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

A Virtual Community of Practice: An International Educational Series in Pediatric Neurocritical Care

Pediatric neurocritical care (PNCC) is a rapidly growing field. Challenges posed by the COVID-19 pandemic on trainee exposure to educational opportunities involving direct patient care led to the creative solutions for virtual education supported by guiding organizations such as the Pediatric Neurocritical Care Research Group (PNCRG). Our objective is to describe the creation of an international, peer-reviewed, online PNCC educational series targeting medical trainees and faculty. More than 1600 members of departments such as pediatrics, pediatric critical care, and child neurology hailing from 75 countries across six continents have participated in this series over a 10-month period. We created an online educational channel in PNCC with over 2500 views to date and over 130 followers. This framework could serve as a roadmap for other institutions and specialties seeking to address the ongoing problems of textbook obsolescence relating to the rapid acceleration in knowledge acquisition, as well as those seeking to create new educational content that offers opportunities for an interactive, global audience. Through the creation of a virtual community of practice, we have created an international forum for pediatric healthcare providers to share and learn specialized expertise and best practices to advance global pediatric health.

A Survey of Neuromonitoring Practices in North American Pediatric Intensive Care Units

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.

Noninvasive neurocritical care monitoring for neonates on extracorporeal membrane oxygenation: where do we stand?

OBJECTIVE

To determine practice variation in the utilization of neuromonitoring modalities in neonatal extracorporeal membrane oxygenation (ECMO) patients across Level IV neonatal intensive care units (NICUs).

STUDY DESIGN

Cross-sectional survey design using electronic surveys sent to site sponsors of a multicenter collaborative of 34 Level IV NICUs of the Children's Hospitals Neonatal Consortium (CHNC) from June to August 2018.

RESULTS

We had 22 survey respondents from CHNC ECMO centers. Twenty-seven percent of respondents routinely monitored for seizures using electroencephalogram. Cerebral near infrared spectroscopy was used by 50%. Head ultrasound was performed by 95% but the frequency, duration, and type of views varied. Post ECMO screening brain MRI prior to hospital discharge was routinely performed by 77% of respondents. A majority of centers (95%) performed neurodevelopmental follow-up after hospital discharge.

CONCLUSIONS

There is variation in neuromonitoring practices in Level IV NICUs performing ECMO. Lack of evidence and clear outcome benefits has contributed to practice variation across institutions.

Pediatric Neurocritical Care: Evolution of a New Clinical Service in PICUs Across the United States

OBJECTIVES

Pediatric neurocritical care as a conceptual service is relatively new, and implementation of such specialized services may improve outcomes for children with disorders of the brain or spinal cord. How many pediatric neurocritical care services currently exist in the United States, and attitudes about such a service are unknown.

DESIGN

Web-based survey, distributed by e-mail.

SETTING

Survey was sent to PICU Medical Directors and Program Directors of Pediatric Neurosurgery fellowship and Child Neurology residency programs.

PATIENTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 378 surveys were distributed; 161 respondents representing 128 distinct hospitals completed the survey (43% response rate). Thirty-five percent (45/128) reported having a pediatric neurocritical care service. The most common type of service used a consultation model (82%; 32/39 responses). Other types of services were intensivist-led teams in the PICU (five hospitals) and dedicated PICU beds (two hospitals). Hospital characteristics associated with availability of pediatric neurocritical care services were level 1 trauma status (p = 0.017), greater numbers of PICU beds (χ [6, n = 128] = 136.84; p < 0.01), and greater volume of children with pediatric neurocritical care conditions (χ [3, n = 128] = 20.16; p < 0.01). The most common reasons for not having a pediatric neurocritical care service were low patient volume (34/119 responses), lack of subspecialists (30/119 responses), and lack of interest by PICU faculty (25/119 responses). The positive impacts of a pediatric neurocritical care service were improved interdisciplinary education/training (16/45 responses), dedicated expertise (13/45 responses), improved interservice communication (9/45 responses), and development/implementation of guidelines and protocols (9/45 responses). The negative impacts of a pediatric neurocritical care service were disagreement among consultants (2/45 responses) and splitting of the PICU population (2/45 responses).

CONCLUSIONS

At least 45 specialized pediatric neurocritical care services exist in the United States. Eighty percent of these services are a consultation service to the PICU. Hospitals with level 1 trauma status, greater numbers of PICU beds, and greater numbers of patients with pediatric neurocritical care conditions were associated with the existence of pediatric neurocritical care as a clinical service.

The cost of a pediatric neurocritical care program for traumatic brain injury: a retrospective cohort study

Background

Inpatient care for children with severe traumatic brain injury (sTBI) is expensive, with inpatient charges averaging over $70,000 per case (Hospital Inpatient, Children Only, National Statistics. Diagnoses– clinical classification software (CCS) principal diagnosis category 85 coma, stupor, and brain damage, and 233 intracranial injury. Diagnoses by Aggregate charges [https://hcupnet.ahrq.gov/#setup]). This ranks sTBI in the top quartile of pediatric conditions with the greatest inpatient costs (Hospital Inpatient, Children Only, National Statistics. Diagnoses– clinical classification software (CCS) principal diagnosis category 85 coma, stupor, and brain damage, and 233 intracranial injury. Diagnoses by Aggregate charges [https://hcupnet.ahrq.gov/#setup]). The Brain Trauma Foundation developed sTBI intensive care guidelines in 2003, with revisions in 2012 (Kochanek, Carney, et. al. PCCM 3:S1-S2, 2012). These guidelines have been widely disseminated, and are associated with improved health outcomes (Pineda, Leonard. et. al. LN 12:45-52, 2013), yet research on the cost of associated hospital care is limited. The objective of this study was to assess the costs of providing hospital care to sTBI patients through a guideline-based Pediatric Neurocritical Care Program (PNCP) implemented at St. Louis Children’s Hospital, a pediatric academic medical center in the Midwest United States.

Methods

This is a retrospective cohort study. We used multi-level regression to estimate pre−/post−implementation effects of the PNCP program on inflation adjusted total cost of in-hospital sTBI care. The study population included 58 pediatric patient discharges in the pre-PNCP implementation group (July 15, 1999 - September 17, 2005), and 59 post-implementation patient discharges (September 18, 2005 - January 15, 2012).

Results

Implementation of the PNCP was associated with a non-significant difference in the cost of care between the pre- and post-implementation periods (e^β = 1.028, p = 0.687).

Conclusions

Implementation of the PNCP to support delivery of guideline-based care for children with sTBI did not change the total per-patient cost of in-hospital care. A key strength of this study was its use of hospital cost data rather than charges. Future research should consider the longitudinal post-hospitalization costs of this approach to sTBI care.

Development of Pediatric Neurologic Emergency Life Support Course: A Preliminary Report

BACKGROUND

Acute neurological emergencies (ANEs) in children are common life-threatening illnesses and are associated with high mortality and severe neurological disability in survivors, if not recognized early and treated appropriately. We describe our experience of teaching a short, novel course "Pediatric Neurologic Emergency Life Support" to pediatricians and trainees in a resource-limited country.

METHODS

This course was conducted at 5 academic hospitals from November 2013 to December 2014. It is a hybrid of pediatric advance life support and emergency neurologic life support. This course is designed to increase knowledge and impart practical training on early recognition and timely appropriate treatment in the first hour of children with ANEs. Neuroresuscitation and neuroprotective strategies are key components of this course to prevent and treat secondary injuries. Four cases of ANEs (status epilepticus, nontraumatic coma, raised intracranial pressure, and severe traumatic brain injury) were taught as a case simulation in a stepped-care, protocolized approach based on best clinical practices with emphasis on key points of managements in the first hour.

RESULTS

Eleven courses were conducted during the study period. One hundred ninety-six physicians including 19 consultants and 171 residents participated in these courses. The mean (SD) score was 65.15 (13.87%). Seventy percent (132) of participants were passed (passing score > 60%). The overall satisfaction rate was 85%.

CONCLUSIONS

Pediatric Neurologic Emergency Life Support was the first-time delivered educational tool to improve outcome of children with ANEs with good achievement and high satisfaction rate of participants. Large number courses are required for future validation.

Pediatric Neurocritical Care: A Short Survey of Current Perceptions and Practices

BACKGROUND

Although attention to neurologic injuries and illnesses in pediatric critical care is not new, a sub-specialized field of pediatric neurocritical care has only recently been recognized. Pediatric neurocritical care is an emerging area of clinical and investigative focus. Little is known about the prevalence of specialized pediatric neurocritical care services nor about perceptions regarding how it is impacting medical practice. This survey sought to capture perceptions about an emerging area of specialized pediatric neurocritical care among practitioners in intersecting disciplines, including pediatric intensivists, pediatric neurologits and pediatric neurosurgeons.

METHODS

A web-based survey was distributed via email to members of relevant professional societies and groups. Survey responses were analyzed using descriptive statistics. Differences in responses between groups of respondents were analyzed using Chi-squared analysis where appropriate.

MAIN RESULTS

Specialized clinical PNCC programs were not uncommon among the survey respondents with 20% currently having a PNCC service at their institution. Despite familiarity with this area of sub-specialization among the survey respondents, the survey did not find consensus regarding its value. Overall, 46% of respondents believed that a specialized clinical PNCC service improves the quality of care of critically ill children. Support for PNCC sub-specialization was more common among pediatric neurologists and pediatric neurosurgeons than pediatric intensivists. This survey found support across specialties for creating PNCC training pathways for both pediatric intensivists and pediatric neurologists with an interest in this specialized field.

CONCLUSIONS

PNCC programs are not uncommon; however, there is not clear agreement on the optimal role or benefit of this area of practice sub-specialization. A broader dialog should be undertaken regarding the emerging practice of pediatric neurocritical care, the potential benefits and drawbacks of this partitioning of neurology and critical care medicine practice, economic and other practical factors, the organization of clinical support services, and the formalization of training and certification pathways for sub-specialization.

Building a pediatric neurocritical care program: a multidisciplinary approach to clinical practice and education from the intensive care unit to the outpatient clinic

We describe our 10-year experience developing the Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program at Northwestern University Feinberg School of Medicine. The neurocritical care team includes intensivists, neurologists, and an advanced practice nurse who have expertise in critical care neurology and who continue care in long-term follow-up of intensive care unit patients in a dedicated neurocritical care outpatient clinic. Brain-directed critical care requires collaboration between intensivists and neurologists with specific expertise in neurocritical care, using protocol-directed consistent care, and physiological measures to protect brain function. The heterogeneity of neurologic disorders in the pediatric intensive care unit requires a background in the relevant basic science and pathophysiology that is beyond the scope of standard neurology or critical care fellowships. To address this need, we also created a fellowship in neurocritical care for intensivists, neurologists, and advanced practice nurses. Last, we discuss the implications for pediatric neurocritical care from the experience of management of pediatric stroke and the development of stroke centers.

Update on pediatric neurocritical care

Paralytic poliomyelitis, Reye syndrome, Hemophilus Influenzae type B epiglottitis, bacterial meningitis, and meningococcal septic shock are catastrophic illnesses that in the last 60 years have shaped the development of pediatric intensive care. Neurocritical care has been at the forefront of our thinking and, more latterly, as a specialty we have had the technology and means to develop this focus, educate the next generation and show that outcomes can be improved-first in adult critical care and now the task is to translate these benefits to critically ill children. In our future we will need to advance interventions in patient care with clinical trials. MeSH terms: Neurocritical care; child; traumatic brain injury; status epilepticus; cerebrovascular.

Introduction of a Pediatric Neurology Hospitalist Service With Continuous Electroencephalography Monitoring at a Children's Hospital

Hospitalists, specializing in inpatient medicine, are increasingly being utilized in the hospital setting to improve efficiency, decrease costs and length of stay, and potentially improve outcomes. With these goals in mind and with the purpose of addressing the specific needs of patients on the inpatient pediatric neurology service, we established a pediatric neurohospitalist service in 2009. The primary purpose of this article is to describe the structure and the rationale for a pediatric neurohospitalist service with continuous electroencephalography at a pediatric teaching hospital and to discuss the categories of disease seen by the inpatient neurology service.

A National Survey of Pediatric Intensive Care Units in Pakistan

Purpose. To describe the structure, staffing resources, equipment, academic activities, and characteristics of pediatric population of pediatric intensive care units across the country. Material & Method. This was a prospective, descriptive, and observational survey of pediatric intensive care units from January to December 2009 across Pakistan. A questionnaire survey was emailed to director of each unit. Results. 16 PICUs were participated in this survey (100% response rate). A total of units with 155 beds were identified (1.1 bed /500,000 children). Regarding the categories, 12 (75%) were medical, 3 (19%) were pure cardiac intensive care units, and one unit (6%) was combined multidisciplinary cardiothoracic unit. 13 (81%) units were in public sector as compared to 3 (19%) were in private sector. The mean unit size was 9.7 (range 4–28) beds. Twelve (75%) units were located in three large cities. Only 3 (19%) units have trained intensivist. 37% (6/16) had nurse to patient ratio of 1 : 1-1 : 2 while others had ratios of 1 : 3–1 : 5 with all nurses specialized trained for pediatric intensive care units with bachelor degree or diploma in nursing. Only 50% had capacity for invasive monitoring. Conclusion. We found inadequacies in several aspects of PICUs in Pakistan including fewer PICUs, inadequate PICU beds, and lack of trained personal to look after critically ill pediatric population.

Advances in pediatric neurocritical care

Because pediatric intensive care units (PICUs) improve survival for a range of acute diseases, attention has turned toward ensuring the best possible functional outcomes after critical illness. The neurocritical care of children is of increasing interest. However, the pediatric population encompasses a heterogeneous set of neurologic conditions, with several possible models of how best to address them. This article reviews the special challenges faced by PICUs with regards to diseases, technologies, and skills and the progress that has been made in treatment, monitoring, and prognostication. Recent advances in translational research expected to modify the field in the near-term are described.

The evolving model of pediatric critical care delivery in North America

The past 50 years have witnessed the emergence and evolution of the modern pediatric ICU and the specialty of pediatric critical care medicine. ICUs have become key in the delivery of health care services. The patient population within pediatric ICUs is diverse. An assortment of providers, including intensivists, trainees, physician assistants, nurse practitioners, and hospitalists, perform a variety of roles. The evolution of critical care medicine also has seen the rise of critical care nursing and other critical care staff collaborating in multidisciplinary teams. Delivery of optimal critical care requires standardized, reliable, and evidence-based processes, such as bundles, checklists, and formalized communication processes.

Pediatric neurocritical care: a neurology consultation model and implication for education and training

Pediatric neurocritical care is developing specialization within pediatric intensive care and pediatric neurology practice, and the evolving clinical expertise has relevance to training and education in both fields. We describe a model of service using a Neurology Consulting Team in the intensive care unit setting. Medical records were reviewed from a 32-month cohort of Neurology Consulting Team referrals. Six hundred eighty-nine (19%) of 3719 patients admitted to the intensive care unit were assessed by the team. The most common diagnostic categories were seizures, neurosurgical, cerebrovascular, or central nervous system infection. Fifty-seven percent (350 of 615 patients) required mechanical ventilation. Cohort mortality was 7% vs 2% for the general intensive care population (P < 0.01). The team provided 4592 initial and subsequent consultations; on average there were five to six new consultations per week. Each patient had a median of two (interquartile range, 1 to 6) consultations during admission. Three quarters of the cohort required neurodiagnostic investigation (1625 tests), with each patient undergoing a median of two (range, 0 to 3) studies. Taken together, the subset of pediatric intensive care unit patients undergoing neurology consultation, investigation, and management represents a significant practice experience for trainees, which has implications for future curriculum development in both pediatric critical care medicine and pediatric neurology.

High critical care usage due to pediatric stroke: results of a population-based study

OBJECTIVES

To measure intensive care unit (ICU) admission, intubation, decompressive craniotomy, and outcomes at discharge in a large population-based study of children with ischemic and hemorrhagic stroke.

METHODS

In a retrospective study of all children enrolled in a Northern Californian integrated health care plan (1993-2003), we identified cases of symptomatic childhood stroke (age >28 days through 19 years) from inpatient and outpatient electronic diagnoses and radiology reports, and confirmed them through chart review. Data regarding stroke evaluation, management, and outcomes at discharge were abstracted. Intensive care unit (ICU) admission, intubation, and decompressive neurosurgery rates were measured, and multivariate logistic regression was used to identify predictors of critical care usage and outcomes at discharge.

RESULTS

Of 256 cases (132 hemorrhagic and 124 ischemic), 61% were admitted to the ICU, 32% were intubated, and 11% were treated with a decompressive neurosurgery. Rates were particularly high among children with hemorrhagic stroke (73% admitted to the ICU, 42% intubated, and 19% received a decompressive neurosurgery). Altered mental status at presentation was the most robust predictor for all 3 measures of critical care utilization. Neurologic deficits at discharge were documented in 57%, and were less common after hemorrhagic than ischemic stroke: 48% vs 66% (odds ratio 0.5, 95% confidence interval 0.3-0.8). Case fatality was 4% overall, 7% among children admitted to the ICU, and was similar between ischemic and hemorrhagic stroke.

CONCLUSIONS

ICU admission is frequent after childhood stroke and appears to be justified by high rates of intubation and surgical decompression.

Pediatric neurocritical care

Pediatric neurocritical care is an emerging multidisciplinary field of medicine and a new frontier in pediatric critical care and pediatric neurology. Central to pediatric neurocritical care is the goal of improving outcomes in critically ill pediatric patients with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and the support of brain function. There is a pressing need for evidence based guidelines in pediatric neurocritical care, notably in pediatric traumatic brain injury and pediatric stroke. These diseases have distinct clinical and pathophysiological features that distinguish them from their adult counterparts and prevent the direct translation of the adult experience to pediatric patients. Increased attention is also being paid to the broader application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit, in both primary neurological and primary non-neurological disease states. Although much can be learned from the adult experience, there are important differences in the critically ill pediatric population and in the circumstances that surround the emergence of neurocritical care in pediatrics.

Brain injuries and neurological system failure are the most common proximate causes of death in children admitted to a pediatric intensive care unit

OBJECTIVE

Mortality rates from critical illness in children have declined over the past several decades, now averaging between 2% and 5% in most pediatric intensive care units. Although these rates, and mortality rates from specific disorders, are widely understood, the impact of acute neurologic injuries in such children who die and the role of these injuries in the cause of death are not well understood. We hypothesized that neurologic injuries are an important cause of death in children.

DESIGN

Retrospective review.

SETTING

Pediatric intensive care unit at Children's Hospital of Pittsburgh, an academic tertiary care center.

PATIENTS

Seventy-eight children who died within the pediatric intensive care unit from April 2006 to February 2008.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data regarding admission diagnosis, presence of chronic illness, diagnosis of brain injury, and cause of death were collected. Mortality was attributed to brain injury in 65.4% (51 of 78) of deaths. Ninety-six percent (28 of 29) of previously healthy children died with brain injuries compared with 46.9% (23 of 49) of chronically ill children (p < .05). The diagnosed brain injury was the proximate cause of death in 89.3% of previously healthy children and 91.3% with chronic illnesses. Pediatric intensive care unit and hospital length of stay was longer in those with chronic illnesses (38.8 ± 7.0 days vs. 8.9 ± 3.7 days and 49.2 ± 8.3 days vs. 9.0 ± 3.8 days, p < .05 and p < .001, respectively).

CONCLUSION

Brain injury was exceedingly common in children who died in our pediatric intensive care unit and was the proximate cause of death in a large majority of cases. Neuroprotective measures for a wide variety of admission diagnoses and initiatives directed to prevention or treatment of brain injury are likely to attain further improvements in mortality in previously healthy children in the modern pediatric intensive care unit.

Severe head injury in children: intensive care unit activity and mortality in England and Wales

OBJECTIVE

To explore the relationship between volume of paediatric intensive care unit (PICU) head injury (HI) admissions, specialist paediatric neurosurgical PICU practice, and mortality in England and Wales.

METHODS

Analysis of HI cases (age  <16 years) from the Paediatric Intensive Care Audit Network national cohort of sequential PICU admissions in 27 units in England and Wales, in the 5 years 2004-2008. Risk-adjusted mortality using the Paediatric Index of Mortality (PIM) model was compared between PICUs aggregated into quartile groups, first to fourth based on descending number of HI admissions/year: highest volume, medium-higher volume, medium-lower volume, and lowest volume. The effect of category of PICU interventions - observation only, mechanical ventilation (MV) only, and intracranial pressure (ICP) monitoring - on outcome was also examined. Observations were reported in relation to specialist paediatric neurosurgical PICU practice.

RESULTS

There were 2575 admissions following acute HI (4.4% of non-cardiac surgery PICU admissions in England and Wales). PICU mortality was 9.3%. Units in the fourth-quartile (lowest volume) group did not have significant specialist paediatric neurosurgical activity on the PICU; the other groups did. Overall, there was no effect of HI admissions by individual PICU on risk-adjusted mortality. However, there were significant effects for both intensive care intervention category (p<0.001) and HI admissions by grouping (p<0.005). Funnel plots and control charts using the PIM model showed a hierarchy in increasing performance from lowest volume (group IV), to medium-higher volume (group II), to highest volume (group I), to medium-lower volume (group III) sectors of the health care system.

CONCLUSIONS

The health care system in England and Wales for critically ill HI children requiring PICU admission performs as expected in relation to the PIM model. However, the lowest-volume sector, comprising 14 PICUs with little or no paediatric neurosurgical activity on the unit, exhibits worse than expected outcome, particularly in those undergoing ICP monitoring. The best outcomes are seen in units in the mid-volume sector. These data do not support the hypothesis that there is a simple relationship between PICU volume and performance.