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Sansevere AJ, Janatti A, DiBacco ML, Cavan K, Rotenberg A. Background EEG Suppression Ratio for Early Detection of Cerebral Injury in Pediatric Cardiac Arrest. Neurocrit Care 2024; 41:156-164. [PMID: 38302644 DOI: 10.1007/s12028-023-01920-0] [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: 08/10/2023] [Accepted: 12/05/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Our objective was to assess the utility of the 1-h suppression ratio (SR) as a biomarker of cerebral injury and neurologic prognosis after cardiac arrest (CA) in the pediatric hospital setting. METHODS Prospectively, we reviewed data from children presenting after CA and monitored by continuous electroencephalography (cEEG). Patients aged 1 month to 21 years were included. The SR, a quantitative measure of low-voltage cEEG (≤ 3 µV) content, was dichotomized as present or absent if there was > 0% suppression for one continuous hour. A multivariate logistic regression analysis was performed including age, sex, type of CA (i.e., in-hospital or out-of-hospital), and the presence of SR as a predictor of global anoxic cerebral injury as confirmed by magnetic resonance imaging (MRI). RESULTS We included 84 patients with a median age of 4 years (interquartile range 0.9-13), 64% were male, and 49% (41/84) had in-hospital CA. Cerebral injury was seen in 50% of patients, of whom 65% had global injury. One-hour SR presence, independent of amount, predicted cerebral injury with 81% sensitivity (95% confidence interval (CI) (66-91%) and 98% specificity (95% CI 88-100%). Multivariate logistic regression analyses indicated that SR was a significant predictor of both cerebral injury (β = 6.28, p < 0.001) and mortality (β = 3.56, p < 0.001). CONCLUSIONS The SR a sensitive and specific marker of anoxic brain injury and post-CA mortality in the pediatric population. Once detected in the post-CA setting, the 1-h SR may be a useful threshold finding for deployment of early neuroprotective strategies prior or for prompting diagnostic neuroimaging.
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Affiliation(s)
- Arnold J Sansevere
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.
- Division of Epilepsy, Department of Neurology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20001, USA.
| | - Ali Janatti
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Melissa L DiBacco
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Kelly Cavan
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Alexander Rotenberg
- Division of Epilepsy and Neurophysiology, Boston Children's Hospital, Boston, MA, USA
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
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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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3
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Yan K, Tang LK, Xiao FF, Zhang P, Cheng GQ, Wang LS, Lu CM, Ge MM, Hu LY, Zhou YF, Xiao TT, Xu Y, Yin ZQ, Yan GF, Lu GP, Li Q, Zhou WH. Brain development in newborns and infants after ECMO. World J Pediatr 2024; 20:556-568. [PMID: 38238638 PMCID: PMC11239726 DOI: 10.1007/s12519-023-00768-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 09/28/2023] [Indexed: 07/12/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) not only significantly improves survival rates in severely ill neonates but also is associated with long-term neurodevelopmental issues. To systematically review the available literature on the neurodevelopmental outcomes of neonates and infants who have undergone ECMO treatment, with a focus on motor deficits, cognitive impairments, sensory impairments, and developmental delays. This review aims to understand the incidence, prevalence, and risk factors for these problems and to explore current nursing care and management strategies. DATA SOURCES A comprehensive literature search was performed across PubMed, EMBASE, and Web of Science using a wide array of keywords and phrases pertaining to ECMO, neonates, infants, and various facets of neurodevelopment. The initial screening involved reviewing titles and abstracts to exclude irrelevant articles, followed by a full-text assessment of potentially relevant literature. The quality of each study was evaluated based on its research methodology and statistical analysis. Moreover, citation searches were conducted to identify potentially overlooked studies. Although the focus was primarily on neonatal ECMO, studies involving children and adults were also included due to the limited availability of neonate-specific literature. RESULTS About 50% of neonates post-ECMO treatment exhibit varying degrees of brain injury, particularly in the frontal and temporoparietal white matter regions, often accompanied by neurological complications. Seizures occur in 18%-23% of neonates within the first 24 hours, and bleeding events occur in 27%-60% of ECMO procedures, with up to 33% potentially experiencing ischemic strokes. Although some studies suggest that ECMO may negatively impact hearing and visual development, other studies have found no significant differences; hence, the influence of ECMO remains unclear. In terms of cognitive, language, and intellectual development, ECMO treatment may be associated with potential developmental delays, including lower composite scores in cognitive and motor functions, as well as potential language and learning difficulties. These studies emphasize the importance of early detection and intervention of potential developmental issues in ECMO survivors, possibly necessitating the implementation of a multidisciplinary follow-up plan that includes regular neuromotor and psychological evaluations. Overall, further multicenter, large-sample, long-term follow-up studies are needed to determine the impact of ECMO on these developmental aspects. CONCLUSIONS The impact of ECMO on an infant's nervous system still requires further investigation with larger sample sizes for validation. Fine-tuned management, comprehensive nursing care, appropriate patient selection, proactive monitoring, nutritional support, and early rehabilitation may potentially contribute to improving the long-term outcomes for these infants.
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Affiliation(s)
- Kai Yan
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
| | - Lu-Kun Tang
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
- Kunming Medical University Affiliated Dehong Hospital, Dehong, Yunnan, China
- Graduate School, Kunming Medical University, Kunming, Yunnan, China
| | - Fei-Fan Xiao
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
| | - Peng Zhang
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
| | - Guo-Qiang Cheng
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
| | - Lai-Shuan Wang
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
| | - Chun-Mei Lu
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
| | - Meng-Meng Ge
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
| | - Li-Yuan Hu
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China
| | - Yuan-Feng Zhou
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Tian-Tian Xiao
- School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Yan Xu
- Department of Neurology, Children's Hospital of Fudan University, Shanghai, China
| | - Zhao-Qing Yin
- Kunming Medical University Affiliated Dehong Hospital, Dehong, Yunnan, China
- Graduate School, Kunming Medical University, Kunming, Yunnan, China
| | - Gang-Feng Yan
- Department of Intensive Care Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Guo-Ping Lu
- Department of Intensive Care Medicine, Children's Hospital of Fudan University, Shanghai, China
| | - Qi Li
- Department of Intensive Care Medicine, The Sixth Medical Center of PLA General Hospital, Beijing, China.
| | - Wen-Hao Zhou
- Department of Neonatology, Children Hospital of Fudan University, Shanghai, 201102, China.
- Key Laboratory of Neonatology, National Health Care Commission, Shanghai, China.
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4
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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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Tabet M, Custer C, Khan IR, Sanford E, Sharma J, Choe R, Singh S, Sirsi D, Olson DM, Morriss MC, Raman L, Busch DR. Neuromonitoring of Pediatric and Adult Extracorporeal Membrane Oxygenation Patients: The Importance of Continuous Bedside Tools in Driving Neuroprotective Clinical Care. ASAIO J 2024; 70:167-176. [PMID: 38051987 DOI: 10.1097/mat.0000000000002107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of temporary cardiopulmonary bypass for patients with acute respiratory or cardiac failure refractory to conventional therapy. Its usage has become increasingly widespread and while reported survival after ECMO has increased in the past 25 years, the incidence of neurological injury has not declined, leading to the pressing question of how to improve time-to-detection and diagnosis of neurological injury. The neurological status of patients on ECMO is clinically difficult to evaluate due to multiple factors including illness, sedation, and pharmacological paralysis. Thus, increasing attention has been focused on developing tools and techniques to measure and monitor the brain of ECMO patients to identify dynamic risk factors and monitor patients' neurophysiological state as a function in time. Such tools may guide neuroprotective interventions and thus prevent or mitigate brain injury. Current means to continuously monitor and prevent neurological injury in ECMO patients are rather limited; most techniques provide indirect or postinsult recognition of irreversible brain injury. This review will explore the indications, advantages, and disadvantages of standard-of-care, emerging, and investigational technologies for neurological monitoring on ECMO, focusing on bedside techniques that provide continuous assessment of neurological health.
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Affiliation(s)
- Margherita Tabet
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Chasity Custer
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Imad R Khan
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ethan Sanford
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Jayesh Sharma
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Regine Choe
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, New York
| | - Sumit Singh
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Deepa Sirsi
- Division of Pediatric Neurology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Department of Pediatrics, The University of Texas Southwestern medical center
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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Benedetti GM, Guerriero RM, Press CA. Review of Noninvasive Neuromonitoring Modalities in Children II: EEG, qEEG. Neurocrit Care 2023; 39:618-638. [PMID: 36949358 PMCID: PMC10033183 DOI: 10.1007/s12028-023-01686-5] [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: 07/28/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Critically ill children with acute neurologic dysfunction are at risk for a variety of complications that can be detected by noninvasive bedside neuromonitoring. Continuous electroencephalography (cEEG) is the most widely available and utilized form of neuromonitoring in the pediatric intensive care unit. In this article, we review the role of cEEG and the emerging role of quantitative EEG (qEEG) in this patient population. cEEG has long been established as the gold standard for detecting seizures in critically ill children and assessing treatment response, and its role in background assessment and neuroprognostication after brain injury is also discussed. We explore the emerging utility of both cEEG and qEEG as biomarkers of degree of cerebral dysfunction after specific injuries and their ability to detect both neurologic deterioration and improvement.
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Affiliation(s)
- Giulia M Benedetti
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA.
- Division of Pediatric Neurology, Department of Pediatrics, C.S. Mott Children's Hospital and the University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI, 48109-4279, USA.
| | - Rejéan M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Craig A Press
- Departments of Neurology and Pediatric, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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7
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deCampo D, Husari KS, Bembea MM, Habela CW, Ritzl EK. Continuous Electroencephalography (EEG) Protocol Improves Seizure Detection in Children on Extracorporeal Membrane Oxygenation. J Child Neurol 2023; 38:581-589. [PMID: 37624689 PMCID: PMC11060699 DOI: 10.1177/08830738231190145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
BACKGROUND / OBJECTIVE Seizures are a complication for pediatric patients requiring extracorporeal membrane oxygenation (ECMO). There are no standardized guidelines regarding continuous electroencephalography (EEG) monitoring to detect seizures in these patients, and the impact of protocolized monitoring has not been evaluated. Here we examined the effects of continuous EEG protocol implementation in our pediatric ECMO population. METHODS Retrospective chart reviews were conducted on 57 patients who underwent extracorporeal membrane oxygenation and concurrent continuous EEG out of 165 patients supported on extracorporeal membrane oxygenation. Timing of continuous EEG initiation and seizures detected by continuous EEG was determined for 5 years prior to and 15 months after protocol implementation. RESULTS Protocol implementation was associated with increased ECMO-supported patients who were concurrently monitored by continuous EEG. Time from ECMO cannulation to continuous EEG initiation was shorter (median 7 hours after versus 16.2 hours before; P < .001). Patients who had ongoing seizures at the start of continuous EEG recording decreased from 64% preprotocol to 0% postprotocol (P < .001), and there was an associated earlier time to break in status epilepticus postprotocol. Seizures were detected past 48 hours after cannulation in 50% of patients in the postprotocol group. CONCLUSIONS Protocol implementation resulted in earlier continuous EEG initiation and more EEGs initiated before seizure onset with evidence of altered seizure dynamics. Although current recommendations suggest that continuous EEG duration of 24-48 hours results in seizure detection for >90% of critically ill adults, longer monitoring may be needed to reliably detect seizures in children supported with ECMO, particularly if monitoring is initiated earlier in the post-cannulation period.
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Affiliation(s)
- Danielle deCampo
- Departments of Neurology, Johns Hopkins Hospital, Baltimore, MD
- Department of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Melania M. Bembea
- Department of Anesthesiology and Critical Care, Johns Hopkins Hospital, Baltimore, MD
| | | | - Eva K. Ritzl
- Departments of Neurology, Johns Hopkins Hospital, Baltimore, MD
- Department of Anesthesiology and Critical Care, Johns Hopkins Hospital, Baltimore, MD
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Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [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: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
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Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
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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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Marchetto L, Alshammari H, Todd M, Guerguerian AM. It All Circles Back to Cerebral Autoregulation: Understanding the Risk of Hypocapnia and Arterial Hypertension When Initialing Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2023; 24:614-617. [PMID: 37409897 DOI: 10.1097/pcc.0000000000003290] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
- Luca Marchetto
- SickKids ECLS Program, Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Hadeel Alshammari
- SickKids ECLS Program, Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mark Todd
- SickKids ECLS Program, Departments of Critical Care Medicine and Respiratory Therapy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anne-Marie Guerguerian
- SickKids ECLS Program, Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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11
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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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12
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Danzer E, Massey SL, Flohr SJ, Mathew L, Hoffman C, Abramson A, Selenski P, Canning CE, Eppley E, Connelly JT, Herkert L, Rintoul NE, Adzick NS, Abend NS, Hedrick HL. Extracorporeal Membrane Oxygenation for Neonates With Congenital Diaphragmatic Hernia: Prevalence of Seizures and Outcomes. Pediatr Crit Care Med 2023; 24:e224-e235. [PMID: 37140337 PMCID: PMC10160669 DOI: 10.1097/pcc.0000000000003197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES We aimed to determine the prevalence of electrographic seizures and associated odds of adverse outcomes of electrographic seizures in neonates with congenital diaphragmatic hernia (CDH) receiving extracorporeal membrane oxygenation (ECMO). DESIGN Retrospective, descriptive case series. SETTING Neonatal ICU (NICU) in a quaternary care institution. PATIENTS All neonates with CDH receiving ECMO undergoing continuous electroencephalographic monitoring (CEEG) and follow-up between January 2012 and December 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All eligible neonates with CDH receiving ECMO underwent CEEG (n = 75). Electrographic seizures occurred in 14 of 75 (19%): they were exclusively electrographic-only in nine of 14, both electrographic-only and electroclinical in three of 14, and electroclinical only in two of 14. Two neonates developed status epilepticus. We identified an association between presence of seizures, rather than not, and longer duration of initial session of CEEG monitoring (55.7 hr [48.2-87.3 hr] vs 48.0 hr [43.0-48.3 hr]; p = 0.001). We also found an association between presence of seizures, rather than not, and greater odds of use of a second CEEG monitoring (12/14 vs 21/61; odds ratio [OR], 11.43 [95% CI, 2.34-55.90; p = 0.0026). Most neonates with seizures (10/14), experienced their onset of seizures more than 96 hours after the start of ECMO. Overall, the presence of electrographic seizures, compared with not, was associated with lower odds of survival to NICU discharge (4/14 vs 49/61; OR 0.10 [95% CI 0.03 to 0.37], p = 0.0006). Also, the presence of seizures-rather than not-was associated with greater odds of a composite of death and all abnormal outcomes on follow-up (13/14 vs 26/61; OR, 17.5; 95% CI, 2.15-142.39; p = 0.0074). CONCLUSIONS Nearly one in five neonates with CDH receiving ECMO developed seizures during the ECMO course. Seizures were predominantly electrographic-only and when present were associated with great odds of adverse outcomes. The current study provides evidence to support standardized CEEG in this population.
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Affiliation(s)
- Enrico Danzer
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shavonne L. Massey
- Department of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sabrina J. Flohr
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leny Mathew
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Casey Hoffman
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abigail Abramson
- Department of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paige Selenski
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Caroline E. Canning
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth Eppley
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - James T Connelly
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lisa Herkert
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Natalie E. Rintoul
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N. Scott Adzick
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nicholas S. Abend
- Department of Neurology and Pediatrics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Holly L. Hedrick
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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13
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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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14
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Stroke in pediatric ECMO patients: analysis of the National Inpatient Sample (NIS) database. Pediatr Res 2022; 92:754-761. [PMID: 35505077 DOI: 10.1038/s41390-022-02088-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/30/2022] [Accepted: 04/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The rates, outcomes, and long-term trends of stroke complicating the use of extracorporeal membrane oxygenation (ECMO) have been inconsistently reported. We compared the outcomes of pediatric ECMO patients with and without stroke and described the frequency trends between 2000 and 2017. METHODS Using the National Inpatient Sample (NIS) database, pediatric patients (age ≤18 years) who received ECMO were identified using ICD-9&10 codes. Binary, regression, and trend analyses were performed to compare patients with and without stroke. RESULTS A total of 114,477,997 records were reviewed. Overall, 28,695 (0.025%) ECMO patients were identified of which 2982 (10.4%) had stroke, which were further classified as hemorrhagic (n = 1464), ischemic (n = 1280), or combined (n = 238). Mortality was higher in the hemorrhagic and combined groups compared to patients with ischemic stroke and patients without stroke. Length of stay (LOS) was significantly longer in stroke vs. no-stroke patients. Hypertension and septicemia were more encountered in the hemorrhagic group, whereas the combined group demonstrated higher frequency of cardiac arrest and seizures. CONCLUSIONS Over the years, there is an apparent increase in the diagnosis of stroke. All types of stroke in ECMO patients are associated with increased LOS, although mortality is increased in hemorrhagic and combined stroke only. IMPACT Stroke is a commonly seen complication in pediatric patients supported by ECMO. Understanding the trends will help in identifying modifiable risk factors that predict poor outcomes in this patient population.
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15
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Amorim E, Firme MS, Zheng WL, Shelton KT, Akeju O, Cudemus G, Yuval R, Westover MB. High incidence of epileptiform activity in adults undergoing extracorporeal membrane oxygenation. Clin Neurophysiol 2022; 140:4-11. [PMID: 35691268 PMCID: PMC9340813 DOI: 10.1016/j.clinph.2022.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 02/20/2022] [Accepted: 04/27/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The prevalence of seizures and other types of epileptiform brain activity in patients undergoing extracorporeal membrane oxygenation (ECMO) is unknown. We aimed to estimate the prevalence of seizures and ictal-interictal continuum patterns in patients undergoing electroencephalography (EEG) during ECMO. METHODS Retrospective review of a prospective ECMO registry from 2011-2018 in a university-affiliated academic hospital. Adult subjects who had decreased level of consciousness and underwent EEG monitoring for seizure screening were included. EEG classification followed the American Clinical Neurophysiology Society criteria. Poor neurological outcome was defined as a Cerebral Performance Category of 3-5 at hospital discharge. RESULTS Three hundred and ninety-five subjects had ECMO, and one hundred and thirteen (28.6%) had EEG monitoring. Ninety-two (23.3%) subjects had EEG performed during ECMO and were included in the study (average EEG duration 54 h). Veno-arterial ECMO was the most common cannulation strategy (83%) and 26 (28%) subjects had extracorporeal cardiopulmonary resuscitation. Fifty-eight subjects (63%) had epileptiform activity or ictal-interictal continuum patterns on EEG, including three (3%) subjects with nonconvulsive status epilepticus, 33 (36%) generalized periodic discharges, and 4 (5%) lateralized periodic discharges. Comparison between subjects with or without epileptiform activity showed comparable in-hospital mortality (57% vs. 47%, p = 0.38) and poor neurological outcome (and 56% and 36%, p = 0.23). Twenty-seven subjects (33%) had acute neuroimaging abnormalities (stroke N = 21). CONCLUSIONS Seizures and ictal-interictal continuum patterns are commonly observed in patients managed with ECMO. Further studies are needed to evaluate whether epileptiform activity is an actionable target for interventions. SIGNIFICANCE Epileptiform and ictal-interictal continuum abnormalities are frequently observed in patients supported with ECMO undergoing EEG monitoring.
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Affiliation(s)
- Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA; Neurology Service, Zuckerberg San Francisco General Hospital, San Francisco, California, USA; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Marcos S Firme
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wei-Long Zheng
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kenneth T Shelton
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Oluwaseun Akeju
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gaston Cudemus
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raz Yuval
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.
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16
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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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17
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Massey SL, Glass HC, Shellhaas RA, Bonifacio S, Chang T, Chu C, Cilio MR, Lemmon ME, McCulloch CE, Soul JS, Thomas C, Wusthoff CJ, Xiao R, Abend NS. Characteristics of Neonates with Cardiopulmonary Disease Who Experience Seizures: A Multicenter Study. J Pediatr 2022; 242:63-73. [PMID: 34728234 PMCID: PMC8882137 DOI: 10.1016/j.jpeds.2021.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/18/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare key seizure and outcome characteristics between neonates with and without cardiopulmonary disease. STUDY DESIGN The Neonatal Seizure Registry is a multicenter, prospectively acquired cohort of neonates with clinical or electroencephalographic (EEG)-confirmed seizures. Cardiopulmonary disease was defined as congenital heart disease, congenital diaphragmatic hernia, and exposure to extracorporeal membrane oxygenation. We assessed continuous EEG monitoring strategy, seizure characteristics, seizure management, and outcomes for neonates with and without cardiopulmonary disease. RESULTS We evaluated 83 neonates with cardiopulmonary disease and 271 neonates without cardiopulmonary disease. Neonates with cardiopulmonary disease were more likely to have EEG-only seizures (40% vs 21%, P < .001) and experience their first seizure later than those without cardiopulmonary disease (174 vs 21 hours of age, P < .001), but they had similar seizure exposure (many-recurrent electrographic seizures 39% vs 43%, P = .27). Phenobarbital was the primary initial antiseizure medication for both groups (90%), and both groups had similarly high rates of incomplete response to initial antiseizure medication administration (66% vs 68%, P = .75). Neonates with cardiopulmonary disease were discharged from the hospital later (hazard ratio 0.34, 95% CI 0.25-0.45, P < .001), although rates of in-hospital mortality were similar between the groups (hazard ratio 1.13, 95% CI 0.66-1.94, P = .64). CONCLUSION Neonates with and without cardiopulmonary disease had a similarly high seizure exposure, but neonates with cardiopulmonary disease were more likely to experience EEG-only seizures and had seizure onset later in the clinical course. Phenobarbital was the most common seizure treatment, but seizures were often refractory to initial antiseizure medication. These data support guidelines recommending continuous EEG in neonates with cardiopulmonary disease and indicate a need for optimized therapeutic strategies.
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Affiliation(s)
- Shavonne L. Massey
- Division of Neurology, Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Hannah C. Glass
- Departments of Neurology and UCSF Weill Institute for Neuroscience, University of California, San Francisco,Department of Epidemiology & Biostatistics, University of California San Francisco
| | | | | | - Taeun Chang
- Department of Neurology, Children’s National Hospital, George Washington University School of Medicine & Health Sciences
| | - Catherine Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Maria Roberta Cilio
- Departments of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Monica E. Lemmon
- Department of Pediatrics and Population Health Sciences, Duke University School of Medicine
| | - Charles E. McCulloch
- Department of Epidemiology & Biostatistics, University of California San Francisco
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School
| | - Cameron Thomas
- Department of Pediatrics, Division of Neurology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati
| | | | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas S. Abend
- Division of Neurology, Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA,Department of Anesthesia & Critical Care Medicine, University of Pennsylvania
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18
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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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Hassumani DO, Shan M, Mastropietro CW, Wing SE, Friedman ML. Seizures in Children with Cardiac Disease on Extracorporeal Membrane Oxygenation. Neurocrit Care 2021; 36:157-163. [PMID: 34268643 DOI: 10.1007/s12028-021-01276-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/11/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Children supported with extracorporeal membrane oxygenation (ECMO) have been shown to be at risk for developing seizures. However, previous studies have consisted of heterogeneous patient populations. We aimed to describe the rate of seizures in pediatric patients receiving ECMO for cardiac indications and to identify risk factors for the occurrence of this complication. METHODS This is a retrospective cohort study of consecutive pediatric patients on ECMO for congenital or acquired cardiac disease between 2014 and 2018 at a tertiary care pediatric hospital. RESULTS We reviewed 110 children, of whom 104 (95%) received continuous electroencephalogram for at least 48 h after ECMO initiation. Seizures were observed in 20 (18%) children. Seizures were subclinical only in 13 (65%) patients, and 8 (40%) developed status epilepticus. The median time from ECMO initiation to first seizure was 34 h (25%, 75%: 19, 44). Children with seizures were more likely to have suffered pre-ECMO cardiac arrest (odds ratio 5.7, 95% confidence interval 2.0-16.1, p < 0.001), require extracorporeal cardiopulmonary resuscitation (odds ratio 5.2, 95% confidence interval 1.9-14.7, p < 0.001), and have been cannulated via the cervical vessels (p = 0.029). Children with seizures also had lower pH nadir prior to ECMO (p = 0.015) and had higher peak lactate prior to ECMO (p = 0.002). Patients with seizures had significantly a longer median intensive care unit length of stay, (43 versus 32 days, p = 0.02), had a significantly worse pediatric cerebral performance score (2 versus 1, p = 0.03), and tended to have worse survival to hospital discharge (50% versus 71%, p = 0.069). CONCLUSIONS Seizures in pediatric patients on ECMO for cardiac indications are common, occurring in nearly one in five patients. Seizures are frequently subclinical only and often progress to status epilepticus. Continuous electroencephalogram is therefore warranted for this patient population, especially in the setting of cardiac arrest, extracorporeal cardiopulmonary resuscitation, or severe metabolic acidosis.
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Affiliation(s)
- Daniel O Hassumani
- Section of Pediatric Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Mu Shan
- Department of Biostatistics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Phase 2, Room 4900, Indianapolis, IN, 46202-5225, USA
| | - Sarah E Wing
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children At Indiana University Health, Indianapolis, IN, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Phase 2, Room 4900, Indianapolis, IN, 46202-5225, USA.
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20
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Shoskes A, Whitman G, Cho SM. Neurocritical Care of Mechanical Circulatory Support Devices. Curr Neurol Neurosci Rep 2021; 21:20. [PMID: 33694065 DOI: 10.1007/s11910-021-01107-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) devices have demonstrated improved survival outcomes in otherwise refractory cardiopulmonary failure but are associated with significant neurologic morbidity and mortality. This review aims to characterize MCS-associated brain injury and discuss the neurocritical care of this population. RECENT FINDINGS We found no practice guidelines or specific management strategies for the neurocritical care of patients with MCS devices. Acute brain injury was commonly observed in short-term and durable MCS devices. There is emerging evidence that a standardized neurological monitoring and management algorithm for MCS device-associated brain injury is feasible and potentially improves neurological outcomes. While MCS devices are associated with significant neurologic morbidity and mortality, there is scant evidence regarding optimal neuromonitoring and neurocritical care. With the increase in use of MCS devices for both short-term and durable applications, improved outcomes will depend on early identification and intervention of neurologic complications and further research into their pathophysiology.
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Affiliation(s)
- Aaron Shoskes
- Department of Neurology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Sung-Min Cho
- Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Division of Neuroscience Critical Care, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA.
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21
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Identifying Injury to Improve Care in Infant Extracorporeal Membrane Oxygenation: Why Autopsy Is Important. Pediatr Crit Care Med 2021; 22:334-336. [PMID: 33657617 DOI: 10.1097/pcc.0000000000002624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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