Implementation of Multimodality Neurologic Monitoring Reporting in Pediatric Traumatic Brain Injury Management

Abstract

Background/Objective Multimodality neurologic monitoring (MMM) is an emerging technique for management of traumatic brain injury (TBI). An increasing array of MMM-derived biomarkers now exist that are associated with injury severity and functional outcomes after TBI. A standardized MMM reporting process has not been well described, and a paucity of evidence exists relating MMM reporting in TBI management with functional outcomes or adverse events. Methods Prospective implementation of standardized MMM reporting at a single pediatric intensive care unit (PICU) is described that included monitoring of intracranial pressure (ICP), cerebral oxygenation and electroencephalography (EEG). The incidence of clinical decisions made using MMM reporting is described, including timing of neuroimaging, ICP monitoring discontinuation, use of paralytic, hyperosmolar and pentobarbital therapies, neurosurgical interventions, ventilator and CPP adjustments and neurologic prognostication discussions. Retrospective analysis was performed on the association of MMM reporting with initial Glasgow Coma Scale (GCS) and Pediatric Risk of Mortality III (PRISM III) scores, duration of total hospitalization and PICU hospitalization, duration of mechanical ventilation and invasive ICP monitoring, inpatient complications, time with ICP > 20 mmHg, time with cerebral perfusion pressure (CPP) < 40 mmHg and 12-month Glasgow Outcome Scale—Extended Pediatrics (GOSE-Peds) scores. Association of outcomes with MMM reporting was investigated using the Wilcoxon rank-sum test or Fisher’s exact test, as appropriate. Results Eighty-five children with TBI underwent MMM over 6 years, among which 18 underwent daily MMM reporting over a 21-month period. Clinical decision-making influenced by MMM reporting included timing of neuroimaging (100.0%), ICP monitoring discontinuation (100.0%), timing of extubation trials of surviving patients (100.0%), body repositioning (11.1%), paralytic therapy (16.7%), hyperosmolar therapy (22.2%), pentobarbital therapy (33.3%), provocative cerebral autoregulation testing (16.7%), adjustments in CPP thresholds (16.7%), adjustments in PaCO2 thresholds (11.1%), neurosurgical interventions (16.7%) and neurologic prognostication discussions (11.1%). The implementation of MMM reporting was associated with a reduction in ICP monitoring duration (p = 0.0017) and mechanical ventilator duration (p = 0.0018). No significant differences were observed in initial GCS or PRISM III scores, total hospitalization length, PICU hospitalization length, total complications, time with ICP > 20 mmHg, time with CPP < 40 mmHg, use of tier 2 therapy, or 12-month GOS-E Peds scores. Conclusion Implementation of MMM reporting in pediatric TBI management is feasible and can be impactful in tailoring clinical decisions. Prospective work is needed to understand the impact of MMM and MMM reporting systems on functional outcomes and clinical care efficacy. ...

Multi-Mechanistic Approaches to the Treatment of Traumatic Brain Injury: A Review

“…A combination of intraparenchymal sensors has shown promise in better characterizing the general cerebral environment and local hemodynamics, however, these results must be validated with more established techniques [ 209 ]. While the data derived from MMM can effectively guide treatment [ 113 , 121 ], the invasiveness of MMM probes has limited MMM to use in moderate and severe TBI. Invasive MMM is generally considered safe [ 210 ], however, noninvasive approaches to MMM could expand its use to the mTBI population.…”

Seizure detection with reduced electroencephalogram channels: research trends and outlook

“…In the clinical setting of the ICU, the use of a reduced number of electrodes for continuous EEG (cEEG) without compromising seizure detection accuracy is a common practice [74][75][76]. The nature of critical care provided in neonatal and adult ICUs makes it challenging for technicians to apply and review a full electrode set, resulting in the current consensus on the reliability and use of a reduced number of electrodes [77,78].…”

Multi-mechanistic Approaches to the Treatment of Traumatic Brain Injury: A Review

“…A combination of intraparenchymal sensors has shown promise in better characterizing the general cerebral enviroment and local hemodynamics, however these results must be validated with more established techniques [173]. While the data derived from MMM can effectively guide treatment [82,174], the invasiveness of MMM probes has limited MMM to use in moderate and severe TBI. Invasive MMM is generally considered safe [175], however noninvasive approaches to MMM could expand its use to the mTBI population.…”