childhood 'post intensive are syndrome' and approaches for neurodevelopmental follow-up. Better understanding of these concepts is vital for taking PICU survivorship to the next level.
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Affiliation(s)
- Kate L Brown
- Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK. .,Institute of Cardiovascular, Science University College London, London, UK.
| | - Shruti Agrawal
- Paediatric Intensive Care Unit Addenbrookes Hospital, Cambridge, UK
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, USA, Philadelphia.,University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Chani Traube
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, USA, Philadelphia.,University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Ronit Pressler
- Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK.,Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK.,University College London Institute of Child Health, London, UK
| | - Cecil D Hahn
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Barnaby R Scholefield
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Hari Krishnan Kanthimathinathan
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Aparna Hoskote
- Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK.,Institute of Cardiovascular, Science University College London, London, UK
| | - Felice D'Arco
- Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK.,University College London Institute of Child Health, London, UK
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph C Manning
- Nottingham Children's Hospital and Neonatology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Centre for Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Maayke Hunfeld
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Pediatric Neurology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Corinne Buysse
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Selwyn College, Cambridge University, Cambridge, UK
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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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McGetrick ME, Schneider N, Olson DM, Aiyagari V, Miles D. Automated Infrared Pupillometer Use in Assessing the Neurological Status in Pediatric Neurocritical Care Patients: Case Reports and Literature Review. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0041-1731074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AbstractAutomated infrared pupillometry (AIP) is rapidly becoming an accepted standard for the evaluation of pupil size and reactivity in adult neurocritical care. Recently, pediatric centers are increasingly utilizing this technology, but data supporting its use in children are limited. Our pediatric intensive care unit instituted AIP as a standard of care for pupillary light assessments in neurocritical care patients in early 2020. In this article, we describe four cases highlighting the advantage of using objective assessments of the pupillary light reactivity response measured by the Neurological Pupil index (NPi) to detect early changes in the patient's neurological status. These cases support the applicability of AIP in pediatric neurocritical care as a noninvasive neurologic monitoring tool. The NPi may be superior to manual pupil assessments by providing a numerical scale for accurate trending clinical status of a patient's neurologic condition.
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Affiliation(s)
- Molly E. McGetrick
- Division of Critical Care, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Nathan Schneider
- The University of Texas Southwestern ODL Brain Institute, Dallas, Texas, United States
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - DaiWai M. Olson
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
- Department of Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Venkatesh Aiyagari
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
- Department of Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Darryl Miles
- Division of Critical Care, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas, United States
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