1
|
Erklauer JC, Lai YC. The State of the Field of Pediatric Multimodality Neuromonitoring. Neurocrit Care 2024; 40:1160-1170. [PMID: 37864125 DOI: 10.1007/s12028-023-01858-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/08/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND The use of multimodal neuromonitoring in pediatrics is in its infancy relative to adult neurocritical care. Multimodal neuromonitoring encompasses the amalgamation of information from multiple individual neuromonitoring devices to gain a more comprehensive understanding of the condition of the brain. It allows for adaptation to the changing state of the brain throughout various stages of injury with potential to individualize and optimize therapies. METHODS Here we provide an overview of multimodal neuromonitoring in pediatric neurocritical care and its potential application in the future. RESULTS Multimodal neuromonitoring devices are key to the process of multimodal neuromonitoring, allowing for visualization of data trends over time and ideally improving the ability of clinicians to identify patterns and find meaning in the immense volume of data now encountered in the care of critically ill patients at the bedside. Clinical use in pediatrics requires more study to determine best practices and impact on patient outcomes. Potential uses include guidance for targets of physiological parameters in the setting of acute brain injury, neuroprotection for patients at high risk for brain injury, and neuroprognostication. Implementing multimodal neuromonitoring in pediatric patients involves interprofessional collaboration with the development of a simultaneous comprehensive program to support the use of multimodal neuromonitoring while maintaining the fundamental principles of the delivery of neurocritical care at the bedside. CONCLUSIONS The possible benefits of multimodal neuromonitoring are immense and have great potential to advance the field of pediatric neurocritical care and the health of critically ill children.
Collapse
Affiliation(s)
- Jennifer C Erklauer
- Divisions of Critical Care Medicine and Pediatric Neurology and Developmental Neurosciences, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
| | - Yi-Chen Lai
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| |
Collapse
|
2
|
Agrawal S, Abecasis F, Jalloh I. Neuromonitoring in Children with Traumatic Brain Injury. Neurocrit Care 2024; 40:147-158. [PMID: 37386341 PMCID: PMC10861621 DOI: 10.1007/s12028-023-01779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/05/2023] [Indexed: 07/01/2023]
Abstract
Traumatic brain injury remains a major cause of mortality and morbidity in children across the world. Current management based on international guidelines focuses on a fixed therapeutic target of less than 20 mm Hg for managing intracranial pressure and 40-50 mm Hg for cerebral perfusion pressure across the pediatric age group. To improve outcome from this complex disease, it is essential to understand the pathophysiological mechanisms responsible for disease evolution by using different monitoring tools. In this narrative review, we discuss the neuromonitoring tools available for use to help guide management of severe traumatic brain injury in children and some of the techniques that can in future help with individualizing treatment targets based on advanced cerebral physiology monitoring.
Collapse
Affiliation(s)
- Shruti Agrawal
- Department of Paediatric Intensive Care, Cambridge University Hospitals National Health Service Foundation Trust, Level 3, Box 7, Addenbrookes Hospital Hills Road, Cambridge, UK.
- University of Cambridge, Cambridge, UK.
| | - Francisco Abecasis
- Paediatric Intensive Care Unit, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ibrahim Jalloh
- University of Cambridge, Cambridge, UK
- Department of Neurosurgery, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| |
Collapse
|
3
|
Hossain I, Rostami E, Marklund N. The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 2023; 29:650-658. [PMID: 37851061 PMCID: PMC10624411 DOI: 10.1097/mcc.0000000000001094] [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: 10/19/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. RECENT FINDINGS Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. SUMMARY Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.
Collapse
Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala
- Department of Neuroscience, Karolinska institute, Stockholm
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
4
|
Lang SS, Kumar N, Zhao C, Rahman R, Flanders TM, Heuer GG, Huh JW. Intracranial Pressure and Brain Tissue Oxygen Multimodality Neuromonitoring in Gunshot Wounds to the Head in Children. World Neurosurg 2023; 178:101-113. [PMID: 37479026 DOI: 10.1016/j.wneu.2023.07.059] [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: 06/02/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Gunshot wounds to the head (GSWH) are a cause of severe penetrating traumatic brain injury (TBI). Although multimodal neuromonitoring has been increasingly used in blunt pediatric TBI, its role in the pediatric population with GSWH is not known. We report on 3 patients who received multimodal neuromonitoring as part of clinical management at our institution and review the existing literature on pediatric GSWH. METHODS We identified 3 patients ≤18 years of age who were admitted to a quaternary children's hospital from 2005 to 2021 with GSWH and received invasive intracranial pressure (ICP) and Pbto2 (brain tissue oxygenation) monitoring with or without noninvasive near-infrared spectroscopy (NIRS). We analyzed clinical and demographic characteristics, imaging findings, and ICP, Pbto2, cerebral perfusion pressure, and rSo2 (regional cerebral oxygen saturation) NIRS trends. RESULTS All patients were male with an average admission Glasgow Coma Scale score of 4. One patient received additional NIRS monitoring. Episodes of intracranial hypertension (ICP ≥20 mm Hg) and brain tissue hypoxia (Pbto2 <15 mm Hg) or hyperemia (Pbto2 >35 mm Hg) frequently occurred independently of each other, requiring unique targeted treatments. rSo2 did not consistently mirror Pbto2. All children survived, with favorable Glasgow Outcome Scale-Extended score at 6 months after injury. CONCLUSIONS Use of ICP and Pbto2 multimodality neuromonitoring enabled specific management for intracranial hypertension or brain tissue hypoxia episodes that occurred independently of one another. Multimodality neuromonitoring has not been studied extensively in pediatric GSWH; however, its use may provide a more complete picture of patient injury and prognosis without significant added procedural risk.
Collapse
Affiliation(s)
- Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Nankee Kumar
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chao Zhao
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raphia Rahman
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Tracy M Flanders
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gregory G Heuer
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
5
|
Balzi APDCC, Otsuki DA, Andrade L, Paiva W, Souza FL, Aureliano LGC, Malbouisson LMS. Can a Therapeutic Strategy for Hypotension Improve Cerebral Perfusion and Oxygenation in an Experimental Model of Hemorrhagic Shock and Severe Traumatic Brain Injury? Neurocrit Care 2023; 39:320-330. [PMID: 37535176 DOI: 10.1007/s12028-023-01802-5] [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: 02/17/2023] [Accepted: 07/03/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Restoration of brain tissue perfusion is a determining factor in the neurological evolution of patients with traumatic brain injury (TBI) and hemorrhagic shock (HS). In a porcine model of HS without neurological damage, it was observed that the use of fluids or vasoactive drugs was effective in restoring brain perfusion; however, only terlipressin promoted restoration of cerebral oxygenation and lower expression of edema and apoptosis markers. It is unclear whether the use of vasopressor drugs is effective and beneficial during situations of TBI. The objective of this study is to compare the effects of resuscitation with saline solution and terlipressin on cerebral perfusion and oxygenation in a model of TBI and HS. METHODS Thirty-two pigs weighing 20-30 kg were randomly allocated into four groups: control (no treatment), saline (60 ml/kg of 0.9% NaCl), terlipressin (2 mg of terlipressin), and saline plus terlipressin (20 ml/kg of 0.9% NaCl + 2 mg of terlipressin). Brain injury was induced by lateral fluid percussion, and HS was induced through pressure-controlled bleeding, aiming at a mean arterial pressure (MAP) of 40 mmHg. After 30 min of circulatory shock, resuscitation strategies were initiated according to the group. The systemic and cerebral hemodynamic and oxygenation parameters, lactate levels, and hemoglobin levels were evaluated. The data were subjected to analysis of variance for repeated measures. The significance level established for statistical analysis was p < 0.05. RESULTS The terlipressin and saline plus terlipressin groups showed an increase in MAP that lasted until the end of the experiment (p < 0.05). There was a notable increase in intracranial pressure in all groups after starting treatment for shock. Cerebral perfusion pressure and cerebral oximetry showed no improvement after hemodynamic recovery in any group. The groups that received saline at resuscitation had the lowest hemoglobin concentrations after treatment. CONCLUSIONS The treatment of hypotension in HS with saline and/or terlipressin cannot restore cerebral perfusion or oxygenation in experimental models of HS and severe TBI. Elevated MAP raises intracranial pressure owing to brain autoregulation dysfunction caused by TBI.
Collapse
Affiliation(s)
- Ana Paula de Carvalho Canela Balzi
- Anesthesiology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
- Divisão de Anestesia do ICHC, UTI Cirúrgica Pediátrica, Av. Enéas Carvalho de Aguiar, 255 - 8° Andar, Cerqueira César, São Paulo, SP, 05403-900, Brazil.
| | - Denise Aya Otsuki
- Medical Research Laboratory -LIM-08, Anesthesiology Department, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Lucia Andrade
- Nephrology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wellingson Paiva
- Neurosurgery Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Felipe Lima Souza
- Medical Research Laboratory, Nephrology Department, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Guilherme Cernaglia Aureliano
- Pathology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, São Paulo, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Anesthesiology Department, Hospital das Clinicas SP, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 255, Cerqueira César, São Paulo, SP, 05403-000, Brazil
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
6
|
Alois CI, Luntz A. Recognizing and managing hydrocephalus in children. JAAPA 2023; 36:18-26. [PMID: 36913610 DOI: 10.1097/01.jaa.0000921260.32212.39] [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: 03/14/2023]
Abstract
ABSTRACT Hydrocephalus is one of the most common indications for pediatric neurosurgical intervention and is associated with the need for lifelong monitoring. All clinicians should be familiar with the complications that may arise throughout life in these patients so that they can provide timely intervention. This article focuses on the assessment of hydrocephalus, the appropriate diagnostic workup and differential diagnoses, and evidence-based surgical treatments and associated outcomes.
Collapse
Affiliation(s)
- Corinne I Alois
- Corinne I. Alois is an assistant professor in the PA program at St. John's University in Jamaica, N.Y., an adjunct faculty member in the PA program at Pace University-Lenox Hill Hospital in New York City, and an adjunct research faculty member at St. Elizabeth University in Morristown, N.J. At the time this article was written, Allison Luntz was a student in the PA program at St. John's University. She now is in the PA surgical residency program at Yale University School of Medicine/Norwalk (Conn.) Hospital. The authors have disclosed no potential conflicts of interest, financial or otherwise
| | | |
Collapse
|
7
|
Lang SS, Rahman R, Kumar N, Tucker A, Flanders TM, Kirschen M, Huh JW. Invasive Neuromonitoring Modalities in the Pediatric Population. Neurocrit Care 2023; 38:470-485. [PMID: 36890340 DOI: 10.1007/s12028-023-01684-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 01/30/2023] [Indexed: 03/10/2023]
Abstract
Invasive neuromonitoring has become an important part of pediatric neurocritical care, as neuromonitoring devices provide objective data that can guide patient management in real time. New modalities continue to emerge, allowing clinicians to integrate data that reflect different aspects of cerebral function to optimize patient management. Currently, available common invasive neuromonitoring devices that have been studied in the pediatric population include the intracranial pressure monitor, brain tissue oxygenation monitor, jugular venous oximetry, cerebral microdialysis, and thermal diffusion flowmetry. In this review, we describe these neuromonitoring technologies, including their mechanisms of function, indications for use, advantages and disadvantages, and efficacy, in pediatric neurocritical care settings with respect to patient outcomes.
Collapse
Affiliation(s)
- Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA. .,Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Raphia Rahman
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.,School of Osteopathic Medicine, Rowan University, Stratford, NJ, USA
| | - Nankee Kumar
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Alexander Tucker
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Tracy M Flanders
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Matthew Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
8
|
Czosnyka M, Santarius T, Donnelly J, van den Dool REC, Sperna Weiland NH. Pro-Con Debate: The Clinical (Ir)relevance of the Lower Limit of Cerebral Autoregulation for Anesthesiologists. Anesth Analg 2022; 135:734-743. [DOI: 10.1213/ane.0000000000006123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
9
|
Batson C, Froese L, Sekhon MS, Griesdale DE, Gomez A, Thelin EP, Raj R, Aries M, Gallagher CN, Bernard F, Kramer AH, Zeiler FA. Impact of Chronological Age and Biological Sex on Cerebrovascular Reactivity in Moderate/Severe Traumatic Brain Injury: A CAnadian High-Resolution TBI (CAHR-TBI) Study. J Neurotrauma 2022. [PMID: 36047825 DOI: 10.1089/neu.2022.0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Impaired cerebrovascular reactivity has emerged as an important associate with poor long-term outcome after moderate/severe traumatic brain injury (TBI). However, our understanding of what drives or modulates the degree of impaired cerebrovascular function remains poor. Age and biological sex remain important modifiers of cerebrovascular function in health and disease, yet their impact on cerebrovascular reactivity after TBI remains unclear. The aim of this study was to explore subgroup responses based on age and biological sex on cerebral physiology. Data from 283 TBI patients from the CAnadian High Resolution TBI (CAHR-TBI) Research Collaborative were evaluated. Cerebrovascular reactivity was determined using high-frequency cerebral physiology for the derivation of three intracranial pressure (ICP) based indices: (1). PRx - correlation between ICP and mean arterial pressure (MAP), (2). PAx - correlation between pulse amplitude of ICP (AMP) and MAP and (3). RAC - correlation between AMP and cerebral perfusion pressure (CPP). Insult burden (% time above clinically defined thresholds) were calculated for these indices. These cerebral physiology indices were studied for their relationship with age via linear regression, age trichotomization (< 40, 40 - 60, > 60) and decades of age (< 30, 30 - 39, 40 - 49, 50 - 59, 60 - 69, > 69) schemes. Similarly, differences based on biological sex were assessed. A statistically significant positive linear correlation was found between PAx, RAC and age. In corollary, a statistically significant relationship was found between increasing age on trichotomized and decades of age analysis with PAx and RAC measures. PRx failed to demonstrate such relationships to advancing age. There was no clear difference in cerebrovascular reactivity profiles between biological sex categories. These findings suggest that AMP-based cerebrovascular reactivity indices may be better positioned to detect impairment in TBI patients with advancing age. Further investigation into the utility of PAx and RAC is required, as they may prove useful for certain subgroups of patients.
Collapse
Affiliation(s)
| | - Logan Froese
- University of Manitoba Faculty of Engineering, Biomedical Engineering, SP-422 EITC, 75 Chancellor`s Circle, Winnipeg, Manitoba, Canada, R3T 5V6;
| | - Mypinder Singh Sekhon
- University of British Columbia, Critical Care Medicine, 899 West 12th Avenue, Vancouver, British Columbia, Canada, V5Z 1M9;
| | - Donald E Griesdale
- University of British Columbia, Anesthesiology, Pharmacology and Therapeutics, Vancouver, British Columbia, Canada;
| | - Alwyn Gomez
- University of Manitoba Faculty of Health Sciences, Surgery, GF231, Health Sciences Centre, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Eric Peter Thelin
- Karolinska Institutet, Department of Clinical Neuroscience, Neurosurgical Research Laboratory, Building R2:02, Karolinska University Hospital, Stockholm, Sweden, 171 76;
| | - Rahul Raj
- HUS, Topeliuksenkatu 5, Helsinki, Finland, 00029 HUS;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Clare N Gallagher
- University of Calgary, Department of Clinical Neurosciences, Calgary, Alberta, Canada;
| | - Francis Bernard
- Hôpital du Sacré-Coeur de Montreal, Intensive Care Unit, 5400 Boul Gouin O, Montreal, Quebec, Canada, H4J1C5;
| | - Andreas H Kramer
- University of Calgary, Departments of Critical Care Medicine and Clinical Neurosciences, 3132 Hospital Drive NW, Calgary, Calgary, Alberta, Canada, T2N 2T9;
| | - Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
| |
Collapse
|
10
|
Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience. Pediatr Rep 2022; 14:352-365. [PMID: 35997419 PMCID: PMC9397046 DOI: 10.3390/pediatric14030042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 08/04/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Intracranial hypertension (IC-HTN) is significantly associated with higher risk for an unfavorable outcome in pediatric trauma. Intracranial pressure (ICP) monitoring is widely becoming a standard of neurocritical care for children. Methods: The present study was designed to evaluate influences of IC-HTN on clinical outcomes of pediatric TBI patients. Demographic, injury severity, radiologic characteristics were used as possible predictors of IC-HTN or of functional outcome. Results: A total of 118 pediatric intensive care unit (PICU) patients with severe TBI (sTBI) were included. Among sTBI cases, patients with GCS < 5 had significantly higher risk for IC-HTN and for mortality. Moreover, there was a statistically significant positive correlation between IC-HTN and severity scoring systems. Kaplan−Meier analysis determined a significant difference for good recovery among patients who had no ICP elevations, compared to those who had at least one episode of IC-HTN (log-rank chi-square = 11.16, p = 0.001). A multivariable predictive logistic regression analysis distinguished the ICP-monitored patients at risk for developing IC-HTN. The model finally revealed that higher ISS and Helsinki CT score increased the odds for developing IC-HTN (p < 0.05). Conclusion: The present study highlights the importance of ICP-guided clinical practices, which may lead to increasing percentages of good recovery for children.
Collapse
|
11
|
Lang SS, Kumar NK, Zhao C, Zhang DY, Tucker AM, Storm PB, Heuer GG, Gajjar AA, Kim CT, Yuan I, Sotardi S, Kilbaugh TJ, Huh JW. Invasive brain tissue oxygen and intracranial pressure (ICP) monitoring versus ICP-only monitoring in pediatric severe traumatic brain injury. J Neurosurg Pediatr 2022; 30:239-249. [PMID: 35623367 DOI: 10.3171/2022.4.peds21568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Severe traumatic brain injury (TBI) is a leading cause of disability and death in the pediatric population. While intracranial pressure (ICP) monitoring is the gold standard in acute neurocritical care following pediatric severe TBI, brain tissue oxygen tension (PbtO2) monitoring may also help limit secondary brain injury and improve outcomes. The authors hypothesized that pediatric patients with severe TBI and ICP + PbtO2 monitoring and treatment would have better outcomes than those who underwent ICP-only monitoring and treatment. METHODS Patients ≤ 18 years of age with severe TBI who received ICP ± PbtO2 monitoring at a quaternary children's hospital between 1998 and 2021 were retrospectively reviewed. The relationships between conventional measurements of TBI were evaluated, i.e., ICP, cerebral perfusion pressure (CPP), and PbtO2. Differences were analyzed between patients with ICP + PbtO2 versus ICP-only monitoring on hospital and pediatric intensive care unit (PICU) length of stay (LOS), length of intubation, Pediatric Intensity Level of Therapy scale score, and functional outcome using the Glasgow Outcome Score-Extended (GOS-E) scale at 6 months postinjury. RESULTS Forty-nine patients, including 19 with ICP + PbtO2 and 30 with ICP only, were analyzed. There was a weak negative association between ICP and PbtO2 (β = -0.04). Conversely, there was a strong positive correlation between CPP ≥ 40 mm Hg and PbtO2 ≥ 15 and ≥ 20 mm Hg (β = 0.30 and β = 0.29, p < 0.001, respectively). An increased number of events of cerebral PbtO2 < 15 mm Hg or < 20 mm Hg were associated with longer hospital (p = 0.01 and p = 0.022, respectively) and PICU (p = 0.015 and p = 0.007, respectively) LOS, increased duration of mechanical ventilation (p = 0.015 when PbtO2 < 15 mm Hg), and an unfavorable 6-month GOS-E score (p = 0.045 and p = 0.022, respectively). An increased number of intracranial hypertension episodes (ICP ≥ 20 mm Hg) were associated with longer hospital (p = 0.007) and PICU (p < 0.001) LOS and longer duration of mechanical ventilation (p < 0.001). Lower minimum hourly and average daily ICP values predicted favorable GOS-E scores (p < 0.001 for both). Patients with ICP + PbtO2 monitoring experienced longer PICU LOS (p = 0.018) compared to patients with ICP-only monitoring, with no significant GOS-E score difference between groups (p = 0.733). CONCLUSIONS An increased number of cerebral hypoxic episodes and an increased number of intracranial hypertension episodes resulted in longer hospital LOS and longer duration of mechanical ventilator support. An increased number of cerebral hypoxic episodes also correlated with less favorable functional outcomes. In contrast, lower minimum hourly and average daily ICP values, but not the number of intracranial hypertension episodes, were associated with more favorable functional outcomes. There was a weak correlation between ICP and PbtO2, supporting the importance of multimodal invasive neuromonitoring in pediatric severe TBI.
Collapse
Affiliation(s)
- Shih-Shan Lang
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Nankee K Kumar
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chao Zhao
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - David Y Zhang
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alexander M Tucker
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Phillip B Storm
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Gregory G Heuer
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Pennsylvania
| | - Avi A Gajjar
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- 3Department of Chemistry, Union College, Schenectady, New York
| | - Chong Tae Kim
- 4Department of Physical Medicine and Rehabilitation and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ian Yuan
- 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | - Susan Sotardi
- 6Department of Radiology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Todd J Kilbaugh
- 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | - Jimmy W Huh
- 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| |
Collapse
|
12
|
Zimphango C, Alimagham FC, Carpenter KLH, Hutchinson PJ, Hutter T. Monitoring Neurochemistry in Traumatic Brain Injury Patients Using Microdialysis Integrated with Biosensors: A Review. Metabolites 2022; 12:metabo12050393. [PMID: 35629896 PMCID: PMC9146878 DOI: 10.3390/metabo12050393] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023] Open
Abstract
In a traumatically injured brain, the cerebral microdialysis technique allows continuous sampling of fluid from the brain’s extracellular space. The retrieved brain fluid contains useful metabolites that indicate the brain’s energy state. Assessment of these metabolites along with other parameters, such as intracranial pressure, brain tissue oxygenation, and cerebral perfusion pressure, may help inform clinical decision making, guide medical treatments, and aid in the prognostication of patient outcomes. Currently, brain metabolites are assayed on bedside analysers and results can only be achieved hourly. This is a major drawback because critical information within each hour is lost. To address this, recent advances have focussed on developing biosensing techniques for integration with microdialysis to achieve continuous online monitoring. In this review, we discuss progress in this field, focusing on various types of sensing devices and their ability to quantify specific cerebral metabolites at clinically relevant concentrations. Important points that require further investigation are highlighted, and comments on future perspectives are provided.
Collapse
Affiliation(s)
- Chisomo Zimphango
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (F.C.A.); (K.L.H.C.); (P.J.H.); (T.H.)
- Correspondence:
| | - Farah C. Alimagham
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (F.C.A.); (K.L.H.C.); (P.J.H.); (T.H.)
| | - Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (F.C.A.); (K.L.H.C.); (P.J.H.); (T.H.)
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (F.C.A.); (K.L.H.C.); (P.J.H.); (T.H.)
| | - Tanya Hutter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (F.C.A.); (K.L.H.C.); (P.J.H.); (T.H.)
- Walker Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78712, USA
| |
Collapse
|
13
|
Kirschen MP, LaRovere K, Balakrishnan B, Erklauer J, Francoeur C, Ganesan SL, Jayakar A, Lovett M, Luchette M, Press CA, Wolf M, Ferrazzano P, Wainwright MS, Appavu B. A Survey of Neuromonitoring Practices in North American Pediatric Intensive Care Units. Pediatr Neurol 2022; 126:125-130. [PMID: 34864306 PMCID: PMC9135309 DOI: 10.1016/j.pediatrneurol.2021.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Neuromonitoring is the use of continuous measures of brain physiology to detect clinically important events in real-time. Neuromonitoring devices can be invasive or non-invasive and are typically used on patients with acute brain injury or at high risk for brain injury. The goal of this study was to characterize neuromonitoring infrastructure and practices in North American pediatric intensive care units (PICUs). METHODS An electronic, web-based survey was distributed to 70 North American institutions participating in the Pediatric Neurocritical Care Research Group. Questions related to the clinical use of neuromonitoring devices, integrative multimodality neuromonitoring capabilities, and neuromonitoring infrastructure were included. Survey results were presented using descriptive statistics. RESULTS The survey was completed by faculty at 74% (52 of 70) of institutions. All 52 institutions measure intracranial pressure and have electroencephalography capability, whereas 87% (45 of 52) use near-infrared spectroscopy and 40% (21/52) use transcranial Doppler. Individual patient monitoring decisions were driven by institutional protocols and collaboration between critical care, neurology, and neurosurgery attendings. Reported device utilization varied by brain injury etiology. Only 15% (eight of 52) of institutions utilized a multimodality neuromonitoring platform to integrate and synchronize data from multiple devices. A database of neuromonitoring patients was maintained at 35% (18 of 52) of institutions. Funding for neuromonitoring programs was variable with contributions from hospitals (19%, 10 of 52), private donations (12%, six of 52), and research funds (12%, six of 52), although 73% (40 of 52) have no dedicated funds. CONCLUSIONS Neuromonitoring indications, devices, and infrastructure vary by institution in North American pediatric critical care units. Noninvasive modalities were utilized more liberally, although not uniformly, than invasive monitoring. Further studies are needed to standardize the acquisition, interpretation, and reporting of clinical neuromonitoring data, and to determine whether neuromonitoring systems impact neurological outcomes.
Collapse
Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Kerri LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Binod Balakrishnan
- Division of Pediatric Critical Care Medicine, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Erklauer
- Departments of Critical Care Medicine and Neurology, Texas Children's Hospital, Houston, Texas
| | - Conall Francoeur
- Department of Pediatrics, CHU de Québec - Université Laval Research Center, Quebec City, Quebec, Canada
| | - Saptharishi Lalgudi Ganesan
- Department of Paediatrics, Children's Hospital of Western Ontario, Schulich School of Medicine & Dentistry at the Western University, London, Ontario, Canada
| | - Anuj Jayakar
- Department of Neurology, Nicklaus Children's Hospital, Miami, Florida
| | - Marlina Lovett
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Matthew Luchette
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Craig A Press
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael Wolf
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Peter Ferrazzano
- Division of Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Mark S Wainwright
- Division of Pediatric Neurology, University of Washington School of Medicine, Seattle, Washington
| | - Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine - Phoenix, Phoenix, UK
| |
Collapse
|
14
|
Batson C, Froese L, Gomez A, Sainbhi AS, Stein KY, Alizadeh A, Zeiler FA. Impact of Age and Biological Sex on Cerebrovascular Reactivity in Adult Moderate/Severe Traumatic Brain Injury: An Exploratory Analysis. Neurotrauma Rep 2021; 2:488-501. [PMID: 34901944 PMCID: PMC8655816 DOI: 10.1089/neur.2021.0039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Age and biological sex are two potential important modifiers of cerebrovascular reactivity post-traumatic brain injury (TBI) requiring close evaluation for potential subgroup responses. The goal of this study was to provide a preliminary exploratory analysis of the impact of age and biological sex on measures of cerebrovascular function in moderate/severe TBI. Forty-nine patients from the prospectively maintained TBI database at the University of Manitoba with archived high-frequency digital cerebral physiology were evaluated. Cerebrovascular reactivity indices were derived as follows: PRx (correlation between intracranial pressure [ICP] and mean arterial pressure [MAP]), PAx (correlation between pulse amplitude of ICP [AMP] and MAP), and RAC (correlation between AMP and cerebral perfusion pressure [CPP]). Time above clinically significant thresholds for each index was calculated over different periods of the acute intensive care unit stay. The association between PRx, PAx, and RAC measures with age was assessed using linear regression, and an age trichotomization scheme (<40, 40-60, >60) using Kruskal-Wallis testing. Similarly, association with biological sex was tested using Mann-Whitney U testing. Biological sex did not demonstrate an impact on any measures of cerebrovascular reactivity. Linear regression between age and PAx and RAC demonstrated a statistically significant positive linear relationship. Median PAx and RAC measures between trichotomized age categories demonstrated statistically significant increases with advancing age. The PRx failed to demonstrate any statistically significant relationship with age in this cohort, suggesting that in elderly patients with controlled ICP, PAx and RAC may be better metrics for detecting impaired cerebrovascular reactivity. Biological sex appears to not be associated with differences in cerebrovascular reactivity in this cohort. The PRx performed the worst in detecting impaired cerebrovascular reactivity in those with advanced age, where PAx and RAC appear to have excelled. Future work is required to validate these findings and explore the utility of different cerebrovascular reactivity indices.
Collapse
Affiliation(s)
- Carleen Batson
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arsalan Alizadeh
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
15
|
Monitoring cerebrovascular reactivity in pediatric traumatic brain injury: comparison of three methods. Childs Nerv Syst 2021; 37:3057-3065. [PMID: 34212250 DOI: 10.1007/s00381-021-05263-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To study three different methods of monitoring cerebral autoregulation in children with severe traumatic brain injury. METHODS Prospective cohort study of all children admitted to the pediatric intensive care unit at a university-affiliated hospital with severe TBI over a 4-year period to study three different methods of monitoring cerebral autoregulation: pressure-reactivity index (PRx), transcranial Doppler derived mean flow velocity index (Mx), and near-infrared spectroscopy derived cerebral oximetry index (COx). RESULTS Twelve patients were included in the study, aged 5 months to 17 years old. An empirical regression analyzing dependence of PRx on cerebral perfusion pressure (CPP) displayed the classic U-shaped distribution, with low PRx values (< 0.3) reflecting intact auto-regulation, within the CPP range of 50-100 mmHg. The optimal CPP was 75-80 mmHg for PRx and COx. The correlation coefficients between the three indices were as follows: PRx vs Mx, r = 0.56; p < 0.0001; PRx vs COx, r = 0.16; p < 0.0001; and COx vs Mx, r = 0.15; p = 0.022. The mean PRx with a cutoff value of 0.3 predicted correctly long-term outcome (p = 0.015). CONCLUSIONS PRx seems to be the most robust index to access cerebrovascular reactivity in children with TBI and has promising prognostic value. Optimal CPP calculation is feasible with PRx and COx.
Collapse
|
16
|
Deshmukh KP, Rahmani Dabbagh S, Jiang N, Tasoglu S, Yetisen AK. Recent Technological Developments in the Diagnosis and Treatment of Cerebral Edema. ADVANCED NANOBIOMED RESEARCH 2021. [DOI: 10.1002/anbr.202100001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Karthikeya P. Deshmukh
- Department of Chemical Engineering Imperial College London Imperial College Road, Kensington London SW7 2AZ UK
| | - Sajjad Rahmani Dabbagh
- Department of Mechanical Engineering Koc University Rumelifeneri Yolu, Sariyer Istanbul 34450 Turkey
| | - Nan Jiang
- West China School of Basic Medical Sciences & Forensic Medicine Sichuan University Chengdu 610041 China
| | - Savas Tasoglu
- Department of Mechanical Engineering Koc University Rumelifeneri Yolu, Sariyer Istanbul 34450 Turkey
- Boğaziçi Institute of Biomedical Engineering Boğaziçi University Istanbul 34684 Turkey
| | - Ali K. Yetisen
- Department of Chemical Engineering Imperial College London Imperial College Road, Kensington London SW7 2AZ UK
| |
Collapse
|
17
|
Shope C, Alshareef M, Larrew T, Bolling C, Reagan J, Yazdani M, Spampinato M, Eskandari R. Utility of a pediatric fast magnetic resonance imaging protocol as surveillance scanning for traumatic brain injury. J Neurosurg Pediatr 2021; 27:475-481. [PMID: 33545669 DOI: 10.3171/2020.8.peds20496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a prevalent pediatric pathology in the modern emergency department. Computed tomography (CT) is utilized for detection of TBI and can result in cumulatively high radiation exposure. Recently, a fast brain magnetic resonance imaging (fbMRI) protocol has been employed for rapid imaging of hydrocephalus in pediatric patients. The authors investigate the utility of a modified trauma-focused fbMRI (t-fbMRI) protocol as an alternative to surveillance CT in the setting of acute TBI in pediatric patients, thus reducing radiation exposure while improving diagnostic yield. METHODS A retrospective review was performed at the authors' institution for all pediatric patients who had undergone t-fbMRI within 72 hours of an initial CT scan, using a 1.5- or 3-T MR scanner for trauma indications. Forty patients met the study inclusion criteria. The authors performed a comparison of findings on the reads of CT and fbMRI, and a board-certified neuroradiologist conducted an independent review of both modalities. RESULTS T-fbMRI outperformed CT in specificity, sensitivity, and negative predictive value for all injury pathologies measured, except for skull fractures. T-fbMRI demonstrated a sensitivity of 100% in the detection of extraaxial bleed, intraventricular hemorrhage, and subarachnoid hemorrhage and had a sensitivity of 78% or greater for epidural hematoma, subdural hematoma, and intraparenchymal hemorrhage. T-fbMRI yielded a specificity of 100% for all types of intracranial hemorrhages, with a corresponding negative predictive value that exceeded that for CT. CONCLUSIONS In pediatric populations, the t-fbMRI protocol provides a valid alternative to CT in the surveillance of TBI and intracranial hemorrhage. Although not as sensitive in the detection of isolated skull fractures, t-fbMRI can be used to monitor pathologies implicated in TBI patients while minimizing radiation exposure from traditional surveillance imaging.
Collapse
Affiliation(s)
- Chelsea Shope
- 1College of Medicine, Medical University of South Carolina; and
| | | | | | - Christopher Bolling
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Justin Reagan
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Milad Yazdani
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Maria Spampinato
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | | |
Collapse
|
18
|
Nacoti M, Fazzi F, Biroli F, Zangari R, Barbui T, Kochanek PM. Addressing Key Clinical Care and Clinical Research Needs in Severe Pediatric Traumatic Brain Injury: Perspectives From a Focused International Conference. Front Pediatr 2021; 8:594425. [PMID: 33537259 PMCID: PMC7849211 DOI: 10.3389/fped.2020.594425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/06/2020] [Indexed: 12/28/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Survivors of severe TBI are more prone to functional deficits, resulting in poorer school performance, poor health-related quality of life (HRQoL), and increased risk of mental health problems. Critical gaps in knowledge of pathophysiological differences between children and adults concerning TBI outcomes, the paucity of pediatric trials and prognostic models and the uncertain extrapolation of adult data to pediatrics pose significant challenges and demand global efforts. Here, we explore the clinical and research unmet needs focusing on severe pediatric TBI to identify best practices in pathways of care and optimize both inpatient and outpatient management of children following TBI.
Collapse
Affiliation(s)
- Mirco Nacoti
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Fazzi
- Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Biroli
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rosalia Zangari
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Tiziano Barbui
- Fondazione per la Ricerca dell'Ospedale di Bergamo Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G Rangos Research Center, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| |
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW To provide a summary of recent developments in the field of paediatric traumatic brain injury (TBI). RECENT FINDINGS The epidemiology of paediatric TBI with falling rates of severe TBI, and increasing presentations of apparently minor TBI. There is growing interest in the pathophysiology and outcomes of concussion in children, and detection of 'significant' injury, arising from concern about risks of long-term chronic traumatic encephalopathy. The role of decompressive craniectomy in children is still clarifying. SUMMARY Paediatric TBI remains a major public health issue.
Collapse
Affiliation(s)
| | - Rob J Forsyth
- Department of Paediatric Neurology, Newcastle upon Tyne Hospitals NHS Foundation Trust
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
20
|
Gao J, Wei L, Xu G, Ren C, Zhang Z, Liu Y. Effects of dexmedetomidine vs sufentanil during percutaneous tracheostomy for traumatic brain injury patients: A prospective randomized controlled trial. Medicine (Baltimore) 2019; 98:e17012. [PMID: 31464960 PMCID: PMC6736089 DOI: 10.1097/md.0000000000017012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Percutaneous tracheostomy, almost associated with cough reflex and hemodynamic fluctuations, is a common procedure for traumatic brain injury (TBI) patients, especially those in neurosurgery intensive care units (NICUs). However, there are currently a lack of effective preventive measures to reduce the risk of secondary brain injury. The aim of this study was to compare the effect of dexmedetomidine (DEX) vs sufentanil during percutaneous tracheostomy in TBI patients. METHODS The 196 TBI patients who underwent percutaneous tracheostomy were randomized divided into 3 groups: group D1 (n = 62, DEX infusion at 0.5 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), group D2 (n = 68, DEX infusion at 1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour), and group S (n = 66, sufentanil infusion 0.3 μg·kg for 10 minutes, then adjusted to 0.2-0.4 μg·kg·hour). The bispectral index (BIS) of all patients was maintained at 50 to 70 during surgery. Anesthesia onset time, hemodynamic variables, total cumulative dose of DEX/sufentanil, total doses of rescue propofol and fentanyl, time to first dose of rescue propofol and fentanyl, number of intraoperative patient movements and cough reflexes, adverse events, and surgeon satisfaction score were recorded. RESULTS Anesthesia onset time was significantly lower in group D2 than in both other groups (14.35 ± 3.23 vs 12.42 ± 2.12 vs 13.88 ± 3.51 minutes in groups D1, D2, and S, respectively; P < .001). Both heart rate and mean arterial pressure during percutaneous tracheostomy were more stable in group D2. Total doses of rescue propofol and fentanyl were significantly lower in group D2 than in group D1 (P < .001). The time to first dose of rescue propofol and fentanyl were significantly longer in group D2 than in both other groups (P < .001). The number of patient movements and cough reflexes during percutaneous tracheostomy were lower in group D2 than in both other groups (P < .001). The overall incidences of tachycardia and hypertension (which required higher doses of esmolol and urapidil, respectively) were also lower in group D2 than in both other groups (P < .05). Three patients in group S had respiratory depression compared to X in the D1 group and X in the D2 group. The surgeon satisfaction score was significantly higher in group D2 than in both other groups (P < .05). CONCLUSIONS During percutaneous tracheostomy, compared with sufentanil, DEX (1 μg·kg for 10 minutes, then adjusted to 0.2-0.7 μg·kg·hour) can provide the desired attenuation of the hemodynamic response without increased adverse events. Consequently, DEX could be used safely and effectively during percutaneous tracheostomy in TBI patients.
Collapse
|
21
|
Lovett ME, O'Brien NF, Leonard JR. Children With Severe Traumatic Brain Injury, Intracranial Pressure, Cerebral Perfusion Pressure, What Does it Mean? A Review of the Literature. Pediatr Neurol 2019; 94:3-20. [PMID: 30765136 DOI: 10.1016/j.pediatrneurol.2018.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 11/28/2018] [Accepted: 12/06/2018] [Indexed: 11/18/2022]
Abstract
Severe traumatic brain injury is a leading cause of morbidity and mortality in children. In 2003 the Brain Trauma Foundation released guidelines that have since been updated (2010) and have helped standardize and improve care. One area of care that remains controversial is whether the placement of an intracranial pressure monitor is advantageous in the management of traumatic brain injury. Another aspect of care that is widely debated is whether management after traumatic brain injury should be based on intracranial pressure-directed therapy, cerebral perfusion pressure-directed therapy, or a combination of the two. The aim of this article was to provide an overview and review the current evidence regarding these questions.
Collapse
Affiliation(s)
- Marlina E Lovett
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio.
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Jeffrey R Leonard
- Division of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| |
Collapse
|
22
|
Ångerman S, Länkimäki S, Neuvonen N, Kirves H, Nurmi J. Prospective pilot study of cerebral near infrared spectroscopy monitoring during pre-hospital anaesthesia. Acta Anaesthesiol Scand 2018; 62:1139-1145. [PMID: 29790148 DOI: 10.1111/aas.13146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/02/2018] [Accepted: 04/17/2018] [Indexed: 11/29/2022]
Abstract
BACKROUND Near-infrared spectroscopy (NIRS) provides a non-invasive measure of cerebral tissue oxygenation. The literature on application of this method in pre-hospital setting is limited. The aims of this study were to determine the feasibility of cerebral NIRS during pre-hospital anaesthesia and to quantify the changes in front lobe regional oxygen saturation (rSO2 ) during the pre-hospital phase. METHODS NIRS monitoring (Nonin SenSmart X-100) of front lobe regional oxygen saturation (rSO2) was initiated before induction of anaesthesia in 31 adult patients and continued until hospital arrival. The median age of the patients was 55 years (IQR [range] 43-63 [20-84]), and 20 (65%) of the patients were male. The indications for pre-hospital anaesthesia were neurological reasons (29%), intoxication (23%), traumatic brain injury (23%) and successful resuscitation from cardiac arrest (16%). RESULTS The NIRS monitoring was successful in 29 of 31 cases (94%; 95% CI: 78-99). One patient could not be monitored due to poor probe-skin contact, and 1 patient had poor contact with 1 hemisphere. Monitoring was performed for a total of 1335 minutes and was successful in both hemispheres 95% (95% CI: 94-96) of the time. The median lowest rSO2 was 8% (IQR [range] 2-13 [0-30]) below baseline, and median peak rSO2 was 7% (IQR [range] 2-11 [0-34]) above the baseline. Changes in rSO2 without accompanying changes in vital signs were observed. CONCLUSION NIRS is feasible during pre-hospital anaesthesia and substantial changes were observed in some patients. It provides data beyond the standard monitoring used in the pre-hospital setting.
Collapse
Affiliation(s)
- S Ångerman
- Emergency Medicine and Services, Helsinki University Hospital and Department of Emergency Medicine, University of Helsinki, Helsinki, Finland
| | - S Länkimäki
- Emergency Medicine and Services, Helsinki University Hospital and Department of Emergency Medicine, University of Helsinki, Helsinki, Finland
- Centre of Prehospital Emergency Care, The Hospital District of South Ostrobothnia, Seinäjoki, Finland
| | - N Neuvonen
- Emergency Medicine and Services, Helsinki University Hospital and Department of Emergency Medicine, University of Helsinki, Helsinki, Finland
| | - H Kirves
- Prehospital Emergency Care, Hyvinkää Hospital Area, Hospital District of Helsinki and Uusimaa, Hyvinkää, Finland
| | - J Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and Department of Emergency Medicine, University of Helsinki, Helsinki, Finland
- FinnHEMS Research and Development Unit, Vantaa, Finland
| |
Collapse
|