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Bedside clinical neurologic assessment utilisation in paediatric cardiac intensive care units

Published online by Cambridge University Press:  16 October 2018

Matthew P Kirschen ,
Josh Blinder ,
Aaron Dewitt ,
Megan Snyder ,
Rebecca Ichord ,
Robert A Berg ,
Vinay Nadkarni  and
Alexis Topjian
Matthew P Kirschen*
Affiliation:
Department 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 Department of Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104 Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104
Josh Blinder
Affiliation:
Department 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 Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104
Aaron Dewitt
Affiliation:
Department 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 Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104
Megan Snyder
Affiliation:
Department of Nursing, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104
Rebecca Ichord
Affiliation:
Department of Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104 Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104
Robert A Berg
Affiliation:
Department 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 Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104
Vinay Nadkarni
Affiliation:
Department 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 Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104
Alexis Topjian
Affiliation:
Department 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 Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA19104
*
Author for correspondence: M. P. Kirschen, MD, PhD, Department of Critical Care Medicine, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, 8 NE Suite 8566, Philadelphia, PA 19104, USA. Tel: 215-590-5511; Fax: 215-590-4735; E-mail: [email protected]
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Abstract

Introduction

Neurodevelopmental 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 methods

We 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.

Keywords

Neurologic assessmentsneuro checkGlasgow Coma Scaleacute brain injury
Type
Original Article
Information
Cardiology in the Young , Volume 28 , Issue 12 , December 2018 , pp. 1457 - 1462
Copyright
© Cambridge University Press 2018 

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References

1. Marino, BS, Lipkin, PH, Newburger, JW, et al. Neurodevelopmental outcomes in children with congenital heart disease: evaluation and management: a scientific statement from the American Heart Association. Circulation 2012; 126: 1143–1172.Google Scholar
2. Mebius, MJ, Kooi, EMW, Bilardo, CM, Bos, AF. Brain injury and neurodevelopmental outcome in congenital heart disease: a systematic review. Pediatrics 2017; 140: 1–21.Google Scholar
3. Sterken, C, Lemiere, J, Vanhorebeek, I, Van den Berghe, G, Mesotten, D. Neurocognition after paediatric heart surgery: a systematic review and meta-analysis. Open Heart 2015; 2: e000255.Google Scholar
4. Bellinger, DC, Wypij, D, duPlessis, AJ, et al. Neurodevelopmental status at eight years in children with dextro-transposition of the great arteries: the Boston Circulatory Arrest Trial. J Thorac Cardiovasc Surg 2003; 126: 1385–1396.Google Scholar
5. Wernovsky, G. Current insights regarding neurological and developmental abnormalities in children and young adults with complex congenital cardiac disease. Cardiol Young 2006; 16 (Suppl 1): 92–104.Google Scholar
6. Wernovsky, G, Licht, DJ. Neurodevelopmental outcomes in children with congenital heart disease-what can we impact? Pediatr Crit Care Med 2016; 17: S232–S242.Google Scholar
7. Dominguez, TE, Wernovsky, G, Gaynor, JW. Cause and prevention of central nervous system injury in neonates undergoing cardiac surgery. Semin Thorac Cardiovasc Surg 2007; 19: 269–277.Google Scholar
8. Fogel, MA, Li, C, Elci, OU, et al. Neurological injury and cerebral blood flow in single ventricles throughout staged surgical reconstruction. Circulation 2017; 135: 671–682.Google Scholar
9. Limperopoulos, C, Majnemer, A, Shevell, MI, Rosenblatt, B, Rohlicek, C, Tchervenkov, C. Neurologic status of newborns with congenital heart defects before open heart surgery. Pediatrics 1999; 103: 402–408.Google Scholar
10. Teasdale, G, Maas, A, Lecky, F, Manley, G, Stocchetti, N, Murray, G. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol 2014; 13: 844–854.Google Scholar
11. Durham, SR, Clancy, RR, Leuthardt, E, et al. CHOP Infant Coma Scale (“Infant Face Scale”): a novel coma scale for children less than two years of age. J Neurotrauma 2000; 17: 729–737.Google Scholar
12. Kirkham, FJ, Newton, CR, Whitehouse, W. Paediatric coma scales. Dev Med Child Neurol 2008; 50: 267–274.Google Scholar
13. Tatman, A, Warren, A, Williams, A, Powell, JE, Whitehouse, W. Development of a modified paediatric coma scale in intensive care clinical practice. Arch Dis Child 1997; 77: 519–521.Google Scholar
14. Reilly, PL, Simpson, DA, Sprod, R, Thomas, L. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst 1988; 4: 30–33.Google Scholar
15. Kirschen, MP, Snyder, M, Winters, M, et al. Survey of bedside neurologic assessments in U.S. pediatric intensive care units. Pediatr Crit Care Med. In press.Google Scholar
16. Posner, JB, Saper, CB, Schiff, ND, Plum, F. Plum and Posner’s Diagnosis of Stupor and Coma. 4th edn. Oxford University Press, New York, 2007.Google Scholar
17. Olson, DM, Stutzman, S, Saju, C, Wilson, M, Zhao, W, Aiyagari, V. Interrater reliability of pupillary assessments. Neurocrit Care 2016; 24: 251–257.Google Scholar
18. Couret, D, Boumaza, D, Grisotto, C, et al. Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study. Crit Care 2016; 20: 99.Google Scholar
19. Olson, DM, Fishel, M. The use of automated pupillometry in critical care. Crit Care Nurs Clin North Am 2016; 28: 101–107.Google Scholar
20. Zafar, SF, Suarez, JI. Automated pupillometer for monitoring the critically ill patient: a critical appraisal. J Crit Care 2014; 29: 599–603.Google Scholar
21. Wijdicks, EF, Bamlet, WR, Maramattom, BV, Manno, EM, McClelland, RL. Validation of a new coma scale: The FOUR score. Ann Neurol 2005; 58: 585–593.Google Scholar
22. Cohen, J. Interrater reliability and predictive validity of the FOUR score coma scale in a pediatric population. J Neurosci Nurs: J Am Assoc Neurosci Nurses 2009; 41: 261–267; quiz 8-9.Google Scholar
23. Czaikowski, BL, Liang, H, Stewart, CT. A pediatric FOUR score coma scale: interrater reliability and predictive validity. J Neurosci Nurs: J Am Assoc Neurosci Nurses 2014; 46: 79–87.Google Scholar
24. Trauma ACoSCo. Advanced Life Support Course for Physicians. American College of Surgeons, Chicago, IL, 1993.Google Scholar
25. Wijdicks, EF. Clinical scales for comatose patients: the Glasgow Coma Scale in historical context and the new FOUR Score. Rev Neurol Dis 2006; 3: 109–117.Google Scholar
26. Teasdale, G, Allen, D, Brennan, P, McElhinney, E, Mackinnon, L. Forty years on: updating the Glasgow Coma Scale. Nursing. Times 2014; 110: 12–16.Google Scholar
27. Stocchetti, N, Pagan, F, Calappi, E, et al. Inaccurate early assessment of neurological severity in head injury. J Neurotrauma 2004; 21: 1131–1140.Google Scholar
28. Livingston, BM, Mackenzie, SJ, MacKirdy, FN, Howie, JC. Should the pre-sedation Glasgow Coma Scale value be used when calculating Acute Physiology and Chronic Health Evaluation scores for sedated patients? Scottish Intensive Care Society Audit Group. Crit Care Med 2000; 28: 389–394.Google Scholar
29. Zuercher, M, Ummenhofer, W, Baltussen, A, Walder, B. The use of Glasgow Coma Scale in injury assessment: a critical review. Brain Inj 2009; 23: 371–384.Google Scholar
30. Reith, FC, Brennan, PM, Maas, AI, Teasdale, GM. Lack of standardization in the use of the Glasgow Coma Scale: results of international surveys. J Neurotrauma 2016; 33: 89–94.Google Scholar
31. Simpson, DA, Cockington, RA, Hanieh, A, Raftos, J, Reilly, PL. Head injuries in infants and young children: the value of the Paediatric Coma Scale. Review of literature and report on a study. Childs Nerv Syst 1991; 7: 183–190.Google Scholar
32. Yager, JY, Johnston, B, Seshia, SS. Coma scales in pediatric practice. Am J Dis Child 1990; 144: 1088–1091.Google Scholar
33. Duncan, CC, Ment, LR, Smith, B, Ehrenkranz, RA. A scale for the assessment of neonatal neurologic status. Childs Brain 1981; 8: 299–306.Google Scholar
34. Raimondi, AJ, Hirschauer, J. Head injury in the infant and toddler. Coma scoring and outcome scale. Childs Brain 1984; 11: 12–35.Google Scholar
35. Licht, D, Brandsema, J, Von Rhein, M, Latal, B. Neurologic disorders in children with heart disease. In: Swaiman KF, Ashwal S, Ferriero DM, et al. (eds). Swaiman’s Pediatric Neurology: Principles and Practice, 6th edn. Elsevier, Edinburgh, New York, 2018:xxvi, 1403 pages.Google Scholar
36. Fiser, DH. Assessing the outcome of pediatric intensive care. J Pediatr 1992; 121: 68–74.Google Scholar
37. Kirschen, MP, Lourie, K, Snyder, M, et al. Improving routine nursing neurologic assessments in the pediatric intensive care unit. Critical care nurse. In press.Google Scholar
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