Pediatric Moyamoya Revascularization Perioperative Care: A Modified Delphi Study

Background Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies w...

Ausführliche Beschreibung

Gespeichert in:
Bibliographische Detailangaben
Veröffentlicht in:Neurocritical care 2024-04, Vol.40 (2), p.587-602
Hauptverfasser: Sun, Lisa R., Jordan, Lori C., Smith, Edward R., Aldana, Philipp R., Kirschen, Matthew P., Guilliams, Kristin, Gupta, Nalin, Steinberg, Gary K., Fox, Christine, Harrar, Dana B., Lee, Sarah, Chung, Melissa G., Dirks, Peter, Dlamini, Nomazulu, Maher, Cormac O., Lehman, Laura L., Hong, Sue J., Strahle, Jennifer M., Pineda, Jose A., Beslow, Lauren A., Rasmussen, Lindsey, Mailo, Janette, Piatt, Joseph, Lang, Shih-Shan, Adelson, P. David, Dewan, Michael C., Mineyko, Aleksandra, McClugage, Samuel, Vadivelu, Sudhakar, Dowling, Michael M., Hersh, David S.
Format: Artikel
Sprache:eng
Schlagworte:
Online-Zugang:Volltext
Tags: Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
Beschreibung
Zusammenfassung:Background Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies widely. Using a modified Delphi process, we sought to establish expert consensus on key components of the perioperative care of children with moyamoya undergoing indirect revascularization surgery and identify areas of equipoise to define future research priorities. Methods Thirty neurologists, neurosurgeons, and intensivists practicing in North America with expertise in the management of pediatric moyamoya were invited to participate in a three-round, modified Delphi process consisting of a 138-item practice patterns survey, anonymous electronic evaluation of 88 consensus statements on a 5-point Likert scale, and a virtual group meeting during which statements were discussed, revised, and reassessed. Consensus was defined as ≥ 80% agreement or disagreement. Results Thirty-nine statements regarding perioperative pediatric moyamoya care for indirect revascularization surgery reached consensus. Salient areas of consensus included the following: (1) children at a high risk for stroke and those with sickle cell disease should be preadmitted prior to indirect revascularization; (2) intravenous isotonic fluids should be administered in all patients for at least 4 h before and 24 h after surgery; (3) aspirin should not be discontinued in the immediate preoperative and postoperative periods; (4) arterial lines for blood pressure monitoring should be continued for at least 24 h after surgery and until active interventions to achieve blood pressure goals are not needed; (5) postoperative care should include hourly vital signs for at least 24 h, hourly neurologic assessments for at least 12 h, adequate pain control, maintaining normoxia and normothermia, and avoiding hypotension; and (6) intravenous fluid bolus administration should be considered the first-line intervention for new focal neurologic deficits following indirect revascularization surgery. Conclusions In the absence of data supporting specific care practices before and after indirect revascularization surgery in children with moyamoya, this Delphi process defined areas of consensus among neurosurgeons, neurologists, and intensivists with moyamoya expertise. Research priorities identified include determining the
ISSN:1541-6933
1556-0961
1556-0961
DOI:10.1007/s12028-023-01788-0