Multimodality neurologic monitoring in the neurocritical care unit is a method of continuous monitoring for brain and body function using different tools in a single patient. This form of monitoring for brain injury is being increasingly recognized as useful tool in clinical decision support in the neurocritical care field. It represents an extension of the neurologic examination and clinical skill set of bedside clinicians to better understand brain physiology in real time for unstable critically ill patients who may be comatose.
The fundamental goal of multimodality neurologic monitoring is to detect early signs of brain injury or worsening brain injury before irreversible brain damage takes place.
To that end, it adds value in:
- Detecting early signs of brain injury before irreversible brain damage takes place
- Allowing the clinical team to set individualized goals for blood pressure, intracranial pressure and ventilation management for optimal brain health
- Monitoring the response of therapies administered
- Enhancing clinicians’ understanding of cerebral autoregulation, brain compliance, and autonomic function in real time
- Aiding in the design and implementation of management protocols
By adding value in this manner, the fundamental goal of this strategy is to help in improving outcomes and quality of life for survivors of critical brain injury.
The Challenge
Secondary brain injury can result in the hours and days after initial injury because of changes in cellular injury cascade or secondary brain insults such as increased intracranial pressure, poor ventilation or lack of sufficient blood flow to the brain. Despite standard guidelines for blood pressure, intracranial pressure or ventilation parameters established for patients with acute injuries, every patient is unique and may require their own distinct hour-to-hour parameters for goals of care. There is need to better understand the goals that every individual child needs to optimize brain health during critical illness.
Multiple modalities can be used to monitor for secondary brain injury, including continuous electroencephalography, transcranial Doppler ultrasound (CD), pupillometry, brain tissue oxygenation monitoring, and intracranial pressure (ICP) monitoring. Each modality, in isolation, gives a limited window into real-time brain physiology. By combining these tools in real-time, clinicians are able to have broader insights into brain pathophysiology. Furthermore, advanced calculation of model-based indices of cerebral autoregulation, brain compliance and autonomic function allow physicians to better understand what specific parameters may be used in care to promote optimal brain health and recovery.
Currently, there are only a handful of pediatric and adult centers that integrate multimodality neurologic monitoring into routine patient care because of the requirement of advanced technology and expertise to use and implement these tools in real-time.
Real-Time Analysis at Barrow Neurological Institute at Phoenix Children’s
The Neurocritical Care Program at Barrow Neurological Institute at Phoenix Children’s utilizes a total of six multimodal monitoring units that are available for use within the hospital’s pediatric, cardiac and neonatal intensive care units. These devices time synchronize all brain and systemic monitoring tools at high resolution with raw waveforms available for analysis. The data is archived into a clinical database capable of storing this data, and network ports are available for streaming the data in real-time over the hospital network so that clinicians both at the bedside, as well as in the operating room or throughout the hospital can look live at changes in brain physiology for their patients. Using advanced software, the data can be used to calculate model-based indices of cerebral dynamics that allow physicians to understand, at any given time, what may be a patient’s clinical state as well as their optimal cerebral perfusion pressure, blood pressure, ventilator settings, or critical closing pressure. Furthermore, a structured process has been developed to provide clinical teams with standardized reporting of these measurements, as well as ascertaining the dose and percent time that goals of care were achieved, as well as the degree in which specific therapies are effective in improving care.
