Approaches to neuroprotection in pediatric neurocritical care

Table 1 Summary of consensus-based guideline recommendations for pediatric neuroprotection

Pathology	Optimize cerebral perfusion	Limit cerebral metabolic demand	Mitigate cerebral edema
Severe traumatic brain injury[15]	Maintain age appropriate CPP (Minimum ≥ 40 mmHg)	Targeted normothermias: 35 °C−38 °C	Maintain sodium: ≥ 140 mEq/L
	If PbtO2 available: ≥ 10 mmHg	Maintain adequate sedation and analgesia	Maintain HOB = 30 °C
	Maintain ICP < 20 mmHg	Benzodiazepine + Opiate as initial therapy	Second tier therapies
	Targeted normoxemia: SpO2 92%−99%	Consider continuous EEG	Surgical intervention
	Maintain PaCo2: 35-40 mmHg	Phenytoin or levetiracetam for seizures	Barbiturate infusion
	Target euglycemia: 100–180 mg/dL		Moderate hypothermia (32 °C−34 °C)
	Target euvolemia: CVP 4−10 mmHg		Hyperventilation (PaCO2 28-34 mmHg)
	Maintain hemoglobin: > 7 g/dL		Increased hyperosmolar therapy
Post-Cardiac arrest[14]	Maintain MAP ≥ 5th percentile for age	Targeted normothermia: 36 °C−37.5 °C
	Targeted normoxemia: SpO2 94%−99%	Consider 48 h of T 32 °C− 34 °C for OHCA
	Maintain PaCo2: 35-45 mmHg	Maintain adequate sedation and analgesia
	Target euglycemia: 80−180 mg/dL	Continuous EEG
		Treat seizures if identified
Acute arterial ischemic stroke[80]	Treat hypertension with caution in patients with intracranial vascular stenosis	Maintain temperature < 38 °C	Consider decompressive surgery for malignant edema
	Aggressively treat hypotension		For large volume infarcts (> 1/2 MCA territory)
	Treat hyperglycemia to target 140-180 mg/dL		Consider early decompressive hemicraniectomy (< 24 h)
	Treat hypoglycemia: < 60 mg/dL		Serial imaging and frequent assessments for 72 h

CPP: Cerebral perfusion pressure; PbtO2: Partial pressure of brain tissue oxygenation; ICP: Intracranial Pressure; SpO2: Peripheral oxygen saturation; PaCo2: Arterial carbon dioxide tension; CVP: Central venous pressure; EEG: Electroencephalography; HOB: Head of bed; MAP: Mean arterial pressure; OHCA: Out-of-hospital cardiac arrest; MCA: Middle cerebral artery.