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The brain in pediatric critical care: unique aspects of assessment, monitoring, investigations, and follow-up

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Abstract

As survival after pediatric intensive care unit (PICU) admission has improved over recent years, a key focus now is the reduction of morbidities and optimization of quality of life for survivors. Neurologic disorders and direct brain injuries are the reason for 11–16% of admissions to PICU. In addition, many critically ill children are at heightened risk of brain injury and neurodevelopmental difficulties affecting later life, e.g., complex heart disease and premature birth. Hence, assessment, monitoring and protection of the brain, using fundamental principles of neurocritical care, are crucial to the practice of pediatric intensive care medicine. The assessment of brain function, necessary to direct appropriate care, is uniquely challenging amongst children admitted to the PICU. Challenges in assessment arise in children who are unstable, or pharmacologically sedated and muscle relaxed, or who have premorbid abnormality in development. Moreover, the heterogeneity of diseases and ages in PICU patients, means that high caliber evidence is harder to accrue than in adult practice, nonetheless, great progress has been made over recent years. In this ‘state of the art’ paper about critically ill children, we discuss (1) patient types at risk of brain injury, (2) new standardized clinical assessment tools for age-appropriate, clinical evaluation of brain function, (3) latest evidence related to cranial imaging, non-invasive and invasive monitoring of the brain, (4) the concept of childhood ‘post intensive are syndrome’ and approaches for neurodevelopmental follow-up. Better understanding of these concepts is vital for taking PICU survivorship to the next level.

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Funding

Research reported in this publication was supported by the National Institute of Health Biomedical Research Center at Great Ormond Street Hospital, London UK and the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under Award Number R01NS106292 (Dr. Bembea). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health”.

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Authors and Affiliations

  1. Biomedical Research Centre, Great Ormond Street Hospital for Children, London, UK

    Kate L. Brown, Ronit Pressler, Aparna Hoskote & Felice D’Arco

  2. Institute of Cardiovascular, Science University College London, London, UK

    Kate L. Brown & Aparna Hoskote

  3. Paediatric Intensive Care Unit Addenbrookes Hospital, Cambridge, UK

    Shruti Agrawal

  4. Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA, Philadelphia

    Matthew P. Kirschen & Alexis Topjian

  5. University of Pennsylvania Perelman School of Medicine, Philadelphia, USA

    Matthew P. Kirschen & Alexis Topjian

  6. Department of Pediatrics, Division of Pediatric Critical Care Medicine, Weill Cornell Medical College, New York, USA

    Chani Traube

  7. Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK

    Ronit Pressler

  8. University College London Institute of Child Health, London, UK

    Ronit Pressler & Felice D’Arco

  9. Division of Neurology, The Hospital for Sick Children, Toronto, Canada

    Cecil D. Hahn

  10. Department of Paediatrics, University of Toronto, Toronto, Canada

    Cecil D. Hahn

  11. Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK

    Barnaby R. Scholefield & Hari Krishnan Kanthimathinathan

  12. Paediatric Intensive Care Unit, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, UK

    Barnaby R. Scholefield & Hari Krishnan Kanthimathinathan

  13. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA

    Melania Bembea

  14. Nottingham Children’s Hospital and Neonatology, Nottingham University Hospitals NHS Trust, Nottingham, UK

    Joseph C. Manning

  15. Centre for Children and Young People Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK

    Joseph C. Manning

  16. Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands

    Maayke Hunfeld & Corinne Buysse

  17. Department of Pediatric Neurology, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands

    Maayke Hunfeld

  18. Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA

    Robert C. Tasker

  19. Selwyn College, Cambridge University, Cambridge, UK

    Robert C. Tasker

Authors
  1. Kate L. Brown
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  2. Shruti Agrawal
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  3. Matthew P. Kirschen
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  4. Chani Traube
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  16. Robert C. Tasker
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Contributions

KB and RT planned the report, MK, CT, AT contributed to clinical assessment section, RP, CH contributed to EEG section, BS, HKK, SA contributed to invasive monitoring section, SA, AH, FD and MB contributed to non-invasive assessment section, JM, MH, CB contributed to the post PICU section. All authors contributed to and approved the final manuscript.

Corresponding author

Correspondence to Kate L. Brown.

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Conflicts of interest

RP is an investigator for studies with UCB and does consultancy work for Kephala, Ireland. She served as a Speaker and/or on Advisory Boards for Natus, GW, Esai, and UCB. The other authors declare no conflict of interest.

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Brown, K.L., Agrawal, S., Kirschen, M.P. et al. The brain in pediatric critical care: unique aspects of assessment, monitoring, investigations, and follow-up. Intensive Care Med 48, 535–547 (2022). https://doi.org/10.1007/s00134-022-06683-4

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