Multimodal Neuromonitoring in Pediatric Neurocritical Care: Current Perspectives

Children with neurological illness in the critical care unit are always at higher risk of developing secondary brain injury (SBI). Brain insult can lead to changes in cerebral autoregulation, intracranial pressure (ICP), cerebral oxygenation, and metabolism. This can cause a raised ICP, cerebral ischemia, hypoxia, excitotoxicity, cellular energy failure, and nonconvulsive status epilepticus. Simultaneous and continuous assessment of these parameters will help to improve patient care and neurological outcomes. Even though clinical examination and neuroimaging can help in the initial diagnosis of the neurological illness, they may not be helpful in continuous monitoring of cerebral pathophysiological changes. The ideal single neuromonitoring device to detect these real-time changes is currently unavailable. However, a range of invasive and noninvasive monitors are available to monitor these cerebral functional parameters. Invasive monitoring techniques include invasive ICP monitoring, cerebral autoregulation monitoring, brain tissue partial oxygen pressure, and cerebral microdialysis. Noninvasive-monitoring techniques include pupillometry, brain and ocular ultrasonography, near-infrared spectroscopy, and electrophysiological monitoring. Multimodal (MM) neuromonitoring involves incorporating these techniques and tools for the early identification and treatment of primary and secondary brain insults. The utility and feasibility of most of these techniques are well described in adult neurocritical care. Even though the evidence on their usage in children is primarily available in pediatric traumatic brain injury, the emerging data help to further expand their utility in pediatric nontraumatic coma. MM neuromonitoring aims to provide clinical and pathophysiological information to the intensivists to improve their understanding of the child's neurological status and to formulate patient-specific treatment approaches.