Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement

Abstract

Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.

Cerebral vasospasm in children with subarachnoid hemorrhage: frequency, diagnosis, and therapeutic management

“…In addition, the decision of brain imaging to explore cerebral arteries using CTA or MRA should be balanced with the transfer to radiological facility in patients who are unstable, and to the risk of radiation exposure (CTA) in children. In this context, the use of TCD to detect signs of cerebral vasospasm may help physicians to suspect cerebral vasospasm as suggested previously [10,12]. A multidisciplinary expert consensus have recently formulated 34 recommendations in four domains regarding the TCD use in pediatrics and provided normal TCD values by age [10].…”

“…In this context, the use of TCD to detect signs of cerebral vasospasm may help physicians to suspect cerebral vasospasm as suggested previously [10,12]. A multidisciplinary expert consensus have recently formulated 34 recommendations in four domains regarding the TCD use in pediatrics and provided normal TCD values by age [10]. Of note was that most of TCD studies included children with traumatic brain injury [4,27] or brain malaria [9,28].…”

“…The frequency of cerebral vasospasm was higher in patients with nontraumatic SAH (12/21) versus 2/59 patients with traumatic SAH (p < 0.001). Patients who developed a vasospasm had a lower Glasgow Coma Score (6 [6-9] vs. 14 [3][4][5][6][7][8][9][10][11][12][13][14][15], p = 0.04) and a higher World Federation of Neurological Surgeons score (5 [4, 5] vs. 4 [2][3][4][5], p < 0.001) on admission. They also required a higher level of care during the first 24 h, as reflected by more use of osmotherapy, external ventricular drains, mechanical ventilation, and vasopressor.…”

“…The management of the 14 patients who had cerebral vasospasm is detailed in Table 2. Thirteen of 14 children were treated with continuous intravenous infusion of milrinone at a dosage of 1.0 (0.6-1.0) µg/kg/minute for a median duration of treatment of 14 (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) days. Despite the use of norepinephrine to restore arterial blood pressure, medical treatment was discontinued in two patients (nimodipine) and one patient (milrinone).…”

“…Because neurological clinical evaluation is limited in patients receiving sedative drugs, transcranial Doppler (TCD) monitoring could be used to detect vasospasm at the bedside [9]. However, no reference values have been established in children until recently [10], and TCD recordings can be influenced by several factors, including age, hematocrit, gender, fever, and metabolic disturbances [11].…”