Plante Virginie, Basu Meera, Gettings Jennifer V, Luchette Matthew, LaRovere Kerri L
Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.
Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.
Semin Neurol. 2024 Jun;44(3):362-388. doi: 10.1055/s-0044-1787047. Epub 2024 May 24.
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
目前，全球儿科重症监护病房（PICUs）近四分之一的入院病例是因神经重症监护诊断，这些诊断与显著的发病率和死亡率相关。儿科神经重症监护是一个快速发展的领域，面临着独特的挑战，这不仅是由于与年龄相关的对原发性神经损伤及其治疗的反应，还因为在任何特定机构中儿科神经重症监护病症都很罕见。因此，儿科神经重症监护服务的结构最常见的是一种协作模式，即重症医学医生协调护理，并由包括神经科医生在内的儿科亚专科多学科团队提供支持。虽然儿科神经重症监护处于重症监护和神经科学的交叉点，但本叙述性综述重点关注儿科神经科医生作为PICU顾问时遇到的最常见临床情况，并综合这些病例的最新证据、最佳实践和正在进行的研究。我们对以下内容进行了深入综述：（1）异常运动（癫痫发作/癫痫持续状态和肌张力障碍状态）的评估和管理；（2）急性无力和瘫痪（重点是小儿卒中及某些儿科神经免疫病症）；（3）采用病理生理学驱动方法的神经监测方式；（4）有证据支持的神经保护策略（例如小儿重型创伤性脑损伤、心脏骤停后护理以及缺血性卒中和出血性卒中）；（5）小儿创伤性脑损伤、心脏骤停和意识障碍中神经预后评估的最佳实践，并突出了2023年脑死亡/神经学标准判定死亡的更新内容。我们从PICU的儿科神经科医生需要了解的角度对儿科神经重症监护的现状进行综述，旨在提高床边医护人员的知识水平，以实现更好的患者护理和治疗效果。
