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Published on: March 26, 2019
Multimodal Neuromonitoring in Pediatric Neurocritical Care: Current Perspectives
1Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
Insights
Children in critical care with neurological illness face high risks of secondary brain injury. Multimodal neuromonitoring offers continuous assessment to improve patient care and outcomes.
Area of Science:
- Pediatric critical care medicine
- Neuroscience
- Neurology
Background:
- Children with neurological illness in critical care are susceptible to secondary brain injury (SBI).
- Brain insults disrupt cerebral autoregulation, intracranial pressure (ICP), oxygenation, and metabolism, leading to ischemia, hypoxia, and excitotoxicity.
- Current clinical examination and neuroimaging lack continuous monitoring capabilities for real-time pathophysiological changes.
Purpose of the Study:
- To explore the role and application of multimodal (MM) neuromonitoring in pediatric neurocritical care.
- To highlight the importance of simultaneous and continuous assessment of cerebral parameters for improved patient outcomes.
- To expand the utility of MM neuromonitoring beyond traumatic brain injury to pediatric non-traumatic coma.
Main Methods:
- Review of invasive monitoring techniques: ICP monitoring, cerebral autoregulation monitoring, brain tissue partial oxygen pressure, and cerebral microdialysis.
- Review of noninvasive monitoring techniques: pupillometry, brain and ocular ultrasonography, near-infrared spectroscopy, and electrophysiological monitoring.
- Integration of various monitoring techniques into a multimodal approach for early detection and treatment of brain insults.
Main Results:
- While evidence for MM neuromonitoring is established in adult neurocritical care, its application in children is growing, particularly in traumatic brain injury.
- Emerging data suggest expanded utility in pediatric non-traumatic coma.
- MM neuromonitoring provides crucial clinical and pathophysiological insights for intensivists.
Conclusions:
- Multimodal neuromonitoring is essential for comprehensive assessment of critically ill children with neurological conditions.
- This approach aids in the early identification and management of primary and secondary brain insults.
- MM neuromonitoring facilitates patient-specific treatment strategies, ultimately improving neurological outcomes in pediatric neurocritical care.
Abstract:
Children with neurological illness in the critical care unit are always at higher risk of developing secondary brain injury (SBI). Brain insult can lead to changes in cerebral autoregulation, intracranial pressure (ICP), cerebral oxygenation, and metabolism. This can cause a raised ICP, cerebral ischemia, hypoxia, excitotoxicity, cellular energy failure, and nonconvulsive status epilepticus. Simultaneous and continuous assessment of these parameters will help to improve patient care and neurological outcomes. Even though clinical examination and neuroimaging can help in the initial diagnosis of the neurological illness, they may not be helpful in continuous monitoring of cerebral pathophysiological changes. The ideal single neuromonitoring device to detect these real-time changes is currently unavailable. However, a range of invasive and noninvasive monitors are available to monitor these cerebral functional parameters. Invasive monitoring techniques include invasive ICP monitoring, cerebral autoregulation monitoring, brain tissue partial oxygen pressure, and cerebral microdialysis. Noninvasive-monitoring techniques include pupillometry, brain and ocular ultrasonography, near-infrared spectroscopy, and electrophysiological monitoring. Multimodal (MM) neuromonitoring involves incorporating these techniques and tools for the early identification and treatment of primary and secondary brain insults. The utility and feasibility of most of these techniques are well described in adult neurocritical care. Even though the evidence on their usage in children is primarily available in pediatric traumatic brain injury, the emerging data help to further expand their utility in pediatric nontraumatic coma. MM neuromonitoring aims to provide clinical and pathophysiological information to the intensivists to improve their understanding of the child's neurological status and to formulate patient-specific treatment approaches.
