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Automated infrared pupillometry (AIP) is rapidly becoming an accepted standard for the evaluation of pupil size and reactivity in adult neurocritical care. Recently, pediatric centers are increasingly utilizing this technology, but data supporting its use in children are limited. Our pediatric intensive care unit instituted AIP as a standard of care for pupillary light assessments in neurocritical care patients in early 2020. In this article, we describe four cases highlighting the advantage of using objective assessments of the pupillary light reactivity response measured by the Neurological Pupil index (NPi) to detect early changes in the patient's neurological status. These cases support the applicability of AIP in pediatric neurocritical care as a noninvasive neurologic monitoring tool. The NPi may be superior to manual pupil assessments by providing a numerical scale for accurate trending clinical status of a patient's neurologic condition.

Acute brain injury (ABI) increases morbidity and mortality in patients with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Optimal neurologic monitoring methods have not been well-explicated. We studied the use of Near-infrared Spectroscopy (NIRS) to monitor cerebral regional oxygenation tissue saturation (rSO2) and its relation to ABI in VA-ECMO. In this prospective, observational cohort study of 39 consecutive patients, we analyzed the ability of rSO2 values from continuous bedside NIRS monitoring to predict ABI during VA-ECMO support. ABI occurred in 24 (61.5%) patients. Those with ABI had a lower pre-ECMO Glasgow Coma Scale, more blood product transfusions of pRBCs and FFP, and higher APACHEII score. Baseline rSO2 values were not significantly different between cohorts (54.25 vs 58.50, p = 0.260), while the minimum rSO2 value was lower for patients who experienced an ABI than those who did not (39.75 vs 44.50, p = 0.039). In patients with ABI, 21 (87.5%) had a drop in rSO2 of 25% from baseline, compared to only 7 (46.7%) patients without ABI (p = 0.017). By ROC analysis, we found that desaturations with >25% drop from the baseline rSO2 on VA-ECMO exhibited 86% sensitivity and 55% specificity to predict ABI, with an area under the curve of 0.68. Patients with ABI were more likely to have withdrawal of life sustaining therapy (17 vs 5, p = 0.049), while neurologic outcome and mortality were not statistically different between patients with or without ABI. Our results support that cerebral NIRS is a useful, real-time bedside neuromonitoring tool to detect ABI in VA-ECMO patients. A >25% drop from the baseline was sensitive in predicting ABI occurrence. Further research is needed to assess how to implement this knowledge to utilize NIRS in developing appropriate intervention strategy in VA-ECMO patients.

Extracorporeal membrane oxygenation (ECMO) is used to provide cardiac and/or pulmonary support in patients refractory to conventional therapies. It is increasingly used in various clinical acute settings and associated with cerebrovascular complications responsible for high morbidity and mortality.

Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.

Objectives To review the neurocritical care aspects of patients supported by extracorporeal membrane oxygenation, including cerebral physiology, neurologic monitoring, use of sedatives and anti-seizure medications, and prevalence and management of extracorporeal membrane oxygenation associated brain injury. Data sources PubMed database search using relevant search terms related to neurologic complications, neurocritical care management, and brain injury management in patients with extracorporeal membrane oxygenation. Study selection Articles included original investigations, review articles, consensus statements and guidelines. Data extraction A detailed review of publications performed and relevant publications were summarized. Data synthesis We found no practice guidelines or management strategies for the neurocritical care of extracorporeal membrane oxygenation patients. Such patients are at high risk for hypoxic-ischemic brain injury, intracranial hemorrhage, cerebral edema, and brain death. Improving clinical outcomes will depend on better defining the neurologic complications and underlying pathophysiology that are specific to extracorporeal membrane oxygenation. Currently, insufficient understanding of the pathophysiology of neurologic complications prevents us from addressing their etiologies with specific, targeted monitoring techniques and interventions. Conclusions A large knowledge gap exists in our understanding and treatment of extracorporeal membrane oxygenation-related neurologic complications. A systematic and multidisciplinary approach is needed to reduce the prevalence of these complications and to better manage the neurologic sequelae of extracorporeal membrane oxygenation in a way that will improve patient outcomes.

Neonatal and pediatric extracorporeal membrane oxygenation (ECMO) is an increasingly utilized, potentially life-saving therapy for critically ill patients. The immediate and long-term neurodevelopmental outcomes for patients who require ECMO is not fully understood or appreciated. There is a growing body of literature examining the neurodevelopmental outcomes of neonatal and pediatric survivors of ECMO. Estimates of ECMO patients’ long-term neurological disabilities range from 10 to 60% (Glass et al. Pediatrics 83:72–78, 1989; Boyle et al. Pediatr Crit Care Med 19:760–766, 2018). Multiple modalities of neurologic monitoring while on ECMO are being investigated for their ability to detect neurologic injury, but their impact on long-term neurodevelopmental outcome remains unknown. Improved knowledge about the long-term neurodevelopmental outcomes for patients receiving ECMO therapy may help providers to access better resources and support patients after recovery from their acute illnesses. This review seeks to highlight some of the current understanding of the risks for poor neurodevelopmental outcomes of patients supported on ECMO, modes of neurologic monitoring, and recent data on neurodevelopmental outcomes.

Mechanical circulatory support (MCS) devices have demonstrated improved survival outcomes in otherwise refractory cardiopulmonary failure but are associated with significant neurologic morbidity and mortality. This review aims to characterize MCS-associated brain injury and discuss the neurocritical care of this population. We found no practice guidelines or specific management strategies for the neurocritical care of patients with MCS devices. Acute brain injury was commonly observed in short-term and durable MCS devices. There is emerging evidence that a standardized neurological monitoring and management algorithm for MCS device–associated brain injury is feasible and potentially improves neurological outcomes. While MCS devices are associated with significant neurologic morbidity and mortality, there is scant evidence regarding optimal neuromonitoring and neurocritical care. With the increase in use of MCS devices for both short-term and durable applications, improved outcomes will depend on early identification and intervention of neurologic complications and further research into their pathophysiology.

Carotid endarterectomy (CEA) is commonly performed to prevent the devastating sequelae of stroke. A focused preoperative cardiac and neurologic evaluation prior to CEA provides valuable data that can be used to optimize patient safety and comfort via an individually tailored anesthetic plan. With invasive monitoring, careful titration of anesthetics, and neurologic monitoring, strict control of hemodynamics can achieve cardiac stability and provide neurologic protection. Postoperative maintenance of hemodynamics and vigilance for possible complications may further ensure excellent patient care and success of surgery.

Background Intraoperative neurologic monitoring (IONM) has become an essential component for decreasing the incidence of spinal cord injury during spine surgeries. Many high-risk surgical maneuvers that result in significant IONM alerts have not been reported systematically. Our objective was to thoroughly summarize some common high-risk surgical points associated with IONM alerts in various spine surgeries. Methods Between November 2010 and April 2017, 62 patients with true-positive IONM alerts from 3139 spine surgeries were enrolled. Transcranial motor evoked potentials, somatosensory evoked potentials, and free-run electromyography were used for IONM. All 62 patients were identified as true-positive IONM cases. Results Of 3139 patients, 101 demonstrated significant IONM changes—62 true-positive cases, 14 false-positive cases, and 25 indeterminate IONM results. IONM alerts most often occurred in thoracic screw placement (n = 10, 16.1%), osteotomy (n = 22, 35.5%), correction (n = 19, 30.6%), and spinal cord decompression (n = 11, 17.8%). Appropriate timely measures are indicated in response to IONM alerts during high-risk surgical maneuvers. Ten (10/62, 16.1%) patients showed permanent postoperative neurologic deficits. Conclusions IONM alerts are often associated with some specific high-risk surgical maneuvers. Careful and timely observation is crucial.

During surgery, one of the primary functions of the anesthesiologist is to monitor the patient and ensure safe and effective conduct of anesthesia to provide the optimum operating conditions. Standard guidelines for perioperative monitoring have been firmly established by the American Society of Anesthesiologists. However, in recent years, new advances in technology has led to the development of many new monitoring modalities, especially involving the neurologic and cardiovascular systems. This article presents a targeted review to discuss the functions and limitations of these new monitors and how they are applied in the modern operating room setting.

Acute compartment syndrome is a well-known complication of tibial fractures, yet it remains difficult to diagnose and the only effective treatment is surgical fasciotomy. Delayed fasciotomy is the most important factor contributing to poor outcomes, and as a result, treatment is biased towards performing early fasciotomy. Current diagnosis of ACS is based on clinical findings and intramuscular pressure (IMP) measurement, and is targeted at identifying safe thresholds for when fasciotomy can be avoided. Since clinical findings are variable and difficult to quantify, measurement of IMP - ideally continuously - is the cornerstone of surgical decision - making. Numerous investigators are searching for less invasive and more direct measurements of tissue ischemia, including measurement of oxygenation, biomarkers, and even neurologic monitoring. This article provides a brief but thorough review of the current state of the art in compartment syndrome diagnosis and treatment.

Neuromonitoring is important for patients with acute brain injury. The bedside neurologic examination is standard for neurologic monitoring; however, a clinical examination may not reliably detect subtle changes in intracranial physiology. Changes found during neurologic examinations are often late signs. The assessment of multiple physiological variables in real time can provide new clinical insights into treatment decisions. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism, such as in multimodal monitoring, allows an innovative approach to individualized patient care.

While preliminary data are encouraging, definitive data are lacking to conclusively demonstrate the benefit of perioperative neurologic monitoring in improving neurodevelopmental outcomes in children who require surgery for congenital heart disease. Nonetheless, in the current era, some form of perioperative neurologic monitoring is important. Strategies include bicortical near infrared spectroscopy monitoring in the pre- and postoperative periods along with bicortical near infrared spectroscopy and transcranial Doppler intraoperatively. These monitors provide real-time information concerning cerebral oxygen delivery and blood flow. These strategies will allow us to refine treatments to optimize neurodevelopmental potential in children with congenital heart disease.

The treatment of spinal deformities has rapidly changed during the past decade. The advent of new surgical techniques, particularly thoracic pedicle screws and spinal osteotomies, allow more aggressive deformity correction, and require an increased focus on safety.Review of the navigation systems and neuromonitoring techniques currently available.Navigation systems today are where intraoperative neuromonitoring was 20 years ago: new, under investigation, not widely accepted, with concerns for cost, safety and efficiency. Navigation enhances the accuracy of pedicle screws placement in deformed spines, reducing the rate of misplaced screws and potential complications. With further use and investigation, navigation, like neuromonitoring, will soon become standard at major spine centers throughout the world.

Poisonings, adverse drug effects, and envenomations continue to be commonly encountered. Patients often present critically ill and warrant ICU admission. Many other patients who are initially stable have the potential for rapid deterioration and require continuous cardiopulmonary and neurologic monitoring. Given the potential for rapid deterioration, and because patients need continuous monitoring, ICU admission is frequently required. This article is the first of a three-part series to be published in CHEST; it discusses general management, laboratory tests, enhanced elimination, and emerging therapies. The second article will address the management of specific overdoses; the last will cover plants, mushrooms, envenomations, and heavy metals.

A brief overview of the most common invasive and noninvasive monitoring tools collectively referred to using the term "multimodal monitoring" is provided. Caring for the critically ill patient with traumatic brain injury requires careful monitoring to prevent or reduce secondary brain injury. Concurrent to the growth of the subspecialty of neurocritical care, there has been a concerted effort to discover novel mechanisms to monitor the physiology of brain injury. The past 2 decades have witnessed an exponential growth in neurologic monitoring in terms of intracranial pressure, blood flow, metabolism, oxygenation, advanced neuroimaging, and electrophysiology.

All neuromonitoring techniques, although imperfect, provide useful information for monitoring cardiothoracic and carotid vascular operations. They may be viewed as providing complementary information, which may help surgical technique and, as a result, possibly improve clinical outcomes. As of this writing, the efficacy of TCD and NIRS monitoring during cardiothoracic and vascular surgery cannot be considered established. Well designed, prospective, adequately powered, double-blind, and randomized outcome studies are needed to determine the optimal neurologic monitoring modality (or modalities), in specific surgical settings.

Improving survival from congenital cardiac repairs using cardiopulmonary bypass has appropriately shifted focus to neurologic outcomes. Hypoxic-ischemic mechanisms are the major cause of neurologic injury in neonatal cardiac surgery, and modifications of techniques of cardiopulmonary bypass can affect organ oxygen delivery and the propensity to injury both during and after surgery. Through successive refinements in the techniques of cardiopulmonary bypass, the risk factors for hypoxic-ischemic injury have been reduced, but not eliminated. The application of specific monitoring to enhance detection of hypoxic conditions associated with neurologic injury would both allow intervention on individual patients and drive refinements in strategies to further reduce risk. Specific neurologic monitoring techniques that can be used during cardiopulmonary bypass include near-infrared spectroscopy, transcranial Doppler ultrasonography, and electroencephalographic techniques. Of these, only near-infrared spectroscopy provides a continuous quantitative signal of the physiologic variable most related to injury and most amenable to intervention. This review will advocate wide adoption of near-infrared spectroscopy monitoring throughout the perioperative period, to enhance detection of hypoxic conditions and to drive patient-specific interventions.

Currently, the detection of emerging injury through intraoperative neurologic monitoring is the best way to prevent neurologic injury. This requires a team approach that includes the anesthesiologist, neurophysiologist, and surgeon. The monitoring modalities available for the patient must be considered in planning the anesthetic management. In addition, intraoperative care for the patient requires an ongoing attention to how the anesthetic drugs affect spinal cord monitoring.

PURPOSE OF REVIEW: The decreasing postoperative mortality in patients with congenital heart disease has enabled an increasing interest in preventing morbidity, especially from the central nervous system. Near-infrared spectroscopy, a noninvasive technology that provides an estimate of tissue oxygenation, has been introduced in the intensive care unit and has gained popularity over the last decade. This review aims to ascertain its ability to affect outcome. RECENT FINDINGS: Recent studies have started to incorporate cerebral near-infrared spectroscopy in the assessment, evolution, and outcomes of surgical patients with congenital heart disease. These studies often represent small single-center high-risk cohorts that are evaluated in a retrospective or an observational manner. Nevertheless, new data are starting to indicate that near-infrared spectroscopy may be helpful not only in the assessment of critical care parameters, such as cardiac output performance or likelihood of adverse events, but, most notably, in the long-term neurological outcome. SUMMARY: In addition to additional corroborative trials from different centers, a critical question that remains to be answered is whether targeting cerebral near-infrared spectroscopy values, as part of goal-directed therapy protocols, can help to improve outcome overall.

Goals and benefits for subspecialty neuroscience critical care unit (NCCU). Focused specialty care for unique ICU populationSpecial expertise required by professionals in NCCU – neuroscience background, Greater case efficiency of neurosurgical and neurointerventional cases. Efficient ICU management. Hub of clinical neuroscience communication. Academic clinical neuroscience concentration. Hospital hub for stroke, acute brain, and spinal cord injury centers. Neurocritical-trained nursing. Cohesive and comprehensive rounds. Neurologic monitoring – capable and savvy. Sensitive neurologic evaluations. Precisely match therapeutics to neurologic pathophysiology. Shorter lengths of stay (LOS) for patient in both the ICU and hospital. Improved patient outcomes. Increased regional referral network. Enhanced marketing strategy

Cardiac surgery (CS) with cardiopulmonary bypass (CPB) is currently the most common surgery in the United States. Understanding, avoiding, and preventing postoperative complications, including neurologic deficits following CS, represents a great public and economic benefit for society, especially considering our aging population. There is a critical need to identify new strategies that will prevent harmful events during and after CS. At present, experience with neurophysiologic techniques includes the ability to measure cerebral blood flow velocity/emboli and regional cerebral venous oxygen saturation by transcranial Doppler ultrasound, and by near-infrared spectroscopy, respectively. Continuous monitoring of these variables along with systemic hemodynamics will provide a better understanding of mechanisms of brain and other organ injury during CPB. Neuroprotective interventions based on multimodality neurologic monitoring would ideally eliminate postoperative complications and improve patient outcomes.

Low flow hypothermic cardiopulmonary bypass, deep hypothermic circulatory arrest, and regional low-flow cerebral perfusion are special techniques used to facilitate complex intracardiac and aortic surgery in neonates and infants. Each carries a risk of cerebral hypoxia and neurologic morbidity. Neurologic monitoring in the form of near-infrared spectroscopy for cerebral oxygenation, transcranial Doppler ultrasound, and the bispectral index electroencephalogram can monitor the brain during these techniques to determine the minimum acceptable bypass flow rates or maximum acceptable duration of deep hypothermic circulatory arrest. The use of this monitoring has the potential to improve long-term neurologic and developmental outcome.

The minimum alveolar concentration (MAC) of nitrous oxide necessary to prevent purposeful movement in rats has not been directly measured; rather, it has been extrapolated because the required partial pressure exceeds 760 mm Hg, or 1 atm absolute pressure (ATA). Values reported have ranged from 1.36 to 2.20 ATA (136-220 vol%, or 1034-1672 mm Hg). By maintaining general anesthesia at 2.25 ATA (1710 mm Hg), we directly measured the nitrous oxide MAC in 17 Long-Evans rats during mechanical ventilation and monitoring of two-channel electroencephalogram, compressed spectral array and cortical evoked potentials, electrocardiograph, and respiratory and anesthetic gases by mass spectrometry. After a minimal stabilization period of 30 min during ventilation by 1.8 ATA nitrous oxide and 0.45 ATA oxygen, MAC measurements were begun. Each rat was given up to three noxious electrical stimulations of 50 V by 10-ms-duration pulses at 50/s for 45 s. The partial pressure of nitrous oxide was decreased by approximately 10% after each negative response. The MAC was taken as the nitrous oxide concentration midway between that at which there was no response and that at which the rat moved purposefully. The nitrous oxide MAC in Long-Evans rats was determined to be 1.55 +/- 0.16 ATA (mean +/- SD). Hyperbaric nitrous oxide decreased electroencephalogram wave frequency to a predominantly theta rhythm of increased amplitude. Cortical evoked potentials had decreased wave amplitudes and increased latencies with increasing partial pressures0.75 ATA.(ABSTRACT TRUNCATED AT 250 WORDS)

Following emergency therapy of cases with severe brain injury, subsequent neurologic monitoring is most important. The prime goal is to reveal early the symptoms of life-threatening severe brain stem lesions which appear as sequelae of intracranial hematoma or diffuse cerebral edema. It is also important to recognize the development of an apallic symptomatology as well as to monitor its further course, particularly the onset of remission.