At least 45 specialized pediatric neurocritical care services exist in the United States. Eighty percent of these services are a consultation service to the PICU. Hospitals with level 1 trauma status, greater numbers of PICU beds, and greater numbers of patients with pediatric neurocritical care conditions were associated with the existence of pediatric neurocritical care as a clinical service.
Objectives: The scope of transcranial Doppler ultrasound in the practice of pediatric neurocritical care is unknown. We have surveyed pediatric neurocritical care centers on their use of transcranial Doppler and analyzed clinical management practices. Design: Electronic-mail recruitment with survey of expert centers using web-based questionnaire. Setting: Survey of 43 hospitals (31 United States, 12 international) belonging to the Pediatric Neurocritical Care Research Group. Patients: None. Interventions: None. Measurements and Main Results: A 67% (29/43) hospital-response rate. Of these centers, 27 reported using transcranial Doppler in the PICU; two hospitals opted out due to lack of transcranial Doppler availability/use. The most common diagnoses for using transcranial Doppler in clinical care were intracranial/subarachnoid hemorrhage (20 hospitals), arterial ischemic stroke (14 hospitals), and traumatic brain injury (10 hospitals). Clinical studies were carried out and interpreted by credentialed individuals in 93% (25/27) and 78% (21/27) of the centers, respectively. A written protocol for performance of transcranial Doppler in the PICU was available in 30% (8/27 hospitals); of these, two of eight hospitals routinely performed correlation studies to validate results. In 74% of the centers (20/27), transcranial Doppler results were used to guide clinical care: that is, when to obtain a neuroimaging study (18 hospitals); how to manipulate cerebral perfusion pressure with fluids/vasopressors (13 hospitals); and whether to perform a surgical intervention (six hospitals). Research studies were also commonly performed for a range of diagnoses. Conclusions: At least 27 pediatric neurocritical care centers use transcranial Doppler during clinical care. In the majority of centers, studies are performed and interpreted by credentialed personnel, and findings are used to guide clinical management. Further studies are needed to standardize these practices.
Introduction: Children with congenital and acquired heart disease are at high risk for stroke. One-quarter of acute ischemic strokes (AIS) in children with cardiac disease occur in the peri-procedural period. Children with AIS can be treated successfully with hyperacute therapies. However, this requires timely identification of stroke, which has historically proved challenging in children. By developing and implementing a standardized screening assessment, we aim to decrease the time to detection of strokes occurring after cardiac catheterization in children. Methods: We retrospectively reviewed the medical records of children who had a stroke after cardiac catheterization at a tertiary children’s hospital between December 2006 and July 2016. We then developed a standardized screening stroke assessment. This was incorporated into the electronic medical record, and cardiology bedside nurses were trained in its use. The performance of the screen was analyzed retrospectively for children with a known stroke after cardiac catheterization. Results: Twenty children had a clinically-apparent stroke after cardiac catheterization prior to implementation of our screen. The time from the end of catheterization to the first documented assessment of neurologic function in any domain ranged from 22 minutes to 3.3 days (median 126 minutes). Given this variability, we developed a screening assessment that is brief, feasible, and within the scope of practice of cardiology bedside nurses. This was introduced to all nurses involved in the acute assessment of children after cardiac catheterization and is now performed on all children after catheterization. Retrospective application of the screen to the 20 children with a post-catheterization stroke would have resulted in detection of 18 (90%) of these strokes. Conclusion: Stroke after cardiac catheterization in children is rare; however, it is accompanied by a high rate of morbidity and mortality. The diagnosis of stroke after cardiac catheterization is often delayed. Development of screening methods to rapidly identify stroke in this population is feasible and has the potential to decrease the time to detection of stroke, thereby expanding access to hyperacute therapies.
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