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Neuromonitoring Modalities in Pediatric Cardiac Anesthesia: A Review of the Literature
Elizabeth Finucane1, Edmund Jooste1, Kelly A Machovec1
1Duke University Medical Center, Durham, NC.
Insights
Improved survival in children with congenital heart disease (CHD) highlights the need to address neurodevelopmental disabilities. Multimodal neuromonitoring during surgery is key to improving neurologic outcomes in these vulnerable patients.
Area of Science:
- Pediatric Cardiology
- Neuroscience
- Anesthesiology
Background:
- Advances in congenital heart disease (CHD) care have increased survival into adulthood.
- Long-term neurologic sequelae are a significant concern, with many children experiencing neurodevelopmental disabilities.
- Factors contributing to impaired neurocognition include prenatal injury, hemodynamic issues, anesthesia, and cardiopulmonary bypass complications.
Purpose of the Study:
- To review current knowledge on neurodevelopmental outcomes in children with CHD.
- To summarize evidence for intraoperative neuromonitoring modalities.
- To emphasize the importance of the intraoperative period for neurologic outcomes.
Main Methods:
- Review of current literature on neurodevelopmental outcomes in pediatric CHD.
- Summary of evidence for four specific neuromonitoring techniques: Transcranial Doppler (TCD) ultrasound, electroencephalography (EEG), near-infrared spectroscopy (NIRS), and processed electroencephalography (pEEG).
Main Results:
- No single neuromonitoring modality reliably guides management to improve neurologic outcomes.
- A multimodal approach to neurologic monitoring is likely the most effective strategy.
- The choice of monitoring combination may vary based on resources and patient-specific risk factors.
Conclusions:
- Optimizing intraoperative management is crucial for mitigating neurologic deficits in children with CHD.
- Multimodal neuromonitoring offers a promising strategy for improving neurodevelopmental outcomes.
- Further research and tailored monitoring approaches are needed for this high-risk population.
Abstract:
Recent decades have witnessed incredible developments in the care of children with congenital heart disease (CHD), such that survival into adulthood is the expected outcome. Improved survival has shifted the focus from improvements in mortality to improvements in morbidity, with long-term neurologic sequelae among the most important. Children with CHD who undergo corrective procedures in infancy and early childhood have a high rate of neurodevelopmental disability later in childhood. Impaired neurocognition is a result of many factors, including prenatal brain injury; preoperative hemodynamic derangements; exposure to anesthetic drugs; and the abnormal physiological states associated with cardiopulmonary bypass, low-flow perfusion, and deep hypothermic circulatory arrest. The intraoperative period presents a challenge to the anesthesiologist because this is a vulnerable period for the neurologic system. Transcranial Doppler ultrasound, electroencephalography, near-infrared spectroscopy, and processed electroencephalography are the neuromonitoring modalities that may be used intraoperatively. Even though each modality has merits, no single modality is able to reliably guide changes to management that improve neurologic outcomes. The best strategy is likely a multimodal neurologic monitoring strategy, although the combination of monitoring may depend on local resources and patient risk factors. This review provides a brief overview of the current knowledge regarding neurodevelopmental outcomes in children with CHD and summarizes the evidence for the use of the following 4 neuromonitoring modalities: transcranial Doppler, cerebral near-infrared spectroscopy, standard electroencephalography, and processed electroencephalography.
