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Continuing to Expand Pediatric Neurocritical Care

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It was an honor and privilege to present at the Symposium on Pediatric Neurocritical Care: From field to follow-up at the annual Child Neurology Society meeting in Chicago, IL on October 18th. This symposium brought together pediatric neurologists from 4 institutions to discuss three of the top causes of childhood morbidity and mortality: cardiac arrest, stroke, and traumatic brain injury (TBI). The final talk introduced an innovative follow-up program to address post-ICU needs, including post-intensive care syndrome (PICS). All of the presentations highlighted important factors and predictors in the recovery process from critical illness.

Pediatric neurocritical care has emerged as a subspecialty within both pediatric neurology and pediatric critical care over the last two decades. Over the preceding decade, adult neurocritical care formed "closed units" staffed by specialty trained neurologists and became a neurologic subspecialty with the formation of the United Council for Neurologic Subspecialties in 2003. In contrast, pediatric neurocritical care is unlikely to follow a similar path, as it is increasingly clear that pediatric neurocritical care requires equal contributions from critical care, neurosurgery and neurology. For example, one of the most frequent presentations in pediatric neurocritical care is traumatic brain injury (TBI), which is often in the context of polytrauma. Similarly, cardiac arrest is almost never due to an isolated (or pure) neurologic cause and strokes may complicate broader infections or inflammatory processes. More importantly, though, is an increasing appreciation of the neurocognitive and psychosocial impacts of critical illness that are not limited to acute brain injury, making almost all patients in a pediatric intensive care unit potential "neurocritical" patients.

Simultaneously, intensive care has continued to improve, decreasing patient mortality. The heightened awareness of the neurocognitive and psychosocial morbidities of an ICU stay are particularly cogent in those with acute brain injury. Dr. Faye Silverstein demonstrated how a quantitative neurologic exam correlated with a patient's ability to adapt to, and cope with, environmental changes after cardiac arrest. Dr. Juan Piantino's discussion of PICS showcased the important value added of neuropsychology in post-ICU care. In more than 80% of patients seen in a neurocritical care follow-up clinic, neuropsychology makes new recommendations for school or neurodevelopmental therapies that were not in place prior to hospitalization or at hospital discharge. Dr. Laura Lehman's data revealed that neuropsychological morbidities are not limited to the patient, as post-traumatic stress disorder (PTSD) was common in parents of children admitted to an ICU for stroke. Interestingly, PTSD symptoms did not directly correlate with severity of the child's stroke, and persisted for months after hospital discharge. These talks illuminated how even "standard" neurology consultation in the ICU may benefit from a greater depth of neurology and neuropsychology assessment.

Dr. Guerriero's talk, Traumatic Brain Injury: from field to follow-up emphasized the breadth and depth of care a neurologist can bring to critical care and rehabilitation in a collaborative, consultative role. Acute TBI, the quintessential pediatric neurocritical care condition, has traditionally been cared for, almost exclusively, by critical care physicians and neurosurgeons in the ICU. On a national level, the potential contribution of neurology in the acute setting has been underemphasized. Dr. Guerriero highlighted 3 key contributions of neurologists to TBI care. First, EEG monitoring adds value to care immediately when the patient enters the ICU with its ability to detect subclinical seizures, assess for hemispheric asymmetries, electrographic reactivity and potentially changes in intracranial pressure. Second, expertise and repeated assessment of the neurologic exam may be able to detect outliers and atypical presentations that change management and improve patient care. This value is difficult to quantify, however, anecdotes may be sufficient if this decreases mortality and morbidity of those children who are the outliers. Lastly, neurology plays a key role in the longitudinal care of these patients. Through coordination and collaboration with neurosurgery and rehabilitation services, neurology is often the provider who manages care in the outpatient setting. Establishing an early rapport with the patient and family is crucial for establishing trust and a therapeutic relationship, particularly as discussions of rehabilitation and prognosis arise. Whether giving good or bad news, understanding the early trajectory of disease, with potential secondary injuries, as well as having an appreciation for psychosocial factors or family dynamics are vital to these conversations.

It is an exciting time to be in the field of pediatric neurocritical care. As the field moves forward there should be common neurocritical care training pathways with multiple points of entry from intensive care, neurosurgery or neurology. Common pathways would foster a deeper understanding and appreciation for each specialists' role in neurocritical care patients.

Regardless of specialized training, the importance of collaborative care in pediatric neurocritical cannot be emphasized enough. The breadth of pediatric neurocritical care is increasing to include the neurodevelopmental and neuropsychological consequences of all critical illnesses. While emerging as a subspecialty, paradoxically pediatric neurocritical care must become one of the broadest, most inclusive and collaborative fields in pediatrics. With this increasing breadth, we should also be thoughtful of the value of deeper neurologic evaluations and the longitudinal care required to improve these neurocognitive outcomes. Given the enormous amounts of work and resources required to improve ICU survival, we cannot lose sight of the larger goal of reintegrating patients into home, school, and the community. With this ultimate goal for each pediatric neurocritical care patient in sight, it is clear that no one person or specialty can accomplish this on their own.

Dr. Réjean Guerriero and Dr. Kristin Guilliams are Assistant Professors of Neurology and Pediatrics, Divisions of Pediatric Neurology and Critical Care Medicine at Washington University School of Medicine. Dr. Guerriero is an epileptologist and directs the ICU-EEG service at St. Louis Children's Hospital, with research interests in neuromonitoring and traumatic brain injury. Dr. Guilliams is an attending physician in critical care and neurology, with research interests in neuroimaging, stroke and cerebrovascular disease.

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