Improving “Neuro Checks” in Neonatal ICU and PICU Is a Serial Neurologic Assessment in Pediatrics*

Abstract

A dequate neurologic examinations in the PICU are an expectation that should be built into the practice of pediatric critical care. Similar to the role a piece of equipment plays in monitoring various physiologic variables to "warn" or provide feedback to clinical decision-makers about a patient's clinical status, serial neurologic examinations are an important part of the "monitoring system" (1, 2). Neurologic assessments on the PICU begin with keen observations and charting of serial neurologic examinations by bedside nurses. A standardized and consistent approach to the neurologic examination and documentation of findings in the medical record are invaluable for critical care practitioners and should improve communication between nurses and clinicians caring for children on the PICU.Kirschen et al (3), in their article published in this issue of Pediatric Critical Care Medicine, developed a new standardized screening tool for bedside nurses to score the neurologic status of critically ill patients in the neonatal ICU (NICU) and PICU setting, known as "Serial Neurologic Assessment in Pediatrics" (SNAP). SNAP is a blend of components of the Glasgow Coma Scale (GCS) (4), Full Outline of UnResponsiveness (FOUR) score ( 5), and pediatric National Institutes of Health Stroke Scale (NIHSS) (6) and has several strengths. Compared with the GCS, SNAP emphasizes the importance of a more complete neurologic assessment with an ordinal arrangement of the degree of impairment in mental status, cranial nerves, communication, and motor function and linearity of all components (equal weighting to individual units of the score). Additionally, SNAP includes separate scales for infants (< 6 mo), toddlers (≥ 6 mo to < 2 yr), and children (≥ 2 yr old) (3). Last, SNAP is most akin to the FOUR score, which has shown good validity (7, 8) and correlation with outcome (9) in critically ill adults in medical ICUs. Some pitfalls and theoretical disadvantages of SNAP, however, are similar to those seen with the scores from which SNAP is derived. The total GCS score, for example, is obtained by adding the values of three different behavioral responses to stimulation that are assumed to be independent variables-best motor response,

Editor’s Choice Articles for May

“…Our PCCM authors again give us unique materials: the three SNAP assessment scoring criteria panels are particularly useful (see Figures). The editorial places the SNAP tool feasibility study in the wider context of neurologic scoring systems (7). For example, over recent years we have seen the latest iteration of the Glasgow Coma Scale score (8) and other scores, but all for older pediatric or adult patients.…”

“…My third choice describes the feasibility of implementing a new tool for serial neurologic assessment in pediatrics (SNAP) in critically ill patients (3). All three articles (1–3) and related editorial material (4–7) will be freely available for the next two months.…”