aDepartment of Pediatrics, Divisions of Neurology bCritical Care cRuth D. and Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA dSection of Pediatric Intensive Care, Department of Pediatrics and Child Health, and University of Manitoba, Children's Hospital, Winnipeg, Manitoba, Canada eDepartment of Pediatrics, Section in Child Neurology - Epilepsy, Oregon Health and Science University, Portland, Oregon, USA.
Curr Opin Crit Care. 2016 Apr;22(2):106-12. doi: 10.1097/MCC.0000000000000288.
Approximately one in five children admitted to a pediatric ICU have a new central nervous system injury or a neurological complication of their critical illness. The spectrum of neurologic insults in children is diverse and clinical practice is largely empirical, as few randomized, controlled trials have been reported. This lack of data poses a substantial challenge to the practice of pediatric neurocritical care (PNCC). PNCC has emerged as a novel subspecialty, and its presence is expanding within tertiary care centers. This review highlights the recent advances in the field, with a focus on traumatic brain injury (TBI), cardiac arrest, and stroke as disease models.
Variable approaches to the structure of a PNCC service have been reported, comprising multidisciplinary teams from neurology, critical care, neurosurgery, neuroradiology, and anesthesia. Neurologic morbidity is substantial in critically ill children and the increased use of continuous electroencephalography monitoring has highlighted this burden. Therapeutic hypothermia has not proven effective for treatment of children with severe TBI or out-of-hospital cardiac arrest. However, results of studies of severe TBI suggest that multidisciplinary care in the ICU and adherence to guidelines for care can reduce mortality and improve outcome.
There is an unmet need for clinicians with expertise in the practice of brain-directed critical care for children. Although much of the practice of PNCC may remain empiric, a focus on the regionalization of care, creating defined training paths, practice within multidisciplinary teams, protocol-directed care, and improved measures of long-term outcome to quantify the impact of such care can provide evidence to direct the maturation of this field.
约五分之一入住儿科重症监护病房（PICU）的儿童会出现新的中枢神经系统损伤或其危重症的神经系统并发症。儿童的神经损伤谱多种多样，临床实践主要是经验性的，因为很少有随机对照试验报告。这种数据的缺乏对儿科神经危重症（PNCC）的实践构成了重大挑战。PNCC 已经成为一个新的亚专科，并且在三级医疗中心内其地位正在不断扩大。本综述重点介绍了该领域的最新进展，重点关注创伤性脑损伤（TBI）、心脏骤停和中风作为疾病模型。
报告了不同的 PNCC 服务结构方法，包括来自神经病学、重症监护、神经外科、神经放射学和麻醉学的多学科团队。危重病儿童的神经发病率很高，连续脑电图监测的使用增加突出了这一负担。亚低温治疗对治疗严重 TBI 或院外心脏骤停的儿童没有效果。然而，严重 TBI 研究的结果表明，重症监护室内的多学科护理以及遵循护理指南可以降低死亡率并改善预后。
对于具有儿童大脑定向重症护理实践专业知识的临床医生存在未满足的需求。尽管 PNCC 的大部分实践可能仍然是经验性的，但关注护理的区域化、创建明确的培训路径、多学科团队内的实践、以方案为导向的护理以及改善长期预后的衡量标准，以量化这种护理的影响，可以为指导该领域的成熟提供证据。
