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.

Keywords: Hospital Complications; Multimodal Neurologic Monitoring; Pediatric Neurocritical Care; Quality Improvement; Traumatic Brain Injury.

Fig. 1

Flow process diagram of the workflow for multimodal neurologic monitoring reporting of children with traumatic brain injury. Abbreviations: ICU, intensive care unit; MMM, multimodality neurologic monitoring; PICU, pediatric intensive care unit; TBI, traumatic brain injury

Fig. 2

In a 9-month-old boy with traumatic brain injury, multiple plateau waves of intracranial hypertension are observed above 20 mmHg. Each plateau wave is associated with increases in ABP, EtCO2 and rSO2, suggestive of increases in intracranial arterial blood volume. Communication with bedside nursing affirms these plateau waves were provoked by nursing care. Findings are communicated with the bedside team and escalation to tier 2 therapy is avoided. Abbreviations: ABP, arterial blood pressure; CPP, cerebral perfusion pressure; EtCO2, end-tidal CO2; ICP, intracranial pressure; rSO2, cerebral oxygenation

Fig. 3

In the patient described in Fig. 2 within the same epoch, scatterplots demonstrate strong positive association between RSO2 to both ETCO2 and ABP. Abbreviations: ABP, arterial blood pressure; ETCO2, end tidal cerebral dioxide; RSO2, cerebral oxygenation

Fig. 4

A 1-year-old girl with abusive head trauma experienced refractory intracranial hypertension secondary to malignant cerebral edema affirmed on neuroimaging. Intracranial hypertension is refractory to all institutional tier 2 therapies. Mean pressure reactivity index value on this recording date is 0.5, suggestive of poor cerebral autoregulation. Continuous bedside TCD is applied to the bilateral MCA regions. Direct association of ICP, ABP and TCD MCA MFVs is observed, reaffirming poor cerebral autoregulation. Tapering of norepinephrine leads to a reduction of CPP from 55 to 45 mmHg, a reduction in bilateral TCD MFVs by 10 cm/sec and reduction of ICP from 27 to 15 mmHg. CPP goals are subsequently adjusted from maintenance above 55 mmHg to above 40 mmHg. Intracranial hypertension is subsequently resolved for the remainder of this patient’s PICU hospitalization. Abbreviations: CPP, cerebral perfusion pressure; ICP, intracranial pressure; MCA, middle cerebral artery; MFVs, mean flow velocities; PICU, pediatric intensive care unit; TCD, transcranial Doppler ultrasound