The Need to Understand Brain Health and Improve Brain Outcomes for Children and Adolescents Warrants Adoption of a More Proactive Approach to Brain Monitoring.
The Need to Understand Brain Health and Improve Brain Outcomes for Children and Adolescents Warrants Adoption of a More Proactive Approach to Brain Monitoring.
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了解儿童和青少年的大脑健康和改善大脑结果的需要需要采取更积极主动的大脑监测方法。
DOI：
10.1097/pcc.0000000000001833
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发表时间：
2019
期刊：
影响因子：
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通讯作者：
Vavilala,MonicaS
中科院分区：
文献类型：
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作者：
Vavilala,MonicaS
(ECMO)，但缺乏减轻这些并发症的战略(1)。许多因素都起到了推动作用。首先，尽管这是一种重要的治疗和挽救生命的治疗方法，但寻求医疗护理和需要体外反搏的儿童人数很少。第二个挑战是，无论疾病负担如何，大脑监测尚未意识到其在照顾患有危重疾病或有神经恶化风险的儿童方面的技术和临床效用。这包括危重、全身麻醉或接受程序镇静的儿童和青少年。第三，缺乏科学严谨的研究来检验神经监测在儿科中的作用和价值。第四，由于缺乏对正常脑血管生理学的了解，从已发表的研究中得出的背景研究结果存在挑战。第五，人们对年龄和性别的影响了解有限，很难将疾病状态的数据与健康正常儿童的数据进行比较。第六，在缺乏来自儿童和青少年的可靠数据的情况下，有时会将儿童的疾病状况与成人的标准数据进行比较，这使得数据解释存在问题。第七，儿科医学的文化往往比成人医学更保守和谨慎，因为成人医学总体上有更大的监测文化。第八，可能会有一种感觉，即使我们不提供最佳和可滴定的护理，可塑性和发展过程也会纠正任何潜在的问题。第九，许多儿科医院没有先进的大脑监测基础设施或专业知识，这使得研究人员很难进行这类研究。最后，儿科医学的实践在结构上已经变得非常孤立，独立的医院和很少有机会联合教育会议，几乎没有机会在创新方面进行协同。总而言之，这些因素可能会限制我们在了解如何优化最脆弱儿童的大脑健康方面取得的进展。尽管存在这些挑战，O‘Brien等人(2)在本期《儿科重症监护医学》上提出了一项前瞻性多中心研究的结果，该研究描述了儿科ECMO期间脑血管生理学的变化。值得祝贺的是，他们从全国各地聚集了一组感兴趣的地点，以解决否则将是一个孤立的问题，即了解是否可以使用经颅多普勒(TCD)超声来识别那些有急性神经损伤风险的患者。作者没有最终实现这一目标，也没有脑出血患者。然而，他们的发现，大脑中动脉血流速度显著低于发表的标准值，对于危重、机械通气、镇静的儿童，确实促进了我们对ECMO对估计脑血流灌注的影响的理解。急性神经损伤患者的搏动指数较高，这一事实不仅提示搏动指数可能是一个标志物，而且可能对ECMO在脑血管阻力中的作用有一定的帮助。一些设计因素可能加强了O‘Brien等人的研究(2)，例如临床方案和使用的药物的标准化，但这超出了这项初步研究的范围。作者正确地认识到需要一项更大的研究，具有很强的评价者间可靠性，更大的样本量，以及对静脉-静脉ECMO对脑血管系统的更多了解。
(ECMO), but strategies to mitigate these complications are lacking (1). A number of factors are contributory. First, although an important therapeutic and life-saving treatment, the number of children who seek medical attention and require ECMO is small. Second, is the challenge that regardless of disease burden, brain monitoring has not yet realized its technological and clinical utility in the care of children with critical illness or who are at risk of neurologic deterioration. This includes children and adolescents who are critically ill, under general anesthesia or receiving procedural sedation. Third, scientifically rigorous research examining the role and value of neuromonitoring in pediatrics is lacking. Fourth, there are challenges with contextualizing findings from the published studies because of the paucity of understanding of normal cerebrovascular physiology. Fifth, the effect of age and sex are understood in a limited manner, making it difficult to compare data from disease states to that of healthy normal children. Sixth, in the absence of robust data from children and adolescents, comparisons are sometimes made between disease states in children with normative data in adults, rendering data interpretation problematic. Seventh, the culture in pediatric medicine tends to be more conservative and careful than in adult medicine where there is a greater culture of monitoring in general. Eighth, there may be a feeling that even if we do no not deliver optimal and titrated care, plasticity and development processes will rectify any potential problems. Ninth, many pediatric hospitals do not have infrastructure or expertise for advanced brain monitoring, making it difficult for researchers to conduct this type of research. Finally, the practice of pediatric medicine has structurally become very siloed with separate hospitals and few opportunities for joint educational sessions, leaving few opportunities for synergy in innovation. Collectively, these factors may limit the progress we are able to make in understanding how to optimize brain health in the most vulnerable children.Despite these challenges, O’Brien et al (2) present results of a prospective observational multicenter study describing changes in cerebrovascular physiology during pediatric ECMO in this issue of Pediatric Critical Care Medicine. They should be congratulated for assembling a group of interested sites from across the nation to address what would otherwise be an orphaned question, which is to understand if the use of transcranial Doppler (TCD) ultrasonography can be used to identify those patients at risk of acute neurologic injury. The authors did not conclusively achieve this goal, and there were no patients with cerebral hemorrhage. However, their findings that middle cerebral artery flow velocities are significantly lower than published normative values for critically ill, mechanically ventilated, sedated children does advance our understanding of the effect of ECMO on estimates of cerebral perfusion. The fact that higher pulsatility index occurred among those with acute neurologic injury not only suggests that pulsatility index may be a marker but also may shed some light on the role of ECMO on cerebrovascular resistance. A number of design factors may have strengthened the study by O’Brien et al (2) such as standardization of the clinical scenario and medications used, but this was beyond the scope of this preliminary study. The authors correctly acknowledge the need for a larger study with strong interrater reliability, larger sample size, and a greater understanding of venous-venous ECMO on cerebral vasculature.