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Totapally A, Fretz EA, Wolf MS. A narrative review of neuromonitoring modalities in critically ill children. Minerva Pediatr (Torino) 2024; 76:556-565. [PMID: 37462589 DOI: 10.23736/s2724-5276.23.07291-9] [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: 07/09/2024]
Abstract
Acute neurologic injury is common in critically ill children. Some conditions - such as traumatic brain injury, meningitis, and hypoxic-ischemic injury following cardiac arrest - require careful consideration of cerebral physiology. Specialized neuromonitoring techniques provide insight regarding patient-specific and disease-specific insight that can improve diagnostic accuracy, aid in targeting therapeutic interventions, and provide prognostic information. In this review, we will discuss recent innovations in invasive (e.g., intracranial pressure monitoring and related computed indices) and noninvasive (e.g., transcranial doppler, near-infrared spectroscopy) neuromonitoring techniques used in traumatic brain injury, central nervous system infections, and after cardiac arrest. We will discuss the pertinent physiological mechanisms interrogated by each technique and discuss available evidence for potential clinical application. We will also discuss the use of innovative neuromonitoring techniques to detect and manage neurologic complications in critically ill children with systemic illness, focusing on sepsis and cardiorespiratory failure requiring extracorporeal membrane oxygenation.
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Affiliation(s)
- Abhinav Totapally
- Division of Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Emily A Fretz
- Division of Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Michael S Wolf
- Division of Critical Care Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA -
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2
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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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3
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Mensink HA, Desai A, Cvetkovic M, Davidson M, Hoskote A, O'Callaghan M, Thiruchelvam T, Roeleveld PP. The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO. Perfusion 2024; 39:81S-94S. [PMID: 38651582 DOI: 10.1177/02676591241236139] [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] [Indexed: 04/25/2024]
Abstract
Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.
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Affiliation(s)
- H A Mensink
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - A Desai
- Paediatric Intensive Care, Royal Brompton Hospital, London, UK
| | - M Cvetkovic
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M Davidson
- Critical Care Medicine, Royal Hospital for Children, Glasgow, UK
| | - A Hoskote
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M O'Callaghan
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - T Thiruchelvam
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - P P Roeleveld
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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Michel A, Vedrenne-Cloquet M, Kossorotoff M, Thy M, Levy R, Pouletty M, De Marcellus C, Grimaud M, Moulin F, Hully M, Simonnet H, Desguerre I, Renolleau S, Oualha M, Chareyre J. Neurologic Outcomes and Quality of Life in Children After Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2024; 25:e158-e167. [PMID: 38088764 DOI: 10.1097/pcc.0000000000003419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
RATIONALE Use of life support with extracorporeal membrane oxygenation (ECMO) is associated with brain injury. However, the consequences of these injuries on subsequent neurologic development and health-related quality of life (HRQoL) are poorly described in children. OBJECTIVES The aim of this preliminary study was to describe short- and long-term neurologic outcomes in survivors of ECMO, as well as their HRQoL. DESIGN Retrospective identified cohort with contemporary evaluations. SETTING Necker Children's Hospital academic PICU. PATIENTS Forty survivors who underwent ECMO (October 2014 to January 2020) were included in follow-up assessments in May 2021. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS We first reviewed the outcomes of ECMO at the time of PICU discharge, which included a summary of neurology, radiology, and Pediatric Overall/Cerebral Performance Category (POPC/PCPC) scores. Then, in May 2021, we interviewed parents and patients to assess HRQoL (Pediatric Quality of Life Inventory [PedsQL]) and POPC/PCPC for children 3 years old or older, and Denver II test (DTII) for younger children. An evaluation of DTII in the youngest patients 1 year after ECMO decannulation was also added. Median age at ECMO was 1.4 years (interquartile range [IQR], 0.4-6 yr). Thirty-five children (88%) underwent a venoarterial ECMO. At PICU discharge, 15 of 40 patients (38%) had neurologic impairment. Assessment of HRQoL was carried out at median of 1.6 years (IQR, 0.7-3.3 yr) after PICU discharge. PedsQL scores were over 70 of 100 for all patients (healthy peers mean results: 80/100), and scores were like those published in patients suffering with chronic diseases. In May 2021, seven of 15 patients had a normal DTII, and 36 of 40 patients had a POPC/PCPC score less than or equal to 3. CONCLUSIONS None of our patients presented severe disability at long term, and HRQoL evaluation was reassuring. Considering the risk of neurologic impairment after ECMO support, a systematic follow-up of these high-risk survivor patients would be advisable.
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Affiliation(s)
- Alizée Michel
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Meryl Vedrenne-Cloquet
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | | | - Michaël Thy
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Raphaël Levy
- Radiologie Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marie Pouletty
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Charles De Marcellus
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marion Grimaud
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Florence Moulin
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Marie Hully
- Neurologie Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
| | - Hina Simonnet
- Service de Rééducation Pédiatrique Hôpital Trousseau, Paris, France
| | | | - Sylvain Renolleau
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Mehdi Oualha
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Judith Chareyre
- Réanimation Medico-Chirurgicale Pédiatrique, Hôpital Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
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Zhang LQ, Chang H, Kalra A, Humayun M, Rosenblatt KR, Shah VA, Geocadin RG, Brown CH, Kim BS, Whitman GJR, Rivera-Lara L, Cho SM. Continuous Monitoring of Cerebral Autoregulation in Adults Supported by Extracorporeal Membrane Oxygenation. Neurocrit Care 2024:10.1007/s12028-023-01932-w. [PMID: 38326536 DOI: 10.1007/s12028-023-01932-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/21/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Impaired cerebral autoregulation (CA) is one of several proposed mechanisms of acute brain injury in patients supported by extracorporeal membrane oxygenation (ECMO). The primary aim of this study was to determine the feasibility of continuous CA monitoring in adult ECMO patients. Our secondary aims were to describe changes in cerebral oximetry index (COx) and other metrics of CA over time and in relation to functional neurologic outcomes. METHODS This is a single-center prospective observational study. We measured COx, a surrogate measurement of cerebral blood flow measured by near-infrared spectroscopy, which is an index of CA derived from the moving correlation between mean arterial pressure (MAP) and slow waves of regional cerebral oxygen saturation. A COx value that approaches 1 indicates impaired CA. Using COx, we determined the optimal MAP (MAPOPT) and lower and upper limits of autoregulation for individual patients. These measurements were examined in relation to modified Rankin Scale (mRS) scores. RESULTS Fifteen patients (median age 57 years [interquartile range 47-69]) with 150 autoregulation measurements were included for analysis. Eleven were on veno-arterial ECMO (VA-ECMO), and four were on veno-venous ECMO (VV-ECMO). Mean COx was higher on postcannulation day 1 than on day 2 (0.2 vs. 0.09, p < 0.01), indicating improved CA over time. COx was higher in VA-ECMO patients than in VV-ECMO patients (0.12 vs. 0.06, p = 0.04). Median MAPOPT for the entire cohort was highly variable, ranging from 55 to 110 mm Hg. Patients with mRS scores 0-3 (good outcome) at 3 and 6 months spent less time outside MAPOPT compared with patients with mRS scores 4-6 (poor outcome) (74% vs. 82%, p = 0.01). The percentage of time when observed MAP was outside the limits of autoregulation was higher on postcannulation day 1 than on day 2 (18.2% vs. 3.3%, p < 0.01). CONCLUSIONS In ECMO patients, it is feasible to monitor CA continuously at the bedside. CA improved over time, most significantly between postcannulation days 1 and 2. CA was more impaired in VA-ECMO patients than in VV-ECMO patients. Spending less time outside MAPOPT may be associated with achieving a good neurologic outcome.
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Affiliation(s)
- Lucy Q Zhang
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Henry Chang
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mariyam Humayun
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Kathryn R Rosenblatt
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishank A Shah
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Romergryko G Geocadin
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lucia Rivera-Lara
- Department of Neurology and Center for Academic Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA.
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 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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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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Zhang LQ, Chang H, Kalra A, Humayun M, Rosenblatt KR, Shah VA, Geocadin RG, Brown CH, Kim BS, Whitman GJR, Rivera-Lara L, Cho SM. Continuous Monitoring of Cerebral Autoregulation in Adults Supported by Extracorporeal Membrane Oxygenation. RESEARCH SQUARE 2023:rs.3.rs-3300834. [PMID: 37790309 PMCID: PMC10543291 DOI: 10.21203/rs.3.rs-3300834/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Background Impaired cerebral autoregulation (CA) is one of several proposed mechanisms of acute brain injury in patients supported by extracorporeal membrane oxygenation (ECMO). The primary aim of this study was to determine the feasibility of continuous CA monitoring in adult ECMO patients. Our secondary aims were to describe changes in cerebral oximetry index (COx) and other metrics of CA over time and in relation to functional neurologic outcomes. Methods This is a single-center prospective observational study. We measured Cox, a surrogate measurement of cerebral blood flow, measured by near-infrared spectroscopy, which is an index of CA derived from the moving correlation between mean arterial pressure and slow waves of regional cerebral oxygen saturation. A COx value that approaches 1 indicates impaired CA. Using COx, we determined the optimal MAP (MAPOPT), lower and upper limits of autoregulation for individual patients. These measurements were examined in relation to modified Rankin Scale (mRS) scores. Results Fifteen patients (median age=57 years [IQR=47-69]) with 150 autoregulation measurements were included for analysis. Eleven were on veno-arterial ECMO and 4 on veno-venous. Mean COx was higher on post-cannulation day 1 than on day 2 (0.2 vs 0.09, p<0.01), indicating improved CA over time. COx was higher in VA-ECMO patients than in VV-ECMO (0.12 vs 0.06, p=0.04). Median MAPOPT for entire cohort was highly variable, ranging 55-110 mmHg. Patients with mRS 0-3 (good outcome) at 3 and 6 months spent less time outside of MAPOPT compared to patients with mRS 4-6 (poor outcome) (74% vs 82%, p=0.01). The percentage of time when observed MAP was outside the limits of autoregulation was higher on post-cannulation day 1 than on day 2 (18.2% vs 3.3%, p<0.01). Conclusions In ECMO patients, it is feasible to monitor CA continuously at the bedside. CA improved over time, most significantly between post-cannulation days 1 and 2. CA was more impaired in VA-ECMO than VV-ECMO. Spending less time outside of MAPOPT may be associated with achieving a good neurologic outcome.
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Affiliation(s)
- Lucy Q Zhang
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Henry Chang
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Andrew Kalra
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Mariyam Humayun
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Kathryn R Rosenblatt
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Vishank A Shah
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | | | - Charles H Brown
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Bo Soo Kim
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Glenn J R Whitman
- Johns Hopkins School of Medicine: The Johns Hopkins University School of Medicine
| | - Lucia Rivera-Lara
- Stanford University Department of Neurology and Neurological Sciences
| | - Sung-Min Cho
- Johns Hopkins Department of Anesthesiology and Critical Care Medicine: Johns Hopkins Medicine Department of Anesthesiology and Critical Care Medicine
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9
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Callier K, Dantes G, Johnson K, Linden AF. Pediatric ECLS Neurologic Management and Outcomes. Semin Pediatr Surg 2023; 32:151331. [PMID: 37944407 DOI: 10.1016/j.sempedsurg.2023.151331] [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] [Indexed: 11/12/2023]
Abstract
Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus.
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Affiliation(s)
- Kylie Callier
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Kevin Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Allison F Linden
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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10
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Rozencwajg S, Heinsar S, Wildi K, Jung JS, Colombo SM, Palmieri C, Sato K, Ainola C, Wang X, Abbate G, Sato N, Dyer WB, Livingstone S, Helms L, Bartnikowski N, Bouquet M, Passmore MR, Hyslop K, Vidal B, Reid JD, McGuire D, Wilson ES, Rätsep I, Lorusso R, Schmidt M, Suen JY, Bassi GL, Fraser JF. Effect of flow change on brain injury during an experimental model of differential hypoxaemia in cardiogenic shock supported by extracorporeal membrane oxygenation. Sci Rep 2023; 13:4002. [PMID: 36899029 PMCID: PMC10006234 DOI: 10.1038/s41598-023-30226-6] [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: 12/23/2022] [Accepted: 02/17/2023] [Indexed: 03/12/2023] Open
Abstract
Differential hypoxaemia (DH) is common in patients supported by femoral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and can cause cerebral hypoxaemia. To date, no models have studied the direct impact of flow on cerebral damage. We investigated the impact of V-A ECMO flow on brain injury in an ovine model of DH. After inducing severe cardiorespiratory failure and providing ECMO support, we randomised six sheep into two groups: low flow (LF) in which ECMO was set at 2.5 L min-1 ensuring that the brain was entirely perfused by the native heart and lungs, and high flow (HF) in which ECMO was set at 4.5 L min-1 ensuring that the brain was at least partially perfused by ECMO. We used invasive (oxygenation tension-PbTO2, and cerebral microdialysis) and non-invasive (near infrared spectroscopy-NIRS) neuromonitoring, and euthanised animals after five hours for histological analysis. Cerebral oxygenation was significantly improved in the HF group as shown by higher PbTO2 levels (+ 215% vs - 58%, p = 0.043) and NIRS (67 ± 5% vs 49 ± 4%, p = 0.003). The HF group showed significantly less severe brain injury than the LF group in terms of neuronal shrinkage, congestion and perivascular oedema (p < 0.0001). Cerebral microdialysis values in the LF group all reached the pathological thresholds, even though no statistical difference was found between the two groups. Differential hypoxaemia can lead to cerebral damage after only a few hours and mandates a thorough neuromonitoring of patients. An increase in ECMO flow was an effective strategy to reduce such damages.
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Affiliation(s)
- Sacha Rozencwajg
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
- UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, Paris, France.
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Australia.
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
- Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Australia
| | - Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Jae-Seung Jung
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Sebastiano Maria Colombo
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anaesthesia and Intensive Care Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Chiara Palmieri
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Xiaomeng Wang
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
| | - Gabriella Abbate
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Department of Anaesthesia and Intensive Care Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Lombardia, Italy
| | - Noriko Sato
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
| | - Wayne B Dyer
- Australian Red Cross Lifeblood, Sydney, Australia
| | - Samantha Livingstone
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
| | - Leticia Helms
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Columbia University, College of Physicians and Surgeons, New York, USA
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Science and Engineering Faculty, Queensland University of Technology, Brisbane, QLD, Australia
| | - Mahe Bouquet
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Kieran Hyslop
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Bruno Vidal
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
| | - Janice D Reid
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Daniel McGuire
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
| | - Emily S Wilson
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Indrek Rätsep
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Matthieu Schmidt
- Service de Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
- UPMC Université Paris 06, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Universités, Paris, France
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Australia.
- Queensland University of Technology, Brisbane, Australia.
- Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Australia.
- Intensive Care Unit, The Wesley Hospital, Brisbane, Australia.
- Wesley Medical Research, The Wesley, Queensland, Auchenflower, Australia.
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3, Clinical Sciences Building, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Australia
- Intensive Care Unit, The Wesley Hospital, Brisbane, Australia
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11
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Neuromonitoring for prognostication under ECMO. Intensive Care Med 2023; 49:451-454. [PMID: 36790513 DOI: 10.1007/s00134-023-06989-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/16/2023] [Indexed: 02/16/2023]
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12
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Kohne JG, MacLaren G, Shellhaas RA, Benedetti G, Barbaro RP. Variation in electroencephalography and neuroimaging for children receiving extracorporeal membrane oxygenation. Crit Care 2023; 27:23. [PMID: 36650540 PMCID: PMC9847194 DOI: 10.1186/s13054-022-04293-6] [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] [Received: 11/14/2022] [Accepted: 12/24/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Seizures, strokes, and intracranial hemorrhage are common and feared complications in children receiving extracorporeal membrane oxygenation (ECMO) support. Researchers and clinicians have proposed and deployed methods for monitoring and detecting neurologic injury, but best practices are unknown. We sought to characterize clinicians' approach to electroencephalography (EEG) and brain imaging modalities in children supported by ECMO. METHODS We performed a retrospective observational cohort study among US Children's Hospitals participating in the Pediatric Health Information System (PHIS) from 2016 to 2021. We identified hospitalizations containing ECMO support. We stratified these admissions by pediatric, neonatal, cardiac surgery, and non-cardiac surgery. We characterized the frequency of EEG, cranial ultrasound, brain computed tomography (CT), magnetic resonance imaging (MRI), and transcranial Doppler during ECMO hospitalizations. We reported key diagnoses (stroke and seizures) and the prescription of antiseizure medication. To assess hospital variation, we created multilevel logistic regression models. RESULTS We identified 8746 ECMO hospitalizations. Nearly all children under 1 year of age (5389/5582) received a cranial ultrasound. Sixty-two percent of the cohort received an EEG, and use increased from 2016 to 2021 (52-72% of hospitalizations). There was marked variation between hospitals in rates of EEG use. Rates of antiseizure medication use (37% of hospitalizations) and seizure diagnoses (20% of hospitalizations) were similar across hospitals, including high and low EEG utilization hospitals. Overall, 37% of the cohort received a CT and 36% received an MRI (46% of neonatal patients). Stroke diagnoses (16% of hospitalizations) were similar between high- and low-MRI utilization hospitals (15% vs 17%, respectively). Transcranial Doppler (TCD) was performed in just 8% of hospitalizations, and 77% of the patients who received a TCD were cared for at one of five centers. CONCLUSIONS In this cohort of children at high risk of neurologic injury, there was significant variation in the approach to EEG and neuroimaging in children on ECMO. Despite the variation in monitoring and imaging, diagnoses of seizures and strokes were similar across hospitals. Future work needs to identify a management strategy that appropriately screens and monitors this high-risk population without overuse of resource-intensive modalities.
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Affiliation(s)
- Joseph G. Kohne
- grid.214458.e0000000086837370Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, USA ,grid.214458.e0000000086837370Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, USA
| | - Graeme MacLaren
- grid.410759.e0000 0004 0451 6143Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Renée A. Shellhaas
- grid.214458.e0000000086837370Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, USA
| | - Giulia Benedetti
- grid.240741.40000 0000 9026 4165Department of Neurology, Seattle Children’s Hospital and University of Washington, Seattle, USA
| | - Ryan P. Barbaro
- grid.214458.e0000000086837370Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, USA ,grid.214458.e0000000086837370Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, USA
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13
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Hoskote A, Hunfeld M, O'Callaghan M, IJsselstijn H. Neonatal ECMO survivors: The late emergence of hidden morbidities - An unmet need for long-term follow-up. Semin Fetal Neonatal Med 2022; 27:101409. [PMID: 36456434 DOI: 10.1016/j.siny.2022.101409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Aparna Hoskote
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Maayke Hunfeld
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, the Netherlands
| | - Maura O'Callaghan
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Hanneke IJsselstijn
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, the Netherlands
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14
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Li Q, Shen J, Lv H, Liu Y, Chen Y, Zhou C, Shi J. Incidence, risk factors, and outcomes in electroencephalographic seizures after mechanical circulatory support: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:872005. [PMID: 35990978 PMCID: PMC9381842 DOI: 10.3389/fcvm.2022.872005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeTo estimate the overall incidence, risk factors, and clinical outcomes of electroencephalographic (EEG) seizures for adults and children after mechanical circulatory support (MCS).Method and measurementsThis systematic review and meta-analysis were carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidance document. MEDLINE EMBASE and CENTRAL were investigated for relevant studies. The related information was retrieved by two independent reviewers and all analyses were conducted by STATA (version 16.0; Stata Corporation, College Station, TX, United States).ResultSixty studies including 36,191 adult and 55,475 pediatric patients with MCS were enrolled for evaluation. The study showed that the overall incidence of EEG seizures in adults was 2% (95%CI: 1–3%), in which 1% (95%CI: 1–2%) after cardiopulmonary bypass (CPB), and 3% (95%CI: 1–6%) after extracorporeal membrane oxygenation (ECMO). For pediatrics patients, the incidence of EEG seizures was 12% (95%CI: 11–14%), among which 12% (9–15%) after CPB and 13% (11–15%) after ECMO. The major risk factors of EEG seizures after MCS in adults were redo surgery (coefficient = 0.0436, p = 0.044), and COPD (coefficient = 0.0749, p = 0.069). In addition, the gestational week of CPB (coefficient = 0.0544, p = 0.080) and respiratory failure of ECMO (coefficient = –0.262, p = 0.019) were also indicated to be associated with EEG seizures in pediatrics.ConclusionEEG seizures after MCS were more common in pediatrics than in adults. In addition, the incidence of EEG seizure after ECMO was higher than CPB both in adults and children. It is expected that appropriate measures should be taken to control modifiable risk factors, thus improving the prognosis and increasing the long-term survival rate of MCS patients.Systematic Review Registration[https://www.crd.york.ac.uk/prospero], identifier [CRD42021287288].
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15
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Chang N, Rasmussen L. Exploring Trends in Neuromonitoring Use in a General Pediatric ICU: The Need for Standardized Guidance. CHILDREN (BASEL, SWITZERLAND) 2022; 9:934. [PMID: 35883918 PMCID: PMC9324621 DOI: 10.3390/children9070934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 12/26/2022]
Abstract
Neuromonitoring has become more standardized in adult neurocritical care, but the utility of different neuromonitoring modalities in children remains debated. We aimed to describe the use of neuromonitoring in critically ill children with and without primary neurological diseases. We conducted a retrospective review of patients admitted to a 32-bed, non-cardiac PICU during a 12-month period. Neuro-imaging, electroencephalogram (EEG), cerebral oximetry (NIRS), automated pupillometry, transcranial doppler (TCD), intracranial pressure (ICP) monitoring, brain tissue oxygenation (PbtO2), primary diagnosis, and outcome were extracted. Neuromonitoring use by primary diagnosis and associations with outcome were observed. Of 1946 patients, 420 received neuro-imaging or neuromonitoring. Primary non-neurological diagnoses most frequently receiving neuromonitoring were respiratory, hematologic/oncologic, gastrointestinal/liver, and infectious/inflammatory. The most frequently used technologies among non-neurological diagnoses were neuro-imaging, EEG, pupillometry, and NIRS. In the multivariate analysis, pupillometry use was associated with mortality, and EEG, NIRS, and neuro-imaging use were associated with disability. Frequencies of TCD and PbtO2 use were too small for analysis. Neuromonitoring is prevalent among various diagnoses in the PICU, without clear benefit on outcomes when used in an ad hoc fashion. We need standard guidance around who, when, and how neuromonitoring should be applied to improve the care of critically ill children.
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Affiliation(s)
- Nathan Chang
- Pediatric Critical Care Medicine and Neurocritical Care, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA 94304, USA;
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