title: Pediatric neurocritical care in the 21st century: from empiricism to evidence.
abstract: OBJECTIVE
  Approximately one in five children admitted to a pediatric ICU have a new central nervous system injury or a neurological complication of their critical illness. The spectrum of neurologic insults in children is diverse and clinical practice is largely empirical, as few randomized, controlled trials have been reported. This lack of data poses a substantial challenge to the practice of pediatric neurocritical care (PNCC). PNCC has emerged as a novel subspecialty, and its presence is expanding within tertiary care centers. This review highlights the recent advances in the field, with a focus on traumatic brain injury (TBI), cardiac arrest, and stroke as disease models.
  
  
  RESULTS
  Variable approaches to the structure of a PNCC service have been reported, comprising multidisciplinary teams from neurology, critical care, neurosurgery, neuroradiology, and anesthesia. Neurologic morbidity is substantial in critically ill children and the increased use of continuous electroencephalography monitoring has highlighted this burden. Therapeutic hypothermia has not proven effective for treatment of children with severe TBI or out-of-hospital cardiac arrest. However, results of studies of severe TBI suggest that multidisciplinary care in the ICU and adherence to guidelines for care can reduce mortality and improve outcome.
  
  
  CONCLUSIONS
  There is an unmet need for clinicians with expertise in the practice of brain-directed critical care for children. Although much of the practice of PNCC may remain empiric, a focus on the regionalization of care, creating defined training paths, practice within multidisciplinary teams, protocol-directed care, and improved measures of long-term outcome to quantify the impact of such care can provide evidence to direct the maturation of this field.
authors: aDepartment of Pediatrics, Divisions of Neurology bCritical Care cRuth D. and Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA dSection of Pediatric Intensive Care, Department of Pediatrics and Child Health, and University of Manitoba, Children's Hospital, Winnipeg, Manitoba, Canada eDepartment of Pediatrics, Section in Child Neurology - Epilepsy, Oregon Health and Science University, Portland, Oregon, USA.
authors: Mark S
authors: MS
authors: Wainwright
authors: Gregory
authors: G
authors: Hansen
authors: Juan
authors: J
authors: Piantino
mesh_terms: D000293:Adolescent; D000070642:Brain Injuries, Traumatic / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D003422:Critical Care / Q000592:standards / Q000639:trends; D016638:Critical Illness; D019348:Empiricism; D019983:Guideline Adherence; D019538:Health Care Surveys; D006301:Health Services Needs and Demand; D006323:Heart Arrest / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D015278:Intensive Care Units, Pediatric; D008991:Monitoring, Physiologic; D009462:Neurology / Q000193:education / Q000639:trends; D017063:Outcome Assessment, Health Care; D010372:Pediatrics / Q000193:education / Q000639:trends; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care; D020521:Stroke / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*