Practice Standards for the Use of Multimodality Neuromonitoring: A Delphi Consensus Process*

Abstract

OBJECTIVES: To address areas in which there is no consensus for the technologies, effort, and training necessary to integrate and interpret information from multimodality neuromonitoring (MNM). DESIGN: A three-round Delphi consensus process. SETTING: Electronic surveys and virtual meeting. SUBJECTS: Participants with broad MNM expertise from adult and pediatric intensive care backgrounds. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two rounds of surveys were completed followed by a virtual meeting to resolve areas without consensus and a final survey to conclude the Delphi process. With 35 participants consensus was achieved on 49% statements concerning MNM. Neurologic impairment and the potential for MNM to guide management were important clinical considerations. Experts reached consensus for the use of MNM—both invasive and noninvasive—for patients in coma with traumatic brain injury, aneurysmal subarachnoid hemorrhage, and intracranial hemorrhage. There was consensus that effort to integrate and interpret MNM requires time independent of daily clinical duties, along with specific skills and expertise. Consensus was reached that training and educational platforms are necessary to develop this expertise and to provide clinical correlation. CONCLUSIONS: We provide expert consensus in the clinical considerations, minimum necessary technologies, implementation, and training/education to provide practice standards for the use of MNM to individualize clinical care.

Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know

“…Substantial heterogeneity exists, however, between and within individuals of different ages over time and across anatomical brain regions. Acknowledging this, the traditional paradigm of population-based guidelines with “one-size-fits-all” thresholds is being challenged, and the focus in PNCC is moving towards multimodal neuromonitoring 12 to develop personalized goals that are based on individual pathophysiology and are dynamically assessed as diseases evolve. This is of relevance in pediatrics where the wide range of age, size, and neurodevelopmental stages might make single threshold approaches especially challenging.…”

“…At the single-patient level, this paradigm aims to detect early signs of clinical change, prevent further neurologic complications, and ultimately find effective treatments that improve outcomes. 11 12…”

“…At the single-patient level, this paradigm aims to detect early signs of clinical change, prevent further neurologic complications, and ultimately find effective treatments that improve outcomes. 11,12 PNCC patients are admitted to the PICU with a broad range of primary neurological and/or neurosurgical conditions, underlying chronic neurologic conditions, and/or severe systemic illnesses with neurological complications. [1][2][3] Beyond consultative care, PNCC is provided in some PICUs by a subsidiary team focused on severe traumatic brain injury (sTBI), 13 whereas other PICUs have designated beds for seizure care and continuous electroencephalography (cEEG) monitoring.…”