Publications by authors named "Matthew P Kirschen"

55 Publications

The association between early impairment in cerebral autoregulation and outcome in a pediatric swine model of cardiac arrest.

Resusc Plus 2020 Dec 5;4:100051. Epub 2020 Dec 5.

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, USA.

Aims: Evaluate cerebral autoregulation (CAR) by intracranial pressure reactivity index (PRx) and cerebral blood flow reactivity index (CBFx) during the first four hours following return of spontaneous circulation (ROSC) in a porcine model of pediatric cardiac arrest. Determine whether impaired CAR is associated with neurologic outcome.

Methods: Four-week-old swine underwent seven minutes of asphyxia followed by ventricular fibrillation induction and hemodynamic-directed CPR. Those achieving ROSC had arterial blood pressure, intracranial pressure (ICP), and microvascular cerebral blood flow (CBF) monitored for 4 h. Animals were assigned an 8 -h post-ROSC swine cerebral performance category score (1 = normal; 2-4=abnormal neurologic function). In this secondary analytic study, we calculated PRx and CBFx using a continuous, moving correlation coefficient between mean arterial pressure (MAP) and ICP, and between MAP and CBF, respectively. Burden of impaired CAR was the area under the PRx or CBFx curve using a threshold of 0.3 and normalized as percentage of monitoring duration.

Results: Among 23 animals, median PRx was 0.14 [0.06,0.25] and CBFx was 0.36 [0.05,0.44]. Median burden of impaired CAR was 21% [18,27] with PRx and 30% [17,40] with CBFx. Neurologically abnormal animals (n = 10) did not differ from normal animals (n = 13) in post-ROSC MAP (63 vs. 61 mmHg, p = 0.74), ICP (15 vs. 14 mmHg, p = 0.78) or CBF (274 vs. 397 Perfusion Units, p = 0.12). CBFx burden was greater among abnormal than normal animals (45% vs. 24%, p = 0.001), but PRx burden was not (25% vs. 20%, p = 0.38).

Conclusion: CAR is impaired early after ROSC. A greater burden of CAR impairment measured by CBFx was associated with abnormal neurologic outcome.CHOP Institutional Animal Care and Use Committee protocol 19-001327.
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http://dx.doi.org/10.1016/j.resplu.2020.100051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244245PMC
December 2020

Intracranial Traumatic Hematoma Detection in Children Using a Portable Near-infrared Spectroscopy Device.

West J Emerg Med 2021 Mar 24;22(3):782-791. Epub 2021 Mar 24.

Alpert Medical School of Brown University, Departments of Emergency Medicine and Pediatrics, Providence, Rhode Island.

Introduction: We sought to validate a handheld, near-infrared spectroscopy (NIRS) device for detecting intracranial hematomas in children with head injury.

Methods: Eligible patients were those <18 years old who were admitted to the emergency department at three academic children's hospitals with head trauma and who received a clinically indicated head computed tomography (HCT). Measurements were obtained by a blinded operator in bilateral frontal, temporal, parietal, and occipital regions. Qualifying hematomas were a priori determined to be within the brain scanner's detection limits of >3.5 milliliters in volume and <2.5 centimeters from the surface of the brain. The device's measurements were positive if the difference in optical density between hemispheres was >0.2 on three successive scans. We calculated diagnostic performance measures with corresponding exact two-sided 95% Clopper-Pearson confidence intervals (CI). Hypothesis test evaluated whether predictive performance exceeded chance agreement (predictive Youden's index > 0).

Results: A total of 464 patients were enrolled and 344 met inclusion for primary data analysis: 10.5% (36/344) had evidence of a hematoma on HCT, and 4.7% (16/344) had qualifying hematomas. The handheld brain scanner demonstrated a sensitivity of 58.3% (21/36) and specificity of 67.9% (209/308) for hematomas of any size. For qualifying hematomas the scanner was designed to detect, sensitivity was 81% (13/16) and specificity was 67.4% (221/328). Predictive performance exceeded chance agreement with a predictive Youden's index of 0.11 (95% CI, 0.10 - 0.15; P < 0.001) for all hematomas, and 0.09 (95% CI, 0.08 - 0.12; P < 0.001) for qualifying hematomas.

Conclusion: The handheld brain scanner can non-invasively detect a subset of intracranial hematomas in children and may serve an adjunctive role to head-injury neuroimaging decision rules that predict the risk of clinically significant intracranial pathology after head trauma.
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http://dx.doi.org/10.5811/westjem.2020.11.47251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203002PMC
March 2021

Variability in Pediatric Brain Death Determination Protocols in the United States.

Neurology 2021 May 28. Epub 2021 May 28.

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania

Objective: To determine the variability in pediatric death by neurologic criteria (DNC) protocols between US pediatric institutions and compared to the 2011 DNC guidelines.

Methods: Cross-sectional study of DNC protocols obtained from pediatric institutions in the United States (US) via regional organ procurement organizations. Protocols were evaluated across five domains: general DNC procedures, prerequisites, neurologic examination, apnea testing and ancillary testing. Descriptive statistics compared protocols to each other and the 2011 guidelines.

Results: One hundred and thirty protocols were analyzed with 118 dated after publication of the 2011 guidelines. Of those 118 protocols, identification of a mechanism of irreversible brain injury was required in 97%, while 67% required an observation period after acute brain injury before DNC evaluation. Most protocols required guideline-based prerequisites such as exclusion of hypotension (94%), hypothermia (97%), and metabolic derangements (92%). On neurologic examination, 91% required a lack of responsiveness, 93% no response to noxious stimuli, and 99% loss of brainstem reflexes. 84% of protocols required the guideline-recommened two apnea tests. CO2 targets were consistent with guidelines in 64%. Contrary to guidelines, fifteen percent required ancillary testing for all patients and 15% permitted ancillary studies that are not validated in pediatrics.

Conclusions: and Relevance: Variability exists between pediatric institutional DNC protocols in all domains of DNC determination, especially with respect to apnea and ancillary testing. Better alignment of DNC protocols with national guidelines may improve the consistency and accuracy of DNC determination.
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http://dx.doi.org/10.1212/WNL.0000000000012225DOI Listing
May 2021

Surgical Treatment of Upper Extremity Segmental Myoclonus in an Adolescent with Chiari Malformation and Cervicothoracic Syrinx.

Pediatr Neurosurg 2021 11;56(4):373-378. Epub 2021 May 11.

Division of Neurosurgery, Department of Neurosurgery, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.

Background: Myoclonus is an involuntary movement disorder characterized by semirhythmic jerking movements of muscle groups but is rarely seen in association with Chiari malformation type I (CM-1). CM-1 is a frequently encountered clinical entity in pediatric neurosurgery characterized by caudal displacement of the cerebellar tonsils with or without syringomyelia. We report a pediatric patient who presented with upper extremity myoclonus and was found to have CM-1 and a complex septated cervicothoracic syrinx eccentric to the left.

Case Presentation: A 12-year-old female presented with 6 months of headaches and upper extremity paresthesias who subsequently developed a left upper extremity segmental myoclonus after a fall. MRI demonstrated a CM-1 and a large complex cervicothoracic syrinx with a midline and left paracentral cavities. Her myoclonus was nonepileptic and refractory to clonazepam, cyclobenzaprine, and gabapentin. She underwent an intradural Chiari decompression and duraplasty. Postoperatively, she had complete resolution of her segmental myoclonus.

Discussion: This case demonstrates a durable resolution of posttraumatic upper extremity segmental myoclonus after surgical decompression of a CM-1 with syringomyelia. Thus, Chiari decompression should be considered in cases of myoclonus with CM-1 and syringomyelia.
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http://dx.doi.org/10.1159/000515519DOI Listing
May 2021

Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurologic Assessment of Critically Ill Children.

Pediatr Crit Care Med 2021 05;22(5):483-495

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Objectives: We developed a tool, Serial Neurologic Assessment in Pediatrics, to screen for neurologic changes in patients, including those who are intubated, are sedated, and/or have developmental disabilities. Our aims were to: 1) determine protocol adherence when performing Serial Neurologic Assessment in Pediatrics, 2) determine the interrater reliability between nurses, and 3) assess the feasibility and acceptability of using Serial Neurologic Assessment in Pediatrics compared with the Glasgow Coma Scale.

Design: Mixed-methods, observational cohort.

Setting: Pediatric and neonatal ICUs.

Subjects: Critical care nurses and patients.

Interventions: None.

Measurements And Main Results: Serial Neurologic Assessment in Pediatrics assesses Mental Status, Cranial Nerves, Communication, and Motor Function, with scales for children less than 6 months, greater than or equal to 6 months to less than 2 years, and greater than or equal to 2 years old. We assessed protocol adherence with standardized observations. We assessed the interrater reliability of independent Serial Neurologic Assessment in Pediatrics assessments between pairs of trained nurses by percent- and bias- adjusted kappa and percent agreement. Semistructured interviews with nurses evaluated acceptability and feasibility after nurses used Serial Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale during routine care. Ninety-eight percent of nurses (43/44) had 100% protocol adherence on the standardized checklist. Forty-three nurses performed 387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < 6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability was substantial to near-perfect across all components for each age-based Serial Neurologic Assessment in Pediatrics scale. Percent agreement was independent of developmental disabilities for all Serial Neurologic Assessment in Pediatrics components except Mental Status and lower extremity Motor Function for patients deemed "Able to Participate" with the assessment. Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, compared with Glasgow Coma Scale, was easier to use and clearer in describing the neurologic status of patients who were intubated, were sedated, and/or had developmental disabilities. About 92% of nurses preferred to use Serial Neurologic Assessment in Pediatrics over Glasgow Coma Scale.

Conclusions: When used by critical care nurses, Serial Neurologic Assessment in Pediatrics has excellent protocol adherence, substantial to near-perfect interrater reliability, and is feasible to implement. Further work will determine the sensitivity and specificity for detecting clinically meaningful neurologic decline.
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http://dx.doi.org/10.1097/PCC.0000000000002675DOI Listing
May 2021

Brain Death Evaluation in Children With Suspected or Confirmed Coronavirus Disease 2019.

Pediatr Crit Care Med 2021 03;22(3):318-322

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

Objectives: To discuss the challenges of conducting a death by neurologic criteria or brain death evaluation in the coronavirus disease 2019 era and provide guidance to mitigate viral transmission risk and maintain patient safety during testing.

Design: Not applicable.

Setting: Not applicable.

Patients: Children with suspected or confirmed coronavirus disease 2019 who suffer catastrophic brain injury due to one of numerous neurologic complications or from an unrelated process and require evaluation for death by neurologic criteria.

Interventions: Not applicable.

Measurements And Main Results: There is a risk to healthcare providers from aerosol generation during the neurologic examination and apnea test for determination of death by neurologic criteria. In this technical note, we provide guidance to mitigate transmission risk and maintain patient safety during each step of the death by neurologic criteria evaluation. Clinicians should put on appropriate personal protective equipment before performing the death by neurologic criteria evaluation. Risk of aerosol generation and viral transmission during the apnea test can be mitigated by using continuous positive airway pressure delivered via the ventilator as a means of apneic oxygenation. Physicians should assess the risk of transporting coronavirus disease 2019 patients to the nuclear medicine suite to perform a radionucleotide cerebral blood flow study, as disconnections to and from the ventilator for transport and inadvertent ventilator disconnections during transport can increase transmission risk.

Conclusions: When conducting the neurologic examination and apnea test required for death by neurologic criteria determination in patients with suspected or confirmed coronavirus disease 2019, appropriate modifications are needed to mitigate the risk of viral transmission and ensure patient safety.
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http://dx.doi.org/10.1097/PCC.0000000000002650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924933PMC
March 2021

Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States: A Review.

JAMA Pediatr 2021 Mar;175(3):293-302

Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Importance: Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR).

Observations: Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes.

Conclusions And Relevance: Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.
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http://dx.doi.org/10.1001/jamapediatrics.2020.5039DOI Listing
March 2021

New perspectives on brain death.

J Neurol Neurosurg Psychiatry 2021 Mar 20;92(3):255-262. Epub 2020 Nov 20.

Neurology, Boston University, Boston, Massachusetts, USA

Brain death, or death by neurological criteria (BD/DNC), has been accepted conceptually, medically and legally for decades. Nevertheless, some areas remain controversial or understudied, pointing to a need for focused research to advance the field. Multiple recent contributions have increased our understanding of BD/DNC, solidified our practice and provided guidance where previously lacking. There have also been important developments on a global scale, including in low-to-middle income countries such as in South America. Although variability in protocols and practice still exists, new efforts are underway to reduce inconsistencies and better train practitioners in accurate and sound BD/DNC determination. Various legal challenges have required formal responses from national societies, and the American Academy of Neurology has filled this void with much needed guidance. Questions remain regarding concepts such as 'whole brain' versus 'brainstem' death, and the intersection of BD/DNC and rubrics of medical futility. These concepts are the subject of this review.
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http://dx.doi.org/10.1136/jnnp-2020-323952DOI Listing
March 2021

Association of MRI Brain Injury With Outcome After Pediatric Out-of-Hospital Cardiac Arrest.

Neurology 2021 02 18;96(5):e719-e731. Epub 2020 Nov 18.

From the Department of Anesthesiology and Critical Care Medicine (M.P.K., K.G., M.W., R.A.B., A.T.), Department of Pediatrics (M.P.K., D.J.L., R.A.B., A.T.), Health Analytics Unit (J.F., A.M.), and Department of Radiology (A.V.), Children's Hospital of Philadelphia; and Department of Neurology (M.P.K., D.J.L., R.B., R.D.-A.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Objective: To determine the association between the extent of diffusion restriction and T2/fluid-attenuated inversion recovery (FLAIR) injury on brain MRI and outcomes after pediatric out-of-hospital cardiac arrest (OHCA).

Methods: Diffusion restriction and T2/FLAIR injury were described according to the pediatric MRI modification of the Alberta Stroke Program Early Computed Tomography Score (modsASPECTS) for children from 2005 to 2013 who had an MRI within 14 days of OHCA. The primary outcome was unfavorable neurologic outcome defined as ≥1 change in Pediatric Cerebral Performance Category (PCPC) from baseline resulting in a hospital discharge PCPC score 3, 4, 5, or 6. Patients with unfavorable outcomes were further categorized into alive with PCPC 3-5, dead due to withdrawal of life-sustaining therapies for poor neurologic prognosis (WLST-neuro), or dead by neurologic criteria.

Results: We evaluated MRI scans from 77 patients (median age 2.21 [interquartile range 0.44, 13.07] years) performed 4 (2, 6) days postarrest. Patients with unfavorable outcomes had more extensive diffusion restriction (median 7 [4, 10.3] vs 0 [0, 0] regions, < 0.001) and T2/FLAIR injury (5.5 [2.3, 8.2] vs 0 [0, 0.75] regions, < 0.001) compared to patients with favorable outcomes. Area under the receiver operating characteristic curve for the extent of diffusion restriction and unfavorable outcome was 0.96 (95% confidence interval [CI] 0.91, 0.99) and 0.92 (95% CI 0.85, 0.97) for T2/FLAIR injury. There was no difference in extent of diffusion restriction between patients who were alive with an unfavorable outcome and patients who died from WLST-neuro ( = 0.11).

Conclusions: More extensive diffusion restriction and T2/FLAIR injury on the modsASPECTS score within the first 14 days after pediatric cardiac arrest was associated with unfavorable outcomes at hospital discharge.
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http://dx.doi.org/10.1212/WNL.0000000000011217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884994PMC
February 2021

A review of current controversies in determining death by neurologic criteria in children.

Curr Opin Pediatr 2020 12;32(6):759-764

Department of Neurology.

Purpose Of Review: Death by neurologic criteria (DNC) is the irreversible cessation of all functions of the entire brain, including the brainstem. It is legally recognized as equivalent to cardiopulmonary death. Legal and ethical controversies surrounding DNC have emerged as a result of several highly publicized cases that have eroded public trust in our ability to declare DNC accurately. In this review, we focus on recently published primary data about DNC and address some of these controversies.

Recent Findings: Approximately 21% of children who die in pediatric intensive care units (PICU) are declared DNC. Although 60% of physicians report that they have been asked to maintain organ support after DNC declaration, less than 1% of patients remain physically present in the PICU more than 5 days after DNC declaration. We discuss strategies for safely conducting the apnea test, indications and prevalence of ancillary testing, and objections to DNC, including issues of consent and requests for ongoing organ support.

Summary: In order to maintain public trust, published guidelines must be followed to accurately and consistently diagnose DNC. We must develop strategies to respond to objections to DNC determination. Ongoing research is needed to improve the safety of apnea testing and indications for and interpretation of ancillary testing.
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http://dx.doi.org/10.1097/MOP.0000000000000952DOI Listing
December 2020

Informed Consent and the Determination of Neurologic Death.

Pediatrics 2020 09;146(3)

Child Neurologist, Ann & Robert H. Lurie Children's Hospital of Chicago.

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http://dx.doi.org/10.1542/peds.2020-008144ADOI Listing
September 2020

Apnea Testing Using Continuous Positive Airway Pressure When Determining Death by Neurologic Criteria in Children: Retrospective Analysis of Potential Adverse Events.

Pediatr Crit Care Med 2020 12;21(12):e1152-e1156

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.

Objectives: To determine the prevalence of adverse events during apnea testing for determination of death by neurologic criteria using continuous positive airway pressure in children.

Design: Single-center retrospective descriptive study.

Setting: Academic children's hospital.

Patients: Children evaluated for death by neurologic criteria in the PICU from 2013 to 2018.

Interventions: None.

Measurements And Main Results: For each patient evaluated for death by neurologic criteria, we abstracted the number of apnea tests performed, vital signs and arterial blood gases during apnea testing, and outcome from the medical record. Adverse events were defined as oxygen-hemoglobin desaturation (arterial oxygen saturation < 85%), hypotension, or other significant event (e.g. arrhythmia, cardiac arrest) based on documentation in the medical record. We determined which adverse events resulted in early termination of the apnea test. We used oxygenation index, ventilator variables, and presence of vasopressors to determine preapnea test cardiopulmonary dysfunction. Seventy-two patients (age 7 yr [2.7-13.2 yr]; 48% male) underwent 121 apnea tests. Nine patients (12%) had 13 potential apnea tests deferred due to concern for cardiopulmonary instability as determined by the attending physician. Patients who underwent apnea testing had an oxygenation index of 3.5 (2.5-4.8) and were receiving vasopressors at the time of 108 apnea tests (89%). Hypotension was reported during seven apnea tests (6%) and resulted in the early termination of one apnea test (<1%). No other adverse events were reported. One hundred and twenty apnea tests (99%) were consistent with death by neurologic criteria.

Conclusions: Apnea testing following a protocol that uses continuous positive airway pressure for apneic oxygenation has a low rate of adverse events in children meeting prerequisite criteria and determined by a pediatric intensivist to be physiologically appropriate for testing.
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http://dx.doi.org/10.1097/PCC.0000000000002457DOI Listing
December 2020

Circulating Neurofilament Light Chain Is Associated With Survival After Pediatric Cardiac Arrest.

Pediatr Crit Care Med 2020 07;21(7):656-661

Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Objectives: To characterize neurofilament light levels in children who achieved return of spontaneous circulation following cardiac arrest compared with healthy controls and determine an association between neurofilament light levels and clinical outcomes.

Design: Retrospective cohort study.

Setting: Academic quaternary PICU.

Patients: Children with banked plasma samples from an acute respiratory distress syndrome biomarker study who achieved return of spontaneous circulation after a cardiac arrest and healthy controls.

Interventions: None.

Measurements And Main Results: Neurofilament light levels were determined with a highly sensitive single molecule array digital immunoassay. Patients were categorized into survivors and nonsurvivors and into favorable (Pediatric Cerebral Performance Category score of 1-2 or unchanged from baseline) or unfavorable (Pediatric Cerebral Performance Category score of 3-6 or Pediatric Cerebral Performance Category score change ≥1 from baseline). Associations between neurofilament light level and outcomes were determined using Wilcoxon rank-sum test. We enrolled 32 patients with cardiac arrest and 18 healthy controls. Demographics, severity of illness, and baseline Pediatric Cerebral Performance Category scores were similar between survivors and nonsurvivors. Healthy controls had lower median neurofilament light levels than patients after cardiac arrest (5.5 [interquartile range 5.0-8.2] vs 31.0 [12.0-338.6]; p < 0.001). Neurofilament light levels were higher in nonsurvivors than survivors (78.5 [26.2-509.1] vs 12.4 [10.3-28.2]; p = 0.012) and higher in survivors than healthy controls (p = 0.009). The four patients who survived with a favorable outcome had neurofilament light levels that were not different from patients with unfavorable outcomes (21.9 [8.5--35.7] vs 37.2 [15.4-419.1]; p = 0.60) although two of the four patients who survived with favorable outcomes had progressive encephalopathies with both baseline and postcardiac arrest Pediatric Cerebral Performance Category scores of 4.

Conclusions: Neurofilament light is a blood biomarker of hypoxic-ischemic brain injury and may help predict survival and neurologic outcome after pediatric cardiac arrest. Further study in a larger, dedicated cardiac arrest cohort with serial longitudinal measurements is warranted.
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http://dx.doi.org/10.1097/PCC.0000000000002294DOI Listing
July 2020

Decadron, Diamox, and Zantac: A Novel Combination for Ventricular Shunt Failure in Pediatric Neurosurgical Patients.

Pediatr Emerg Care 2020 Mar 12. Epub 2020 Mar 12.

Division of Emergency Medicine and Department of Pediatrics, Children's Hospital of Philadelphia.

Objective: Cerebral ventricular shunt failure is common and presents with symptoms that range from headaches to death. The combination of Diamox (acetazolamide), Decadron (dexamethasone), and Zantac (ranitidine) (DDZ) is used at our institution to medically stabilize pediatric patients presenting with symptomatic shunt failure before shunt revision. We describe our experience of this drug combination as a temporizing measure to decrease symptoms associated with shunt failure.

Methods: We performed a single-center retrospective chart review of patients younger than 18 years with ventricular shunt failure who underwent a shunt revision between January 2015 to October 2017 and received DDZ before surgery. The outcome variables evaluated included pre-DDZ and post-DDZ clinical symptoms, pain scores, and vital signs.

Results: There were 112 cases that received DDZ before shunt revision. The 4 most commonly reported symptoms were analyzed. Headache was observed in 42 cases pre-DDZ, and post-DDZ there was a 71% reduction in headache (P < 0.0001); emesis was reported pre-DDZ in 76 cases, and post-DDZ there was an 83% reduction (P < 0.0001); irritability was noted pre-DDZ in 30 cases, and post-DDZ there was a 77% reduction (P = 0.0003); lethargy pre-DDZ was observed in 60 cases, and post-DDZ 73% demonstrated improvement (P < 0.0001). Maximum pain scores significantly decreased post-DDZ (P < 0.0001). Heart rate, systolic, and diastolic blood pressures significantly decreased post-DDZ (P < 0.0001, P < 0.0001, P = 0.0002, respectively).

Conclusions: The combination of Decadron, Diamox, and Zantac is a novel treatment for ventricular shunt failure that may temporarily improve symptoms in patients awaiting shunt revision. Future studies could compare efficacy with other medical treatments.
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http://dx.doi.org/10.1097/PEC.0000000000002070DOI Listing
March 2020

Incidence and Indications for Ancillary Testing in the Determination of Death by Neurological Criteria in Children.

Pediatr Neurol 2020 05 4;106:68-69. Epub 2020 Feb 4.

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.pediatrneurol.2020.01.019DOI Listing
May 2020

Determination of Death by Neurologic Criteria in the United States: The Case for Revising the Uniform Determination of Death Act.

J Law Med Ethics 2019 12;47(4_suppl):9-24

Ariane Lewis, M.D., is an Associate Professor at NYU Langone Medical Center in the Departments of Neurology and Neurosurgery (Division of Neurocritical Care) and an affiliate of the Department of Population Health (Division of Bioethics). She is also a member of the American Academy of Neurology/American Neurological Association/Child Neurology Society Ethics, Law and Humanities Committee. Richard J. Bonnie, LL.B., is Harrison Foundation Professor of Law and Medicine in the School of Law, Professor of Psychiatry and Neurobehavioral Sciences and Professor of Public Health Sciences in the School of Medicine, Professor of Public Policy in the Frank Batten School of Leadership and Public Policy, and Director of the Institute of Law, Psychiatry and Public Policy, at the University of Virginia. He is also a member of the American Academy of Neurology/American Neurological Association/Child Neurology Society Ethics, Law and Humanities Committee. Thaddeus Pope, J.D., Ph.D., is Director of the Health Law Institute and Professor at Mitchell Hamline School of Law (Saint Paul, Minnesota). He is also an Adjunct Professor with the Australian Centre for Health Law Research at Queensland University of Technology (Brisbane, Australia) and Visiting Professor of Medical Jurisprudence at St. George's University (Grenada, West Indies). Leon G. Epstein, M.D., is the Derry A. & Donald L. Shoemaker Professor of Pediatric Neurology at the Ann & Robert H. Lurie Children's Hospital of Chicago and Professor of Pediatrics at the Northwestern University Feinberg School of Medicine. He is also the Chairman of the American Academy of Neurology/American Neurological Association/Child Neurology Society Ethics, Law and Humanities Committee. David M. Greer, M.D., M.A., is Professor and Chairman of Neurology at Boston University School of Medicine, and Chief of Neurology at Boston Medical Center. He is also Adjunct Research Professor at Yale University School of Medicine. Matthew P. Kirschen, M.D., Ph.D., is an Assistant Professor of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics at the Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia. He is also the Vice Chairman of the American Academy of Neurology/American Neurological Association/Child Neurology Society Ethics, Law and Humanities Committee. Michael Rubin, M.D., M.A., is Associate Professor of Neurology and Neurotherapeutics at UT Southwestern Medical Center, Peter O'Donnell Jr. Brain Institute. He is also a member of the American Academy of Neurology/American Neurological Association/Child Neurology Society Ethics, Law and Humanities Committee. James A. Russell, D.O., M.S., is a staff neurologist at Lahey Hospital and Medical Center (Burlington, MA) and Chairman of its Ethics Section, Clinical Professor of Neurology at Tufts University of Medicine, Director of the Curt and Shonda Schilling ALS Clinic at LHMC. He is also the immediate past Chairman of the American Academy of Neurology/American Neurological Association/Child Neurology Society Ethics, Law and Humanities Committee.

Although death by neurologic criteria (brain death) is legally recognized throughout the United States, state laws and clinical practice vary concerning three key issues: (1) the medical standards used to determine death by neurologic criteria, (2) management of family objections before determination of death by neurologic criteria, and (3) management of religious objections to declaration of death by neurologic criteria. The American Academy of Neurology and other medical stakeholder organizations involved in the determination of death by neurologic criteria have undertaken concerted action to address variation in clinical practice in order to ensure the integrity of brain death determination. To complement this effort, state policymakers must revise legislation on the use of neurologic criteria to declare death. We review the legal history and current laws regarding neurologic criteria to declare death and offer proposed revisions to the Uniform Determination of Death Act (UDDA) and the rationale for these recommendations.
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http://dx.doi.org/10.1177/1073110519898039DOI Listing
December 2019

Recent advances in our understanding of neurodevelopmental outcomes in congenital heart disease.

Curr Opin Pediatr 2019 12;31(6):783-788

Department of Anesthesiology and Critical Care Medicine.

Purpose Of Review: Patients with congenital heart disease (CHD) suffer from a pattern of neurodevelopmental abnormalities including deficits in language and executive function. In this review, we summarize recent studies that examine these outcomes, their risk factors, possible biomarkers, and attempts to develop therapeutic interventions.

Recent Findings: The latest literature has highlighted the role of genetics in determining neurologic prognosis, as we have increased our understanding of potentially modifiable perioperative risk factors. The role of potentially neurotoxic medical therapies has become more salient. One recent focus has been how neurodevelopment affects quality of life and leads to a high prevalence of mental illness. Neuroimaging advances have provided new insights into the pathogenesis of deficits.

Summary: Although many risk factors in CHD are not modifiable, there is promise for interventions to improve neurodevelopmental outcomes in patients with CHD. Biomarkers are needed to better understand the timing and prognosis of injury and to direct therapy. Research into psychosocial interventions is urgently needed to benefit the many survivors with CHD.
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http://dx.doi.org/10.1097/MOP.0000000000000829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6852883PMC
December 2019

Reduction of ventriculostomy-associated CSF infection with antibiotic-impregnated catheters in pediatric patients: a single-institution study.

Neurosurg Focus 2019 08;47(2):E4

3Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania.

Objective: External ventricular drains (EVDs) are commonly used in the neurosurgical population. However, very few pediatric neurosurgery studies are available regarding EVD-associated infection rates with antibiotic-impregnated EVD catheters. The authors previously published a large pediatric cohort study analyzing nonantibiotic-impregnated EVD catheters and risk factors associated with infections. In this study, they aimed to analyze the EVD-associated infection rate after implementation of antibiotic-impregnated EVD catheters.

Methods: A retrospective observational cohort of pediatric patients (younger than 18 years of age) who underwent a burr hole for antibiotic-impregnated EVD placement and who were admitted to a quaternary care ICU between January 2011 and January 2019 were reviewed. The ventriculostomy-associated infection rate in patients with antibiotic-impregnated EVD catheters was compared to the authors' historical control of patients with nonantibiotic-impregnated EVD catheters.

Results: Two hundred twenty-nine patients with antibiotic-impregnated EVD catheters were identified. Neurological diagnostic categories included externalization of an existing shunt (externalized shunt) in 34 patients (14.9%); brain tumor (tumor) in 77 patients (33.6%); intracranial hemorrhage (ICH) in 27 patients (11.8%); traumatic brain injury (TBI) in 6 patients (2.6%); and 85 patients (37.1%) were captured in an "other" category. Two of 229 patients (0.9% of all patients) had CSF infections associated with EVD management, totaling an infection rate of 0.99 per 1000 catheter days. This is a significantly lower infection rate than was reported in the authors' previously published analysis of the use of nonantibiotic-impregnated EVD catheters (0.9% vs 6%, p = 0.00128).

Conclusions: In their large pediatric cohort, the authors demonstrated a significant decline in ventriculostomy-associated CSF infection rate after implementation of antibiotic-impregnated EVD catheters at their institution.
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http://dx.doi.org/10.3171/2019.5.FOCUS19279DOI Listing
August 2019

X-linked Charcot-Marie-Tooth Disease Presenting with Stuttering Stroke-like Symptoms.

Neuropediatrics 2019 10 20;50(5):304-307. Epub 2019 Jun 20.

Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States.

X-linked Charcot-Marie-Tooth disease (CMTX1) is the second most common form of Charcot-Marie-Tooth disease (CMT). It is caused by a mutation in the gap junction β 1 () gene, which encodes for connexin-32. In addition to the peripheral neuropathy and foot deformities observed in classic CMT, central nervous system symptoms and magnetic resonance imaging (MRI) signal abnormalities in the brain have been reported in patients with CMTX1. Here we describe two cases of adolescent males who presented with stuttering neurologic deficits that were initially suggestive of acute ischemic stroke and were ultimately diagnosed with genetically confirmed CMTX1. Both patients had evidence of T2 hyperintensity and decreased diffusion on MRI in the centrum semiovale, posterior corona radiata, posterior periventricular white matter, and corpus callosum. Though rare, these cases illustrate the importance of comprehensive neurologic history, physical examination, and appropriate diagnostic evaluation.
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http://dx.doi.org/10.1055/s-0039-1692982DOI Listing
October 2019

Routine Neurological Assessments by Nurses in the Pediatric Intensive Care Unit.

Crit Care Nurse 2019 Jun;39(3):20-32

Matthew P. Kirschen is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Neurology, and Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Kristen Lourie is PICU Nursing Clinical Supervisor, Megan Snyder is Director of Nursing Professional Practice, Kenya Agarwal is a PICU clinical nurse expert, and Pamela DiDonato is a critical care nurse, Department of Nursing, Children's Hospital of Philadelphia; Blair Kraus and Kylie Geddes are senior enterprise improvement advisors, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; Chinonyerem Madu is a data programmer analyst III, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia; Vinay Nadkarni is a professor and Daniela Davis is a clinical professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children's Hospital of Philadelphia; Heather Wolfe is an assistant professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children's Hospital of Philadelphia. She is also the Director of Anesthesia & Critical Care Quality and Safety Programs, Children's Hospital of Philadelphia and the Medical Director of the pediatric intensive care unit; Alexis Topjian is an associate professor, Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children's Hospital of Philadelphia.

Background: Brain injury with changes in clinical neurological signs and symptoms can develop while children are undergoing treatment in the intensive care unit. Critical care nurses routinely screen for neurological decline by using serial bedside neurological assessments. However, assessment components, frequency, and communication thresholds are not standardized.

Objectives: To standardize neurological assessment procedures used by nurses, improve compliance with physicians' ordering and nurses' documentation of neurological assessments, and explore the frequency with which changes from preillness neurological status and previous assessments can be detected by using the assessment tool developed.

Methods: A quality improvement intervention was implemented during a 1-year period in a 55-bed pediatric intensive care unit with 274 nurses. Procedures for neurological assessment by nurses were standardized, a system for physicians to order neurological assessments by nurses at a frequency based on the patient's risk for brain injury was developed and implemented, and a system to compare patients' current neurological status with their preillness neurological status was developed and implemented.

Results: Process metrics that focused on compliance of ordering and documenting the standardized neurological assessments indicated improvement and sustained compliance greater than 80%. Exploratory analyses indicated that 29% of patients had an episode of neurological decline and that these episodes were more common in patients with developmental disabilities than in patients without such disabilities.

Conclusions: Compliance with physicians' ordering and nurses' documentation of standardized neurological assessments significantly increased and had excellent sustainability. Further work is needed to determine the sensitivity of standardized nurses' neurological assessment tools for clinically meaningful neurological decline.
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http://dx.doi.org/10.4037/ccn2019198DOI Listing
June 2019

Prevalence of Isoelectric Electroencephalography Events in Infants and Young Children Undergoing General Anesthesia.

Anesth Analg 2020 02;130(2):462-471

From the Departments of Anesthesiology and Critical Care Medicine.

Background: In infants and young children, anesthetic dosing is based on population pharmacokinetics and patient hemodynamics not on patient-specific brain activity. Electroencephalography (EEG) provides insight into brain activity during anesthesia. The primary goal of this prospective observational pilot study was to assess the prevalence of isoelectric EEG events-a sign of deep anesthesia-in infants and young children undergoing general anesthesia using sevoflurane or propofol infusion for maintenance.

Methods: Children 0-37 months of age requiring general anesthesia for surgery excluding cardiac, intracranial, and emergency cases were enrolled by age: 0-3, 4-6, 7-12, 13-18, and 19-37 months. Anesthesia was maintained with sevoflurane or propofol infusion. EEG was recorded from induction to extubation. Isoelectric EEG events (amplitude <20 µV, lasting ≥2 seconds) were characterized by occurrence, number, duration, and percent of isoelectric EEG time over anesthetic time. Associations with patient demographics, anesthetic, and surgical factors were determined.

Results: Isoelectric events were observed in 63% (32/51) (95% confidence interval [CI], 49-76) of patients. The median (interquartile range [IQR]) number of isoelectric events per patient was 3 (0-31), cumulative isoelectric time per patient was 12 seconds (0-142 seconds), isoelectric time per event was 3 seconds (0-4 seconds), and percent of total isoelectric over anesthetic time was 0.1% (0%-2.2%). The greatest proportion of isoelectric events occurred between induction and incision. Isoelectric events were associated with higher American Society of Anesthesiologists (ASA) physical status, propofol bolus, endotracheal tube use, and lower arterial pressure during surgical phase.

Conclusions: Isoelectric EEG events were common in infants and young children undergoing sevoflurane or propofol anesthesia. Although the clinical significance of these events remains uncertain, they suggest that dosing based on population pharmacokinetics and patient hemodynamics is often associated with unnecessary deep anesthesia during surgical procedures.
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http://dx.doi.org/10.1213/ANE.0000000000004221DOI Listing
February 2020

Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale.

Pediatr Crit Care Med 2019 07;20(7):660-666

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Objectives: Estimate the inter-rater reliability of critical care nurses performing a pediatric modification of the Glasgow Coma Scale in a contemporary PICU.

Design: Prospective observation study.

Setting: Large academic PICU.

Patients/subjects: All 274 nurses with permanent assignments in the PICU were eligible to participate. A subset of 18 nurses were selected as study registered nurses. All PICU patients were eligible to participate.

Interventions: None.

Measurements And Main Results: PICU nurses were educated and demonstrated proficiency on a pediatric modification of the Glasgow Coma Scale we created to make it more applicable to a diverse PICU population that included patients who are sedated, mechanically ventilated, and/or have developmental disabilities. Each study registered nurse observed a sample of nurses perform the Glasgow Coma Scale, and they independently scored the Glasgow Coma Scale. Patients were categorized as having developmental disabilities if their preillness Pediatric Cerebral Performance Category score was greater than or equal to 3. Fleiss' Kappa (κ), intraclass correlation coefficient, and percent agreement assessed inter-rater reliability for each Glasgow Coma Scale component (eye, verbal, motor) and age-specific scale (≥ 2 and < 2-yr-old). The overall percent agreement between study registered nurses and nurses was 89% for the eye, 91% for the verbal, and 79% for the motor responses. Inter-rater reliability ranged from good (intraclass correlation coefficient = 0.75) to excellent (intraclass correlation coefficient = 0.96) for testable patients. Agreement on the motor response was significantly lower for children with developmental disabilities (< 2 yr: 59% vs 95%; p = 0.0012 and ≥ 2 yr: 55% vs 91%; p = 0.0012). Agreement was significantly worse for intermediate range Glasgow Coma Scale motor responses compared with responses at the extremes (e.g., motor responses 2, 3, 4 vs 1, 5, 6; p < 0.05).

Conclusions: A pediatric modification of the Glasgow Coma Scale performed by trained PICU nurses has excellent inter-rater reliability, although reliability was reduced in patients with developmental disabilities and for intermediate range Glasgow Coma Scale responses. Further research is needed to determine the effectiveness of this Glasgow Coma Scale modification to detect clinical deterioration.
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http://dx.doi.org/10.1097/PCC.0000000000001938DOI Listing
July 2019

Epidemiology of Brain Death in Pediatric Intensive Care Units in the United States.

JAMA Pediatr 2019 05;173(5):469-476

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Importance: Guidelines for declaration of brain death in children were revised in 2011 by the Society of Critical Care Medicine, American Academy of Pediatrics, and Child Neurology Society. Despite widespread medical, legal, and ethical acceptance, ongoing controversies exist with regard to the concept of brain death and the procedures for its determination.

Objectives: To determine the epidemiology and clinical characteristics of pediatric patients declared brain dead in the United States.

Design, Setting, And Participants: This study involved the abstraction of all patient deaths from the Virtual Pediatric Systems national multicenter database between January 1, 2012, and June 30, 2017. All patients who died in pediatric intensive care units (PICUs) were included.

Main Outcomes And Measures: Patient demographics, preillness developmental status, severity of illness, cause of death, PICU medical and physical length of stay, and organ donation status, as well as comparison between patients who were declared brain dead vs those who sustained cardiovascular or cardiopulmonary death.

Results: Of the 15 344 patients who died, 3170 (20.7%) were declared brain dead; 1861 of these patients (58.7%) were male, and 1401 (44.2%) were between 2 and 12 years of age. There was a linear association between PICU size and number of patients declared brain dead per year, with an increase of 4.27 patients (95% CI, 3.46-5.08) per 1000-patient increase in discharges (P < .001). The median (interquartile range) of patients declared brain dead per year ranged from 1 (0-3) in smaller PICUs (defined as those with <500 discharges per year) to 10 (7-15) for larger PICUs (those with 2000-4000 discharges per year). The most common causative mechanisms of brain death were hypoxic-ischemic injury owing to cardiac arrest (1672 of 3170 [52.7%]), shock and/or respiratory arrest without cardiac arrest (399 of 3170 [12.6%]), and traumatic brain injury (634 of 3170 [20.0%]). Most patients declared brain dead (681 of 807 [84.4%]) did not have preexisting neurological dysfunction. Patients who were organ donors (1568 of 3144 [49.9%]) remained in the PICU longer after declaration of brain death compared with those who were not donors (median [interquartile range], 29 [6-41] hours vs 4 [1-8] hours; P < .001).

Conclusions And Relevance: Brain death occurred in one-fifth of PICU deaths. Most children declared brain dead had no preexisting neurological dysfunction and had an acute hypoxic-ischemic or traumatic brain injury. Brain death determinations are infrequent, even in large PICUs, emphasizing the importance of ongoing education for medical professionals and standardization of protocols to ensure diagnostic accuracy and consistency.
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http://dx.doi.org/10.1001/jamapediatrics.2019.0249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503509PMC
May 2019

Guide to the statistical analysis plan.

Paediatr Anaesth 2019 Mar 29;29(3):237-242. Epub 2019 Jan 29.

Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania.

Biomedical research has been struck with the problem of study findings that are not reproducible. With the advent of large databases and powerful statistical software, it has become easier to find associations and form conclusions from data without forming an a-priori hypothesis. This approach may yield associations without clinical relevance, false positive findings, or biased results due to "fishing" for the desired results. To improve reproducibility, transparency, and validity among clinical trials, the National Institute of Health recently updated its grant application requirements, which mandates registration of clinical trials and submission of the original statistical analysis plan (SAP) along with the research protocol. Many leading journals also require the SAP as part of the submission package. The goal of this article and the companion article detailing the SAP of an actual research study is to provide a practical guide on writing an effective SAP. We describe the what, why, when, where, and who of a SAP, and highlight the key contents of the SAP.
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http://dx.doi.org/10.1111/pan.13576DOI Listing
March 2019

Bedside clinical neurologic assessment utilisation in paediatric cardiac intensive care units.

Cardiol Young 2018 Dec 16;28(12):1457-1462. Epub 2018 Oct 16.

1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia,Perelman School of Medicine at the University of Pennsylvania,3401 Civic Center Boulevard,Philadelphia,PA19104.

IntroductionNeurodevelopmental disabilities in children with CHD can result from neurologic injury sustained in the cardiac ICU when children are at high risk of acute neurologic injury. Physicians typically order and specify frequency for serial bedside nursing clinical neurologic assessments to evaluate patients' neurologic status.Materials and methodsWe surveyed cardiac ICU physicians to understand how these assessments are performed, and the attitudes of physicians on the utility of these assessments. The survey contained questions regarding assessment elements, assessment frequency, communication of neurologic status changes, and optimisation of assessments. RESULTS: Surveys were received from 50 institutions, with a response rate of 86%. Routine clinical neurologic assessments were reported to be performed in 94% of institutions and standardised in 56%. Pupillary reflex was the most commonly reported assessment. In all, 77% of institutions used a coma scale, with Glasgow Coma Scale being most common. For patients with acute brain injury, 82% of institutions reported performing assessments hourly, whereas assessment frequency was more variable for low-risk and high-risk patients without overt brain injury. In all, 84% of respondents thought their current practice for assessing and monitoring neurologic status was suboptimal. Only 41% felt that the Glasgow Coma Scale was a valuable tool for assessing neurologic function in the cardiac ICU, and 91% felt that a standardised approach to assessing pre-illness neurologic function would be valuable. CONCLUSIONS: Routine nursing neurologic assessments are conducted in most surveyed paediatric cardiac ICUs, although assessment characteristics vary greatly between institutions. Most clinicians rated current neurologic assessment practices as suboptimal.
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http://dx.doi.org/10.1017/S1047951118001634DOI Listing
December 2018

The authors reply.

Pediatr Crit Care Med 2018 07;19(7):696-697

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, and Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, and Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, and Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

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http://dx.doi.org/10.1097/PCC.0000000000001583DOI Listing
July 2018

Evaluating the Inpatient Pediatric Ethical Consultation Service.

Hosp Pediatr 2018 03;8(3):157-161

Center for Bioethics and Humanities, University of Colorado, Aurora, Colorado

Objectives: Pediatric ethical consultation services (ECSs) have been proliferating at medical centers, with little data available on evaluating their implementation. The objective of this study was to evaluate the pediatric ECS and understand the ethical issues occurring within a single quaternary-level pediatric hospital.

Methods: A retrospective chart review of documented ethics consultations at a large pediatric hospital from November 2010 to November 2013 was performed and data was abstracted per the US Department of Veterans Affairs' Domains of Ethics in Health Care. An anonymous, prospective survey regarding ethical issues encountered was distributed electronically to ∼3500 inpatient staff from November 2013 through January 2014. Ethical domains, demographics, feelings of distress by staff, and location of occurrence data were collected. These data were compared with formally documented ethics consults from the retrospective chart review and ECS activity during the same period.

Results: A total of 47 ethics consults were documented between 2010 and 2013, primarily in the domains of end-of-life care (19; 40%) and shared decision-making (17; 36%). Sixty-three staff members (92% female; 42% nurses; 20% attending physicians) logged an encountered ethical issue between November 2013 and January 2014, corresponding to only 5 documented ethics consults in the same time period. Domains included end-of-life care (18; 28.5%), shared decision-making (13; 20.6%), everyday workplace (11; 17.4%), professionalism (8; 12.6%), and resource allocation (7; 11%). Eighty-one percent of subjects reported personal or professional distress.

Conclusions: On the basis of this single-center study in which we reviewed formal documentation, we determined that formal pediatric ECSs are underused, particularly for ethical domains that cause staff members moral distress.
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http://dx.doi.org/10.1542/hpeds.2017-0107DOI Listing
March 2018

Survey of Bedside Clinical Neurologic Assessments in U.S. PICUs.

Pediatr Crit Care Med 2018 04;19(4):339-344

Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Objective: To understand how routine bedside clinical neurologic assessments are performed in U.S. PICUs.

Design: Electronic survey.

Setting: Academic PICUs throughout the United States.

Subjects: Faculty representatives from PICUs throughout the United States.

Interventions: None.

Measurements And Main Results: We surveyed how routine bedside neurologic assessments are reported to be performed in U.S. PICUs and the attitudes of respondents on the utility of these assessments. The survey contained questions regarding 1) components of neurologic assessments; 2) frequency of neurologic assessments; 3) documentation and communication of changes in neurologic assessment; and 4) optimization of neurologic assessments. Surveys were received from 64 of 67 institutions (96%). Glasgow Coma Scale and pupillary reflex were the most commonly reported assessments (80% and 92% of institutions, respectively). For patients with acute brain injury, 95% of institutions performed neurologic assessments hourly although assessment frequency was more variable for patients at low risk of developing brain injury and those at high risk for brain injury, but without overt injury. In 73% of institutions, any change detected on routine neuroassessment was communicated to providers, whereas in 27%, communication depended on the severity or degree of neurologic decline. Seventy percent of respondents thought that their current practice for assessing and monitoring neurologic status was suboptimal. Only 57% felt that the Glasgow Coma Scale was a valuable tool for the serial assessment of neurologic function in the ICU. Ninety-two percent felt that a standardized approach to assessing and documenting preillness neurologic function would be valuable.

Conclusions: Routine neurologic assessments are reported to be conducted in nearly all academic PICUs in the United States with fellowship training programs although the content, frequency, and triggers for communication vary between institutions. Most physicians felt that the current paradigms for neurologic assessments are suboptimal. These data suggest that optimizing and standardizing routine bedside nursing neurologic assessments may be warranted.
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http://dx.doi.org/10.1097/PCC.0000000000001463DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175815PMC
April 2018

An interdisciplinary response to contemporary concerns about brain death determination.

Neurology 2018 02 31;90(9):423-426. Epub 2018 Jan 31.

From the Departments of Neurology and Neurosurgery, Division of Neurocritical Care (A.L.), NYU Langone Medical Center, New York, NY; Department of Neurology (J.L.B.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Pittsburgh Critical Care Associates (S.B.), PA; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics, Division of Neurology (L.G.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; American Academy of Neurology Deputy General Counsel (J.H.), Minneapolis, MN; Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics (M.P.K.), The Children's Hospital of Philadelphia, PA; Departments of Neurology & Neurotherapeutics and Neurological Surgery (M.R.), UT Southwestern Medical Center, Dallas, TX; Department of Neurology (J.A.R.), Lahey Hospital and Medical Center, Burlington, MA; Department of Neurology (J.A.S.) University of Wisconsin, Madison; Department of Neurology, Division of Critical Care Neurology (E.F.M.W.), Mayo Clinic, Rochester, MN; and Department of Neurology (D.M.G.), Boston University School of Medicine, MA.

In response to a number of recent lawsuits related to brain death determination, the American Academy of Neurology Ethics, Law, and Humanities Committee convened a multisociety quality improvement summit in October 2016 to address, and potentially correct, aspects of brain death determination within the purview of medical practice that may have contributed to these lawsuits. This article, which has been endorsed by multiple societies that are stakeholders in brain death determination, summarizes the discussion at this summit, wherein we (1) reaffirmed the validity of determination of death by neurologic criteria and the use of the American Academy of Neurology practice guideline to determine brain death in adults; (2) discussed the development of systems to ensure that brain death determination is consistent and accurate; (3) reviewed strategies to respond to objections to determination of death by neurologic criteria; and (4) outlined goals to improve public trust in brain death determination.
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http://dx.doi.org/10.1212/WNL.0000000000005033DOI Listing
February 2018
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