DOI: 10.1212/01.wnl.0000313379.57609.25 2008

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DOI: 10.1212/01.wnl.0000313379.57609.25 2008

  1. 1. Emerging Subspecialties in Neurology: Building a career and a field: Pediatric neurocritical care Kerri L. LaRovere and James J. Riviello, Jr Neurology 2008;70;e89-e91 DOI: 10.1212/01.wnl.0000313379.57609.25 This information is current as of October 18, 2010 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.neurology.org/cgi/content/full/70/22/e89 Neurology® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2008 by AAN Enterprises, Inc. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X. Downloaded from www.neurology.org by on October 18, 2010
  2. 2. RESIDENT & FELLOW SECTION Emerging Subspecialties in Neurology: Section Editor Building a career and a field Mitchell S.V. Elkind, MD, MS Pediatric neurocritical care Kerri L. LaRovere, The specialty of neurocritical care (NCC) has over, NCC is a new frontier in clinical child MD evolved rapidly and has an exciting future. The neurology with unlimited opportunities for re- James J. Riviello, Jr., current neurologic intensive care units (NICUs) search. Recent collaborative efforts have pro- MD were born in the 1960s as a collaborative effort duced several evidence-based guidelines for the among the various subspecialists caring for pa- field. In 2000, a working group assembled by the tients with neurologic illnesses in multidisci- International Brain Injury Association created Address correspondence and plinary intensive care units (ICUs). The first guidelines for severe pediatric head trauma,2 with reprint requests to Dr. Kerri L. dedicated NICUs appeared in the mid-1970s, and the hope that standardized management of pedi- LaRovere, Children’s Hospital Boston, Department of training programs soon followed. There are now atric traumatic brain injury will allow outcome Neurology, Fegan 11, 300 50 dedicated NICUs run by fellowship-trained analyses intended to improve current therapies. Longwood Avenue, Boston, MA 02115 neurointensivists in 29 states, and 15 hospitals in Guidelines from the United States and United kerri.larovere@childrens. which neurointensivists provide consultant ser- Kingdom have been developed for arterial isch- harvard.edu vices.1 Dedicated NICUs have permitted many emic stroke and cerebral sinovenous thrombosis advances in basic science, diagnostic, monitoring, in children,3,4 and the International Pediatric and therapeutic techniques in NCC. Stroke Study has created an international stroke Neurointensivists apply the basic principles of registry in an effort to develop true evidence- neuroresuscitation, the ABCs (airway, breathing, based practice standards and perform future clin- and circulation/cerebral blood flow), to the man- ical trials. In addition, the American Academy of agement of acute, life-threatening brain and spi- Neurology and Child Neurology Society devel- nal cord insults or “failure.” Common diagnoses oped a practice parameter for the Diagnostic As- in the adult NICU include postoperative tumor, sessment of the Child with Status Epilepticus.5 stroke, subarachnoid hemorrhage, traumatic As in adult NCC, additional pediatric research brain injury, and intracerebral hemorrhage. Suc- topics include age-specific and disease-specific cessful management depends upon properly diag- studies related to measurements of cerebral blood nosing, monitoring, and treating these conditions, flow and intracranial pressure; determinations of as well as upon preventing and treating any sec- clinical, biologic, neurophysiologic, radiologic, ondary complications, namely disturbances of ce- and pathologic markers of CNS injury; therapeu- rebral perfusion and intracranial pressure. The tic effects on outcome; and factors important in clinical and scientific progress in this new spe- recovery of function. Unlike that of adult NCC, cialty has spawned the international Neurocriti- the research agenda in children has a critical addi- cal Care Society; a peer-reviewed scientific tional layer: understanding the response of the de- journal, Neurocritical Care; and the approval of veloping brain to acute and severe CNS injury. NCC for subspecialty certification by an indepen- However, pediatric NCC lags behind adult NCC. dent, nonprofit professional medical organiza- The field of pediatric neurology does not yet have tion, the United Council for Neurologic dedicated pediatric NICUs or training programs, Subspecialties (UCNS). The next step is certifica- and to date, pediatric NCC has been driven for- tion by the Accreditation Council for Graduate ward by work that has “trickled down” from Medical Education, which will signify general ac- adult NICUs or from neonatal neurology. ceptance of NCC. In the current practice of pediatric NCC, the We were drawn to pediatric NCC during our pediatric neurologist functions as a consultant to pediatric neurology training because of an inter- the pediatric ICU (PICU) team in the evaluation est in managing acute neurologic insults. More- and treatment of acute ischemic stroke, intracere- From the Department of Neurology, Children’s Hospital Boston and Harvard Medical School, Boston, MA. Disclosure: The wife of Dr. Riviello was a medical editor for Up-To-Date. Downloaded from www.neurology.org by on October 18, © 2008 by AAN Enterprises, Inc. Copyright 2010 e89
  3. 3. bral hemorrhage, traumatic brain injury, anoxic institution currently does not have the training, brain injury, status epilepticus, CNS infections, experience, or support personnel needed to func- autoimmune and postinfectious disorders, neuro- tion as primary attending physicians in a pediatric muscular emergencies, neurometabolic crises, NICU. Given the current practice of pediatric postoperative CNS tumors and epilepsy surgery, critical care medicine, where the PICUs in major neurologic complications of general medical and children’s hospitals are closed units staffed by pe- surgical illnesses, and brain death. A multidisci- diatric critical care medicine specialists, pediatric plinary approach is needed to best care for these neurologists will most likely remain as consultants children. The pediatric neurologist is needed in to this group. We believe that the best care ulti- the PICU as an expert in the neurologic history mately will be delivered in a dedicated pediatric and examination of a child, an invaluable skill NICU staffed by a team consisting of pediatric in- necessary for decision-making and determining tensivists and pediatric neurointensivists. In any prognostic variables. Furthermore, PICUs need model, evidence-based treatment guidelines are the pediatric neurologist because many of the needed to standardize care and evaluate outcomes. neurologic disorders of these children are chronic, We believe it is time to move away from re- unlike those of their adult counterparts.6,7 A pedi- cruiting child neurology subspecialists who have atric neurologist on the PICU team will provide a critical care interest to the NCC team, and in- the best neurologic care for these children. stead to develop properly trained pediatric NCC To establish this frontier, the Department of subspecialists. The dedicated pediatric neuroin- Neurology at Children’s Hospital Boston, under tensivist would be a member of the PICU team Dr. Joseph Volpe, created a dedicated critical care and help perform research on neurologic disor- neurology service in 1996. All neurology consulta- ders in the PICU. This model should lead to in- tions in the medical/surgical PICU, the cardiac in- creased educational efforts in neurointensive and tensive care unit, and three neonatal intensive non-neurointensive care, effective collaboration care units are performed by a dedicated critical with other caregivers in the ICU, and more effi- care neurology team distinct from the inpatient cient care for children with critical neurologic ill- neurology consult team. This service was created nesses. Collaboration with other neurologic because it became difficult for a general neurol- subspecialists on the NCC team would continue, ogy consult service to incorporate the many ad- since epilepsy, neurovascular, and neuromuscular vances in neonatal neurology and NCC into disorders are frequently seen in the ICU.8 clinical practice. In 2006, this service provided 557 The pediatric neurointensivist should have new consults and 3,539 follow-up consultations. training and knowledge beyond pediatric neurol- Our group includes pediatric neurologists special- ogy residency. In accordance with the UCNS izing in epilepsy and in neurovascular, neuromus- guidelines for fellowship program requirements cular, behavioral, and neonatal neurology, but (http://www.ucns.org/accreditation), fellows must only one had an anesthesiology background. We complete 12 months of on-service critical care believe that in order to move our field forward in training involving the direct diagnosis and man- a manner similar to that of our adult counter- agement of critically ill neurologic patients, and parts, we now need to train dedicated pediatric 12 months of various non-critical care clinical ro- NCC specialists. Presently, the Neurocritical tations. For pediatric NCC, membership on a Care Society is planning a workforce evaluation team in a medical/surgical PICU, pediatric car- for pediatric NCC, which will be important for diac intensive care unit, postanesthesia care unit, developing the field and for identifying funding and adult NICU may count toward the 12-month strategies for training programs. on-service critical care requirement. Possible non- Several models of pediatric NCC delivery are critical care electives include pediatric neurovas- possible. The most common model is an inpatient cular or stroke service, epilepsy, neurosurgery, neurology consult service providing neurologic emergency department, interventional/diagnostic consultations to all inpatients. An alternative is neuroradiology, Doppler lab, clinical neurophysi- the current Boston model, where a dedicated ology, and research. In particular, training in ap- group of neurologists work as consultants to the plications and interpretation of pediatric EEG, PICU team. This requires a large neurology de- continuous EEG, and neuroimaging and neuro- partment or division. The ultimate model is the monitoring devices including transcranial Dopp- creation of a dedicated pediatric NICU staffed ler would be useful. with NCC-trained pediatric neurologists, similar Foundations for a good pediatric NCC pro- to the adult situation. However, the staff at our gram include emphasis on general and neurologic e90 Neurology 70 May 27, 2008 (Part 1 of 2) Downloaded from www.neurology.org by on October 18, 2010
  4. 4. intensive care through exposure to adult and pe- lowship funding may be difficult to find. Funds or diatric general and neurologic ICUs in institutions grants to consider include those available from with interested colleagues and opportunities for the government (http://www.grants.gov), such as clinical and laboratory research. A committee of the National Institute of Neurological Disorders clinical and research mentors from pediatric neu- and Stroke (http://www.ninds.nih.gov) and the rology, as well as from all parent specialties in National Institute of Child Health and Human critical care medicine, anesthesiology, adult development (http://www.nichd.nih.gov). Other NCC, and neurosurgery, are paramount to future funding sources may come from major professional success. Institutions with well-developed ICUs organizations such as the Child Neurology Founda- and robust neurology services should consider de- tion (http://www.childneurologyfoundation.org), vising a program. Post-residency (pediatric neu- American Neurological Association (http://www. rology or anesthesiology) training programs aneuroa.org), Association of University Professors could consider fellowship training integrated of Neurology (http://www.aupn.org), Pediatric with general and neurologic PICU and adult Critical Care Medicine, and the American Academy NICU/vascular neurology. Another possibility of Pediatrics (http://www.aap.org). may be cross training of pediatric NICU special- ists during residency with an effort to follow fel- ACKNOWLEDGMENT lowship or practice track pathways (http://www. Dr. LaRovere thanks Dr. Allan Ropper for his comments on the ini- ucns.org/certification/requirements/#neuroint) so tial manuscript. The authors also thank Shaye Moore for her assis- tance in preparing the manuscript. that eligibility for the NCC certifying examination is possible. The Department of Neurology at Children’s REFERENCES Hospital Boston, under Dr. Scott Pomeroy, has 1. Wright WL. Putting neurocritical care units on the map. Currents 2007;2:4. established a pediatric NCC fellowship training 2. Adelson PD, Bratton SL, Carney NA, et al. Guidelines program in conjunction with the adult vascular for the acute medical management of severe traumatic and NCC program at Massachusetts General brain injury in infants, children, and adolescents. Pedi- Hospital/Brigham and Women’s Hospital and the atr Crit Care Med 2003;4(3 suppl):S1–S75. anesthesia/pediatric critical care program at Chil- 3. Monagle P, Chan A, Massicotte P, Chalmers E, Mich- dren’s Hospital Boston. To our knowledge, this is elson AD. Antithrombotic therapy in children: The the first and only such program in existence. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:645S–687S. first year is a mixture of electives and service time 4. Paediatric Stroke Working Group. Stroke in child- in adult NCC with overnight adult NCC and hood: clinical guidelines for diagnosis, management stroke call. The second year consists of service and rehabilitation [online]. Available at: http://www. time in pediatric critical care with rotations in an- rcplondon.ac.uk/pubs/books/childstroke. Accessed esthesia, cardiac intensive care, and PICU, and December 12, 2007. various pediatric non-critical care electives. These 5. Riviello JJ Jr, Ashwal S, Hirtz D, et al. Practice param- eter: diagnostic assessment of the child with status epi- 2 years are structured according to the practice lepticus (an evidence-based review): Report of the track pathway put forth by the UCNS. This pro- Quality Standards Subcommittee of the American gram is funded by the Neurology Department in Academy of Neurology and the Practice Committee of recognition of the need to provide this service to the Child Neurology Society. Neurology 2006;67:1542– the many children we care for with acute and se- 1550. vere neurologic conditions, as well as the need to 6. Dosa NP, Boeing NM, Ms N, Kanter RK. Excess risk of severe acute illness in children with chronic health train future pediatric neurointensivists. Perhaps conditions. Pediatrics 2001;107:499–504. other major children’s hospitals will recognize 7. Graham RJ, Dumas HM, O’Brien JE, Burns JP. Con- these needs as well, and create similar training genital neurodevelopmental diagnoses and an intensive programs. care unit: defining a population. Pediatr Crit Care Med Fellowship directories in NCC can be found 2004;5:321–328. on the UCNS Web site at http://www.ucns.org 8. Pison JL, Manso MG, Morales LR, Belloc SJ, Amez ´ AF, Gimeno JM. Analisis descriptivo de la patologia as well as through the American Academy of neurologica en una unidad de cuidados intensivos pedi- Neurology at http://www.aan.com/education/ atricos de referencia regional [Descriptive analysis of fellowships. A list of pediatric critical care medi- neurological disorders in the pediatric intensive care cine fellowships is available on the pediatric unit of a regional reference hospital]. An Esp Pediatr critical care Web site at http://pedsccm.org. Fel- 2000;53:119–124. Downloaded from www.neurology.org by on October 18, 70 May 27, 2008 (Part 1 of 2) Neurology 2010 e91
  5. 5. Emerging Subspecialties in Neurology: Building a career and a field: Pediatric neurocritical care Kerri L. LaRovere and James J. Riviello, Jr Neurology 2008;70;e89-e91 DOI: 10.1212/01.wnl.0000313379.57609.25 This information is current as of October 18, 2010 Updated Information including high-resolution figures, can be found at: & Services http://www.neurology.org/cgi/content/full/70/22/e89 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): All Pediatric http://www.neurology.org/cgi/collection/all_pediatric Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.neurology.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.neurology.org/misc/reprints.shtml Downloaded from www.neurology.org by on October 18, 2010

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