Transcranial Doppler Ultrasound During Critical Illness in Children: Survey of Practices in Pediatric Neurocritical Care Centers*

Abstract

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.

Transcranial Doppler Use in Non-traumatic Critically Ill Children: A Multicentre Descriptive Study

“…The broad range of clinical indications for TCD [encompassing almost all diseases in critically ill children for which the use of TCD has ever been described (18)] was an important finding of the present study. The recent web-based survey by LaRovere et al also reported that TCD was used to investigate a dozen or so conditions in clinical practice (37). There is great scope for TCD use beyond the evaluation of patients with primary neurological disorders.…”

“…The early use of TCD (within 24 h of admission), its status as a first-line neuromonitoring tool, and the frequency of use during night shifts highlighted the ready availability of this technique. TCD therefore has the potential to become an influential neuromonitoring strategy in the PICU (37,47).…”

“…Values of peak systolic flow velocity (PSV) and end diastolic flow velocity (EDV) were extracted via the questionnaire. Similarly, the mean flow velocity (MFV), pulsatility index (PI), and resistivity index (RI) were extracted via the questionnaire or (if not available) were calculated using previously published equations (42) (31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41). Arterial blood pressures, heart rates and haemoglobin levels were interpreted as a function of the patient's age (43,44).…”

“…The frequency and timing of TCD use, the indications for investigation, and the influence of TCD findings on clinical practice in the PICU have been rarely described -especially in Europe. An international, web-based survey found that TCD was frequently used in North American neurocritical care centres and was considered as a useful guide for patient management (37). The primary objective of the present prospective, multicentre study was to describe the scope of TCD use (notably with respect to the technique's timing and clinical indications) in four French PICUs.…”

Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury

“…Basilar artery vasospasms occurred in 3% of children with moderate TBI and 21% of children with severe TBI (38). A recent survey of practices in pediatric neurocritical care centers showed that 74% of centers used TCD for clinical care, often for determining timing of neuroimaging, manipulating CPP, and deciding whether to perform surgical interventions (39).…”