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Background: Children presenting to the pediatric emergency department (PED) with neurologic dysfunction require prompt evaluation. Many PEDs successfully implement stroke alerts. However, most pediatric patients presenting with neurologic dysfunction have a non-stroke diagnosis better evaluated using magnetic resonance imaging (MRI). Therefore, we created a Neuro Deterioration clinical pathway using fast MRI to reduce time from PED arrival to completion of radiologic report by 25% in all PED patients presenting with new neurologic dysfunction., Methods: After creating an algorithm and allocating resources, the team used quality improvement methodology to implement a Neuro Deterioration clinical pathway. Interventions focused on patient identification, patient flow, and electronic decision support. Statistical process control charting assessed interventions. The primary outcome measure was time from PED arrival to completion of radiologic report. Additional measures included time from arrival to image finish and percentage of patients on pathway., Results: From 2018 to 2021, time from PED arrival to completion of radiologic report reduced by 32.2%. The average time decrease from a baseline of 211 (n = 287, January 2018-August 2019) to 143 minutes (n = 162, October 2020-December 2021), as noted by a centerline shift on the statistical process control chart. Average time from PED arrival to image finish decreased from 179 to 131 minutes. Percentage of patients on pathway increased. The average age of patients on pathway was 11.5 years, 63.8% were admitted, and 87.5% had a fast MRI for initial imaging. Of the 30.4% of patients with abnormal findings on initial imaging, 85.8% had non-stroke etiologies., Conclusion: The authors created a sustainable Neuro Deterioration clinical pathway to improve time to diagnosis of all pediatric patients with neurologic findings in the PED., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Importance: Neurological manifestations during acute SARS-CoV-2-related multisystem inflammatory syndrome in children (MIS-C) are common in hospitalized patients younger than 18 years and may increase risk of new neurocognitive or functional morbidity., Objective: To assess the association of severe neurological manifestations during a SARS-CoV-2-related hospital admission with new neurocognitive or functional morbidities at discharge., Design, Setting, and Participants: This prospective cohort study from 46 centers in 10 countries included patients younger than 18 years who were hospitalized for acute SARS-CoV-2 or MIS-C between January 2, 2020, and July 31, 2021., Exposure: Severe neurological manifestations, which included acute encephalopathy, seizures or status epilepticus, meningitis or encephalitis, sympathetic storming or dysautonomia, cardiac arrest, coma, delirium, and stroke., Main Outcomes and Measures: The primary outcome was new neurocognitive (based on the Pediatric Cerebral Performance Category scale) and/or functional (based on the Functional Status Scale) morbidity at hospital discharge. Multivariable logistic regression analyses were performed to examine the association of severe neurological manifestations with new morbidity in each SARS-CoV-2-related condition., Results: Overall, 3568 patients younger than 18 years (median age, 8 years [IQR, 1-14 years]; 54.3% male) were included in this study. Most (2980 [83.5%]) had acute SARS-CoV-2; the remainder (588 [16.5%]) had MIS-C. Among the patients with acute SARS-CoV-2, 536 (18.0%) had a severe neurological manifestation during hospitalization, as did 146 patients with MIS-C (24.8%). Among survivors with acute SARS-CoV-2, those with severe neurological manifestations were more likely to have new neurocognitive or functional morbidity at hospital discharge compared with those without severe neurological manifestations (27.7% [n = 142] vs 14.6% [n = 356]; P < .001). For survivors with MIS-C, 28.0% (n = 39) with severe neurological manifestations had new neurocognitive and/or functional morbidity at hospital discharge compared with 15.5% (n = 68) of those without severe neurological manifestations (P = .002). When adjusting for risk factors in those with severe neurological manifestations, both patients with acute SARS-CoV-2 (odds ratio, 1.85 [95% CI, 1.27-2.70]; P = .001) and those with MIS-C (odds ratio, 2.18 [95% CI, 1.22-3.89]; P = .009) had higher odds of having new neurocognitive and/or functional morbidity at hospital discharge., Conclusions and Relevance: The results of this study suggest that children and adolescents with acute SARS-CoV-2 or MIS-C and severe neurological manifestations may be at high risk for long-term impairment and may benefit from screening and early intervention to assist recovery.

Background: Noninvasive neuromonitoring in critically ill children includes multiple modalities that all intend to improve our understanding of acute and ongoing brain injury., Methods: In this article, we review basic methods and devices, applications in clinical care and research, and explore potential future directions for three noninvasive neuromonitoring modalities in the pediatric intensive care unit: automated pupillometry, near-infrared spectroscopy, and transcranial Doppler ultrasonography., Results: All three technologies are noninvasive, portable, and easily repeatable to allow for serial measurements and trending of data over time. However, a paucity of high-quality data supporting the clinical utility of any of these technologies in critically ill children is currently a major limitation to their widespread application in the pediatric intensive care unit., Conclusions: Future prospective multicenter work addressing major knowledge gaps is necessary to advance the field of pediatric noninvasive neuromonitoring., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Background: Pediatric neurocritical care (PNCC) has emerged as a field to care for children at the intersection of critical illness and neurological dysfunction. PNCC fellowship programs evolved over the past decade to train physicians to fill this clinical need. We aimed to characterize PNCC fellowship training infrastructure and curriculum in the United States and Canada., Methods: Web-based survey of PNCC fellowship program leaders during November 2019 to January 2020., Results: There were 14 self-identified PNCC fellowship programs. The programs were supported by Child Neurology and/or Pediatric Critical Care Medicine divisions at tertiary/quaternary care institutions. Most programs accepted trainees who were board-eligible or board-certified in child neurology or pediatric critical care medicine. Clinical training consisted mostly of rotations providing PNCC consultation (n = 13) or as a provider on the pediatric intensive care unit-based neurointensive care team (n = 2). PNCC-specific didactics were delivered at most institutions (n = 13). All institutions provided training in electroencephalography use in the intensive care unit and declaration of death by neurological criteria (n = 14). Scholarly activity was supported by most programs, including protected time for research (n = 10)., Conclusions: We characterized PNCC fellowship training in the United States and Canada, which in this continuously evolving field, lays the foundation for exploring standardization of training going forward., Competing Interests: Declaration of competing interest Mark Wainwright reports board membership with Pediatric Neurocritical Care Research Group (PNCRG) and payment for participation in the Clinical Advisory Board of Sage Therapeutics. Sue Hong reports co-chair for the PNCRG Education Committee, grant from the NIH, and consulting fees from the Chicago Department of Public Health. Jennifer Erklauer reports a co-chair for the PNCRG Education Committee. Nicholas Abend reports grant funding by PCORI and Wolfson Foundation paid to his institution, book royalties paid by Demos Publishing, and payment for expert testimony. Kristin Guilliams reports board membership on the PNCRG and payment for expert testimony by Wiseman Ashworth Law Group for pediatric stroke expertise. Andrea Pardo reports grant funding by the Patrick G and Shirley W. Ryan Foundation, UCB Biosciences, NIH/NINDS, and NIH CSR paid to her institution. Jose Pineda reports board membership for the PNCRG, consulting fees from the NIH, honoraria from the American Board of Pediatrics, and participation in the NINDS Data Safety Monitoring Boards. Brian Appavu reports grants or contracts from the US Department of Defense, American Heart Association, and Innovators for Neuroscience in Kids Foundation and honoraria from Natus. Alexis Topjian reports grants from the NIH, payment for medical legal consulting, and participation in a Data Safety Monitoring Board for ESETT. Anne-Marie Guerguerian reports grants or contracts from the Canadian Institutes of Health Research and Garry Hurwitz Center for Brain and Mental Health, Health Outcomes, participating on the FAST Data Safety Monitoring Board, and leadership or fiduciary role for the Heart and Stroke Foundation of Canada and the American Heart Association., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Over 70% of pediatric organ donors are declared deceased by brain death (BD) criteria. Patients with these devastating neurologic injuries often have accompanying multiple organ dysfunction. This study was performed to characterize organ dysfunction in children who met BD criteria and were able to donate their organs compared with those deemed medically ineligible., Design: Retrospective cohort study., Setting: PICU at a quaternary care children's hospital., Patients: Patients with International Classification of Diseases , 9th Edition codes corresponding to BD between 2012 and 2018 were included., Measurements and Main Results: Demographics, comorbidities, Pediatric Risk of Mortality (PRISM)-III, and injury mechanisms were derived from the medical record. Organ dysfunction was quantified by evaluating peak daily organ-specific variables. Fifty-eight patients, from newborn to 22 years old, were included with a median PRISM-III of 34 (interquartile range [IQR], 26-36), and all met criteria for multiple organ dysfunction syndrome (MODS). Thirty-four of 58 BD children (59%) donated at least one organ. Of the donors (not mutually exclusive proportions), 10 of 34 donated lungs, with a peak oxygenation index of 11 (IQR, 8-23); 24 of 34 donated their heart (with peak Vasoactive Inotrope Score 23 [IQR, 18-33]); 31 of 34 donated kidneys, of whom 16 of 31 (52%) had evidence of acute kidney injury; and 28 of 34 patients donated their liver, with peak alanine transferase (ALT) of 104 U/L (IQR, 44-268 U/L) and aspartate aminotransferase (AST) of 165 U/L (IQR, 94-434 U/L). Organ dysfunction was similar between heart and lung donors and respective medically ineligible nondonors. Those deemed medically ineligible to donate their liver had higher peak ALT 1,518 U/L (IQR, 986-1,748 U/L) ( p = 0.01) and AST 2,200 U/L (IQR, 1,453-2,405 U/L) ( p = 0.01) compared with liver donors., Conclusions: In our single-center experience, all children with BD had MODS, yet more than one-half were still able to donate organs. Future research should further evaluate transplant outcomes of dysfunctional organs prior to standardizing donation eligibility criteria., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: This study was performed to describe the single-center experience of deep vein thrombosis (DVT) in children with severe traumatic brain injury (sTBI) who were mechanically ventilated with a central line, and to identify potentially modifiable risk factors. It was hypothesized that children with DVT would have a longer duration of central venous line (CVL) and a higher use of hypertonic saline (HTS) compared to those without DVT., Procedure/methods: This was a retrospective study of children (0-18 years) with sTBI, who were intubated, had a CVL, and a minimum intensive care unit (ICU) stay of 3 days. Children were analyzed by the presence or absence of DVT. HTS use was evaluated using milliliter per kilogram (ml/kg) of 3% equivalents. Univariable and multivariable logistic regression models were used to determine which factors were associated with DVT., Results: Seventy-seven children met inclusion criteria, 23 (29.9%) had a DVT detected in an extremity. On univariable analysis, children with DVT identified in an extremity had prolonged CVL use (14 vs. 8.5 days, p = .021) and longer duration of mechanical ventilation (15 vs. 10 days, p = .013). HTS 3% equivalent ml/kg was not different between groups. On multivariable analysis, mechanical ventilation duration was associated with DVT detection in an extremity, whereas neither CVL duration nor HTS use had an association., Conclusions: There was a high incidence of extremity DVT detected in children with sTBI who received invasive mechanical ventilation and had a CVL. HTS administration was not associated with DVT detection in an extremity., (© 2022 Wiley Periodicals LLC.)

Pediatric neurocritical care (PNCC) is a rapidly growing field. Challenges posed by the COVID-19 pandemic on trainee exposure to educational opportunities involving direct patient care led to the creative solutions for virtual education supported by guiding organizations such as the Pediatric Neurocritical Care Research Group (PNCRG). Our objective is to describe the creation of an international, peer-reviewed, online PNCC educational series targeting medical trainees and faculty. More than 1600 members of departments such as pediatrics, pediatric critical care, and child neurology hailing from 75 countries across six continents have participated in this series over a 10-month period. We created an online educational channel in PNCC with over 2500 views to date and over 130 followers. This framework could serve as a roadmap for other institutions and specialties seeking to address the ongoing problems of textbook obsolescence relating to the rapid acceleration in knowledge acquisition, as well as those seeking to create new educational content that offers opportunities for an interactive, global audience. Through the creation of a virtual community of practice, we have created an international forum for pediatric healthcare providers to share and learn specialized expertise and best practices to advance global pediatric health.

The use of transcranial Doppler ultrasound (TCD) is increasing in frequency in the pediatric intensive care unit. This review highlights some of the pertinent TCD applications for the pediatric intensivist, including evaluation of cerebral hemodynamics, autoregulation, non-invasive cerebral perfusion pressure/intracranial pressure estimation, vasospasm screening, and cerebral emboli detection.

Background: Our objective was to characterize the frequency, early impact, and risk factors for neurological manifestations in hospitalized children with acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or multisystem inflammatory syndrome in children (MIS-C)., Methods: Multicenter, cross-sectional study of neurological manifestations in children aged <18 years hospitalized with positive SARS-CoV-2 test or clinical diagnosis of a SARS-CoV-2-related condition between January 2020 and April 2021. Multivariable logistic regression to identify risk factors for neurological manifestations was performed., Results: Of 1493 children, 1278 (86%) were diagnosed with acute SARS-CoV-2 and 215 (14%) with MIS-C. Overall, 44% of the cohort (40% acute SARS-CoV-2 and 66% MIS-C) had at least one neurological manifestation. The most common neurological findings in children with acute SARS-CoV-2 and MIS-C diagnosis were headache (16% and 47%) and acute encephalopathy (15% and 22%), both P < 0.05. Children with neurological manifestations were more likely to require intensive care unit (ICU) care (51% vs 22%), P < 0.001. In multivariable logistic regression, children with neurological manifestations were older (odds ratio [OR] 1.1 and 95% confidence interval [CI] 1.07 to 1.13) and more likely to have MIS-C versus acute SARS-CoV-2 (OR 2.16, 95% CI 1.45 to 3.24), pre-existing neurological and metabolic conditions (OR 3.48, 95% CI 2.37 to 5.15; and OR 1.65, 95% CI 1.04 to 2.66, respectively), and pharyngeal (OR 1.74, 95% CI 1.16 to 2.64) or abdominal pain (OR 1.43, 95% CI 1.03 to 2.00); all P < 0.05., Conclusions: In this multicenter study, 44% of children hospitalized with SARS-CoV-2-related conditions experienced neurological manifestations, which were associated with ICU admission and pre-existing neurological condition. Posthospital assessment for, and support of, functional impairment and neuroprotective strategies are vitally needed., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Early post-traumatic seizures (PTS) are associated with worse outcomes in children with traumatic brain injury (TBI). Our aim was to identify the association between continuous electroencephalogram (cEEG) characteristics and early PTS risk following pediatric severe TBI. We also evaluated the relationship between cEEG background features and outcomes. A single-center retrospective cohort study was performed on children between 0 and 18 years of age admitted to the pediatric intensive care unit from 2016 to 2019 with severe TBI and cEEG monitoring within 7 days of injury. Raw cEEG tracings were reviewed by an epileptologist in accordance with American Clinical Neurophysiology Society (ACNS) Critical Care EEG terminology. Univariate comparisons were made between children with and without early PTS, as well as between those with and without varying cEEG background features. Eighteen children (31%) of the 59 included had early PTS. Interictal abnormalities, inclusive of sporadic spikes and sharp waves, rhythmic delta activity, or lateralized periodic discharges (LPDs) were more common among children with seizures (100 vs. 22%; p  < 0.01). LPDs were also more common in the seizure group (44 vs. 2%; p  < 0.01). Background discontinuity was associated with worse Glasgow Outcome Scale-Extended Pediatric Version (GOS-E Peds) scores at discharge and 3-, 6-, and 12-month post-discharge ( p  < 0.01). Lack of reactivity was also associated with worse GOS-E Peds scores at 3-, 6-, and 12-month post-discharge ( p  < 0.01). Interictal abnormalities and LPDs were each associated with early PTS following pediatric severe TBI. Larger studies should evaluate if high-risk patients would benefit from prolonged cEEG monitoring and/or more aggressive anti-seizure prophylaxis. Discontinuity and lack of variability were associated with worse outcomes. Future studies should attempt to clarify their role as potential early markers of prognosis., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

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., Competing Interests: Conflict of Interest K.L.L. has a patent emboli detection method to identify mechanisms of brain injury in susceptible adults and children pending. Rest authors declare no conflict of interest., (Thieme. All rights reserved.)

Objective: To identify if cerebral perfusion pressure (CPP) can be non-invasively estimated by either of two methods calculated using transcranial Doppler ultrasound (TCD) parameters., Design: Retrospective review of previously prospectively gathered data., Setting: Pediatric intensive care unit in a tertiary care referral hospital., Patients: Twenty-three children with severe traumatic brain injury (TBI) and invasive intracranial pressure (ICP) monitoring in place., Interventions: TCD evaluation of the middle cerebral arteries was performed daily. CPP at the time of the TCD examination was recorded. For method 1, estimated cerebral perfusion pressure (CPPe) was calculated as: CPPe = MAP × (diastolic flow (Vd)/mean flow (Vm)) + 14. For method 2, critical closing pressure (CrCP) was identified as the intercept point on the x-axis of the linear regression line of blood pressure and flow velocity parameters. CrCP/CPPe was then calculated as MAP-CrCP., Measurements and Main Results: One hundred eight paired measurements were available. Using patient averaged data, correlation between CPP and CPPe was significant (r = 0.78, p = < 0.001). However, on Bland-Altman plots, bias was 3.7 mmHg with 95% limits of agreement of - 17 to + 25 for CPPe. Using patient averaged data, correlation between CPP and CrCP/CPPe was significant (r = 0.59, p = < 0.001), but again bias was high at 11 mmHg with wide 95% limits of agreement of - 15 to + 38 mmHg., Conclusions: CPPe and CrCP/CPPe do not have clinical value to estimate the absolute CPP in pediatric patients with TBI.

Background and Purpose: Hemoglobin (Hbg) is often thought to impact cerebral blood flow velocity (CBFV). This study was performed to investigate the relationship between Hbg value and CBFV in African children with malaria., Methods: In this prospective, observational study, children aged 3 months to 18 years with malaria and a normal Blantyre coma score underwent a single transcranial Doppler ultrasound (TCD) examination with a concurrent Hbg check., Results: One hundred fifty-six children with a mean age of 43 months were enrolled. Thirty-three children (21%) had severe anemia (Hbg <5g/dL), 46 (29%) had moderate anemia (Hbg 5-6.9 g/dL), 63 children (41%) had mild anemia (7-9.9 g/dL), and 14 children (9%) had no anemia (Hbg >10 g/dL) at the time of TCD examination. Mean averaged CBFV in the middle cerebral artery (MCA) for the cohort was 99% of predicted based on normative values standardized for age. There was no significant correlation between Hbg levels and measured CBFV in the MCA (r = -.09; 95% CI, -.24-.07; P = .29)., Conclusion: In a large sample of African children with malaria, Hbg did not correlate with CBFVs as measured by TCD. Future work that includes baseline TCD measurements and Hbg values as well as other physiological parameters known to influence CBFVs is necessary to confirm these findings., (© 2020 American Society of Neuroimaging.)

Purpose: Abusive head trauma (AHT) is the leading cause of fatal head injuries for children under 2 years. The objective was to evaluate, using transcranial Doppler ultrasound (TCD), whether children with AHT have a similar neurovascular response to injury compared with children without AHT., Methods: Retrospective sub-analysis of previously prospectively acquired data in a pediatric intensive care unit in a level 1 trauma hospital. TCD was performed daily until hospital day 8, discharge, or death. Neurologic outcome was assessed using the Glasgow Outcome Scale Extended (GOS-E Peds) at 1 month from initial injury., Results: Sixty-nine children aged 1 day to 17 years with moderate-to-severe traumatic brain injury were enrolled. Fifteen children suffered AHT and 54 had no suspicion for AHT. Fifteen children with AHT underwent 80 serial TCD examinations; 54 children without AHT underwent 308 exams. After standardization for age and gender normative values, there was no statistically significant difference in mean cerebral blood flow velocity of the middle cerebral artery (V MCA ) between children with and without AHT. There was no difference in the incidence of extreme cerebral blood flow velocity (CBFV, greater or less than 2 standard deviations from normative value) between groups. Within the AHT group, there were no statistically significant differences in V MCA between children with a favorable (GOS-E Peds 1-4) versus unfavorable neurologic outcome (GOS-E Peds 5-8)., Conclusion: Children with AHT have no significant differences in V MCA or percentage of extreme CBFV in the middle cerebral artery compared to with those without AHT.

Introduction: Chest compression (CC) quality directly impacts cardiac arrest outcomes. Provider body type can influence the quality of cardiopulmonary resuscitation (CPR); however, the magnitude of this impact while using visual feedback is not well described. The aim of the study was to determine the association between provider anthropometric variables on fatigue and CC adherence to 2015 American Heart Association CPR while receiving visual feedback., Methods: This was a planned secondary analysis of healthcare professionals from multiple hospitals performing continuous CC for 2 minutes on an adult CPR mannequin with dynamic visual feedback. Main outcome measures include compression data (depth, rate, and lean) evaluated in 30-second epochs to explore performance fatigue. Multivariable models examined the relationship of provider anthropometrics to CC quality. Binomial mixed effects models were used to characterize fatigue by examining performance for 4 epochs., Results: Three hundred seventy-seven 2-minute CC episodes were analyzed. Extreme (low and high) BMI and weight are associated with poorer CC. Larger size (height, weight, and BMI) is associated with better depth but worse lean compliance. Performance fatigued for all providers for 2 minutes, but shorter, lighter weight, female participants had the greatest decline. On multivariable analysis, rate compliance did not deteriorate regardless of provider anthropometrics., Conclusions: Anthropometrics impact provider CC quality. Despite visual feedback, variable effects are seen on compression depth, rate, recoil, and fatigue depending on the provider sex, weight, and BMI. The 2-minute interval for changing chest compressors should be reconsidered based on individual provider characteristics and risk of fatigue's impact on high-quality CPR.

Background: Hanging injury is the most common method of suicide among children 5 to 11 years of age and near-hangings commonly occur. Adult studies in near-hanging injury have shown that need for cardiopulmonary resuscitation, initial blood gas, and poor mental status are associated with poor prognosis. The literature for similar factors in children is lacking., Objectives: This retrospective, single-center study was performed to identify the clinical factors associated with neurologic outcome in children after near-hanging., Methods: Inclusion criteria included <18 years of age and a diagnosis of near-hanging or strangulation. All physician documentation was reviewed, and incidences of respiratory complications, seizure, and multiorgan failure were noted. Pediatric cerebral performance category score was based on information at discharge and was defined as favorable (score of 1-4) or unfavorable (score of 5-6). Comparisons were made between outcome groups and suspected clinical factors., Results: The median age was 11.5 years with a median initial Glasgow Coma Scale (GCS) score of 10. Of all patients, 25% had a prehospital cardiac arrest, and 51% were admitted to the intensive care unit. Patients with unfavorable outcomes had a lower initial pH (6.9 vs. 7.3) and initial GCS score (3T vs. 14). Patients with an unfavorable outcome had significantly higher rates of intensive care unit admission, respiratory complications, anoxic brain injury, and multiorgan failure. No patient who presented with an initial GCS score of 3T and prehospital cardiac arrest had a favorable neurologic outcome., Conclusions: This is the largest single-center study of children with near-hanging injury. An initial GCS score of 3T and prehospital cardiac arrest was uniformly associated with poor neurologic outcome., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Severe traumatic brain injury is a leading cause of morbidity and mortality in children. In 2003 the Brain Trauma Foundation released guidelines that have since been updated (2010) and have helped standardize and improve care. One area of care that remains controversial is whether the placement of an intracranial pressure monitor is advantageous in the management of traumatic brain injury. Another aspect of care that is widely debated is whether management after traumatic brain injury should be based on intracranial pressure-directed therapy, cerebral perfusion pressure-directed therapy, or a combination of the two. The aim of this article was to provide an overview and review the current evidence regarding these questions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To explore changes to expected, age-related transcranial Doppler ultrasound variables during pediatric extracorporeal membrane oxygenation., Design: Prospective, observational, multicenter study., Setting: Tertiary care PICUs., Patients: Children 1 day to 18 years old requiring veno arterial extracorporeal membrane oxygenation., Methods: Participants underwent daily transcranial Doppler ultrasound measurement of bilateral middle cerebral artery flow velocities. Acute neurologic injury was diagnosed if seizures, cerebral hemorrhage, or diffuse cerebral ischemia was detected., Measurements and Main Results: Fifty-two children were enrolled and analyzed. In the 44 children without acute neurologic injury, there was a significant reduction in systolic flow velocity and mean flow velocity compared with predicted values over time (F [8, 434] = 60.44; p ≤ 0.0001, and F [8, 434] = 17.61; p ≤ 0.0001). Middle cerebral artery systolic flow velocity was lower than predicted on extracorporeal membrane oxygenation days 1-5, and mean flow velocity was lower than predicted on extracorporeal membrane oxygenation days 1-3. In the six infants less than 90 days old suffering diffuse cerebral ischemia, middle cerebral artery systolic flow velocity, mean flow velocity, and diastolic flow velocity from extracorporeal membrane oxygenation days 1-9 were not significantly different when compared with children of similar age in the cohort that did not suffer acute neurologic injury (systolic flow velocity F [8, 52] = 0.6659; p = 0.07 and diastolic flow velocity F [8, 52] = 1.4; p = 0.21 and mean flow velocity F [8, 52] = 1.93; p = 0.07). Pulsatility index was higher in these infants over time than children of similar age in the cohort on extracorporeal membrane oxygenation that did not suffer acute neurologic injury (F [8, 52] = 3.1; p = 0.006). No patient in the study experienced cerebral hemorrhage., Conclusions: Flow velocities in the middle cerebral arteries of children requiring extracorporeal membrane oxygenation are significantly lower than published normative values for critically ill, mechanically ventilated, sedated children. Significant differences in measured systolic flow velocity, diastolic flow velocity, and mean flow velocity were not identified in children suffering ischemic injury compared with those who did not. However, increased pulsatility index may be a marker for ischemic injury in young infants on extracorporeal membrane oxygenation.

The authors reviewed cases in which children with a focal infection inside the head (ex: a brain abscess) were cared for in their pediatric ICU to describe the frequency of complications and quantify the ICU resources needed (ex: breathing tube, blood pressure medications, and/or an intracranial pressure monitor). This information helps clarify illness severity and has identified complications that we should further investigate to improve care for these children.

Aim: To describe the cerebral blood flow velocity pattern and investigate cerebral autoregulation using transcranial Doppler ultrasonography (TCD) following a global hypoxic-ischaemic (HI) event in children., Methods: This was a prospective, observational study in a quaternary-level paediatric intensive care unit. Intubated children, newborn to 17 years admitted to the PICU following HI injury (asphyxia, drowning, cardiac arrest) were eligible for inclusion. TCD was performed daily until post-injury day 8, discharge, or death, whichever occurred earliest., Results: Twenty-six patients were enrolled. Median age was 3 years (0.33, 11.75), initial pH 6.95, and initial lactate 5.4. Median post-resuscitation Glasgow Coma Score was 3T. Across the entire cohort, cerebral blood flow velocity (CBFV) was near normal on day 1. Flow velocity increased to a maximum median value of 1.4 standard deviations above normal on day 3 and slowly downtrended back to baseline by the end of the study period. Median Paediatric Extended Version of the Glasgow Outcome Score was 4 at three months. No patient in the favourable outcome group had extreme CBFV on day one, and only one patient in the favourable group had extreme CBFV on PID 2. In contrast, 38% of patients in the unfavourable group had extreme CBFV on PID 1 (p=.039 compared to frequency in favourable group), and 55% had extreme CBFV on PID 2 (p = .023 compared to frequency in favourable group). No patient had consistently intact cerebral autoregulation throughout the study period., Conclusions: Following a HI event, patients with favourable neurologic outcomes had flow velocity near normal whereas unfavourable outcomes had more extreme flow velocity. Intermittently intact cerebral autoregulation was more frequently seen in those with favourable neurologic outcomes though return to the autoregulatory baseline appears delayed., (Copyright © 2018 Elsevier B.V. All rights reserved.)

OBJECTIVE Severe traumatic brain injury remains a leading cause of morbidity and mortality in the pediatric population. Providers focus on reducing secondary brain injury by avoiding hypoxemia, avoiding hypotension, providing normoventilation, treating intracranial hypertension, and reducing cerebral metabolic demand. Hyperthermia is frequently present in patients with severe traumatic brain injury, contributes to cerebral metabolic demand, and is associated with prolonged hospital admission as well as impaired neurological outcome. The objective of this quality improvement initiative was to reduce the duration of hyperthermia for pediatric patients with severe traumatic brain injury during the initial 72 hours of admission to the pediatric intensive care unit. METHODS A retrospective chart review was performed to evaluate the incidence and duration of hyperthermia within a preintervention cohort. The retrospective phase was followed by three 6-month intervention periods (intervention Phase 1, the maintenance phase, and intervention Phase 2). Intervention Phase 1 entailed placement of a cooling blanket on the bed prior to patient arrival and turning it on once the patient's temperature rose above normothermia. The maintenance phase focused on sustaining the results of Phase 1. Intervention Phase 2 focused on total prevention of hyperthermia by initiating cooling blanket use immediately upon patient arrival to the intensive care unit. RESULTS The median hyperthermia duration in the preintervention cohort (n = 47) was 135 minutes. This was reduced in the Phase 1 cohort (n = 9) to 45 minutes, increased in the maintenance phase cohort (n = 6) to 88.5 minutes, and decreased again in the Phase 2 cohort (n = 9) to a median value of 0 minutes. Eight percent of patients in the intervention cohorts required additional sedation to tolerate the cooling blanket. Eight percent of patients in the intervention cohorts became briefly hypothermic while on the cooling blanket. No patient required neuromuscular blockade to tolerate the cooling blanket, experienced an arrhythmia, had new coagulopathy, or developed a pressure ulcer. CONCLUSIONS The placement of a cooling blanket on the bed prior to patient arrival and actively targeting normothermia successfully reduced the incidence and duration of hyperthermia with minimal adverse events.

Independent lung ventilation is an infrequently used ventilation strategy in the pediatric intensive care unit but can be beneficial in unique patient subsets, such as patients who have asymmetric pulmonary pathology. Independent lung ventilation allows for the independent delivery of the appropriate effective tidal volume to each lung on the basis of individual compliance and pathology. In theory, it may help avoid alveolar overdistension and ventilator-induced lung injury in the nondiseased lung. In addition, it allows for targeted interventions. Here, we describe a child with unilateral lung disease requiring veno-venous extracorporeal membrane oxygenation who rapidly improved, allowing decannulation within 24 hours, after the application of independent lung ventilation and unilateral surfactant administration.

Although generally safe and effective, one of the unique properties of linezolid is its weak inhibitory effect on monoamine oxidase. As such, it may interact with other medications that act through the adrenergic or serotonergic systems, including selective-serotonin reuptake inhibitors and vasoactive agents. We present a 3-month-old infant who was being treated with dopamine to maintain mean arterial pressure during mechanical ventilation following viral-induced respiratory failure. Hypertension and tachycardia developed during the administration of linezolid on two separate occasions. The physiology of catecholamine metabolism is reviewed including the role of the monoamine oxidase system. The potential interaction between linezolid and vasoactive agents such as dopamine is discussed., (© The Author(s) 2016.)