RAP, the compensatory-reserve index
A moving-window correlation between ICP pulse amplitude and mean ICP. The number that tells you how much room the cranium has left before a benign-looking ICP spikes catastrophically.
1. Bedside vignettes: why this matters in the PICU
Vignette A. The 7-year-old TBI, ICP 16, RAP +0.7
A 7-year-old severe TBI patient on day 2 has ICP 16 mmHg (within range for an older child by pBTF). The bedside RAP, computed from the ICP probe at 1-min resolution over the last 30 minutes, has risen from +0.2 to +0.7 over the last 3 hours. AMP has grown from 4 to 7 mmHg in the same window. The patient is moving from the flat part of the Marmarou PV curve onto the rising portion. Any next perturbation (suction, posture change, ventilator dyssynchrony, fluid bolus) could spike ICP catastrophically. Action: pre-emptive sedation, optimised head position, avoid unnecessary stimulation, prepare for hyperosmolar therapy; the RAP signal is the warning that buys time.
Vignette B. The adolescent SAH, RAP 0, ICP 18, comfortable
A 15-year-old SAH day 3 post-coiling has ICP 18, MAP 90, CPP 72. RAP has been steady at 0.0 to +0.1 for the last 24 hours. AMP is small and stable (2 to 3 mmHg). Good compensatory reserve. The patient is on the flat part of the PV curve; the cranium has room. The team continues sedation weaning and trial of fluid optimisation for the DCI prophylaxis bundle, knowing that a small fluid bolus is unlikely to drive ICP up acutely. The RAP signal supports the bedside intuition that "ICP 18 looks like good ICP 18" here.
Vignette C. The 5-year-old in advanced refractory ICP, RAP falling below 0
A 5-year-old severe TBI on day 4 has ICP 35 to 38 mmHg sustained, on maximum medical therapy (deep sedation, hyperosmolar, hyperventilation to PaCO2 32). Over the last hour, RAP has fallen from +0.6 to −0.3 while ICP has risen further to 42. The AMP has dropped from 9 to 4 mmHg. This is the decompensation pattern: at very high ICP, the cerebrovascular bed has collapsed; the cardiac pulse no longer fully transmits into the pulse amplitude; mean ICP and AMP decouple; RAP swings negative. This is not recovery; it is impending cerebral circulatory arrest. Action: escalate to decompressive craniectomy decision or, if appropriate to clinical context, transition to brain-death determination and family conversation.
2. What RAP is, and what it is not
RAP is a moving Pearson correlation between two simultaneously recorded ICP-derived signals:
- Mean ICP sampled at 10-second averages.
- AMP: the peak-to-trough amplitude of the ICP pulse waveform for the cardiac cycle, computed beat-to-beat and averaged over the same 10-second window.
The correlation is computed across a rolling window of typically 5 minutes (30 paired 10-s averages); the resulting value (between −1 and +1) is the RAP for that moment. Update typically every 1 minute.
The physiology: the Marmarou pressure-volume (PV) curve relates intracranial volume to ICP. The curve has three regions:
- Flat region (compensated): small volume changes produce small ICP changes; AMP is small and roughly constant; AMP and mean ICP are uncorrelated. RAP near 0.
- Steep rising region (decompensating): small volume changes produce large ICP changes; AMP grows; AMP and mean ICP rise together. RAP near +1.
- Plateau / falling at very high ICP (cerebrovascular collapse): the vascular bed collapses, pulse transmission fails, AMP falls as ICP keeps rising. RAP falls toward 0 and can go negative.
The RAP is therefore the bedside readout of where on the Marmarou PV curve the patient sits right now.
Three things follow.
RAP is a forward-looking signal. ICP tells you what the pressure is now; RAP tells you what will happen next if you add volume. A patient with ICP 16 and RAP 0.7 is one stimulus away from an ICP spike; the same ICP with RAP 0.1 is well buffered.
RAP needs careful interpretation at the extremes. A rising RAP from 0 toward +0.7 is the warning. A RAP that has plateaued at +1 means established poor compliance. A RAP that falls below 0 at high ICP is decompensation, not recovery.
Pediatric RAP data are sparse. Lewis 2014 reported pediatric RAP feasibility in TBI; Kazimierska 2021 added compliance-index analyses. Adult thresholds appear to translate but pediatric-specific reference data are emerging.
RAP is the index that tells you a benign-looking ICP is about to spike. ICP 16 with RAP +0.7 is a different patient from ICP 16 with RAP +0.1. The latter buffers; the former does not. Read RAP alongside ICP, not as a replacement for it.
Pediatric RAP is most useful in severe TBI and SAH where invasive ICP monitoring is in place. The signal is computed from the same ICP probe that gives mean ICP and PRx, so it is "free" once the probe is in.
3. The Marmarou pressure-volume curve and RAP zones
The three zones map to specific clinical states:
| RAP value | Zone | Clinical meaning |
|---|---|---|
| RAP ≈ 0 (−0.1 to +0.2) | Good compensatory reserve | Compensated; volume buffers |
| RAP +0.3 to +0.6 | Diminishing reserve | Warning; tighten ICP management |
| RAP > +0.7 sustained | Poor compensatory reserve | Near exhaustion; pre-empt any stimulus |
| RAP plateaued at +1 | Exhausted | At the steep portion; ICP about to spike or already spiking |
| RAP falling below 0 at very high ICP | Decompensation | Cerebrovascular collapse; pre-arrest |
This is the simplest mapping. In practice, the RAP trend over hours is more informative than a single absolute value.
4. The signal: how RAP is computed
The bedside platform (ICM+, Sickbay, or custom) requires:
- Continuous ICP from a parenchymal probe or EVD at high sample rate (100 Hz minimum to extract the pulse waveform).
- Beat detection on the ICP trace (typically using ECG R-wave timing or a dedicated peak detector).
- AMP per beat: maximum minus minimum within the cardiac cycle.
- Mean ICP: rolling mean over a fixed window (typically 10 s).
- Pair AMP and mean ICP in 10 s averages over a 5 min rolling window (30 pairs).
- Pearson correlation of the 30 pairs = RAP for that 5-min window.
- Update every 1 min; display as a trend.
Common implementation details.
- Sampling rate: 100 to 200 Hz on the ICP probe; the pulse waveform is the substrate.
- AMP detection: simple peak-to-trough on filtered ICP per cardiac cycle; some platforms use FFT-based AMP extraction (the spectral magnitude at the cardiac frequency).
- Artefact rejection: discard windows with probe disconnection, suction, or large transient ICP spikes from cough / movement.
- Display: trend strip of RAP, AMP, and mean ICP on the same screen.
RAP is computed from the same ICP probe that gives mean ICP and PRx, so it is "free" once the bolt is in. The only added cost is the bedside platform that runs the RAP algorithm; modern multimodal platforms (ICM+, Sickbay) compute it by default.
5. The numbers: what to record at the bedside
| Variable | Source | What it tells you |
|---|---|---|
| RAP (rolling 5 min) | Bedside platform | Compensatory reserve, this moment |
| RAP (1 h smoothed) | Bedside platform | Trend over time |
| AMP (pulse amplitude) | Bedside platform | Raw signal driving RAP; rises with poor compliance |
| Mean ICP | ICP probe | Baseline pressure |
| Concurrent PRx | Bedside platform | Autoregulation status (different physiology) |
| Marmarou-style PV index | Computed at bolus events | Direct compliance measurement (less common bedside) |
| ICP waveform morphology (P1, P2, P3) | ICP probe | Compliance signature; P2 > P1 = low compliance |
| Signal quality / artefact flags | Bedside platform | Confidence in RAP |
Plot RAP alongside ICP, AMP, PRx, and the clinical timeline (suction, posture changes, fluid boluses) so that perturbations and RAP responses can be visualised together.
6. What is normal? RAP reference values
| RAP | Interpretation | Typical ICP context |
|---|---|---|
| −0.2 to +0.2 | Good compensatory reserve | Low ICP, intact compliance |
| +0.2 to +0.5 | Borderline | Moderate ICP, transitional |
| +0.5 to +0.8 | Reduced reserve | ICP rising into treatment range |
| +0.8 to +1.0 | Exhausted | High ICP, steep PV curve |
| Falling from +1 toward 0 or negative at very high ICP | Decompensation | Pre-arrest, cerebrovascular collapse |
Pediatric data: adult thresholds appear to translate; Lewis 2014 and Kazimierska 2021 provide pediatric and adult cohort confirmation.
Pediatric RAP normative ranges are similar to adult, but pediatric data are smaller in number. Use trend-within-patient and pair with mean ICP and the Marmarou PV-curve concept; do not interpret a single RAP value in isolation.
7. What is abnormal? Pattern library
| Pattern | Bedside signature | Action |
|---|---|---|
| Compensated | RAP < 0.3, low AMP, stable ICP | Continue routine |
| Rising RAP | RAP from 0.2 → 0.6 over hours | Tighten management; pre-empt stimuli |
| Plateaued at +1 | RAP stuck at +1 with rising ICP | Escalate ICP treatment; do not perturb |
| Post-perturbation spike | RAP was high, brief stimulus, ICP spiked | Sedation depth review; HOB; hyperosmolar |
| Decompensation | RAP fallen from +1 toward 0 or negative at very high ICP | Catastrophic; escalate to surgery or family discussion |
| Pseudo-RAP-low artefact | ICP probe drift, low signal | Recheck probe; do not over-interpret |
| RAP normal with ICP normal | Stable | Continue routine |
Decision tree: "what does RAP tell me?"
flowchart TD
RAP[RAP reading] --> Q1{RAP > +0.7 sustained?}
Q1 -->|No| Q2{Mean ICP very high?}
Q1 -->|Yes| Warn[Reduced reserve; tighten management]
Q2 -->|No| OK[Continue routine]
Q2 -->|Yes > 30 with falling RAP < 0| Dec[Decompensation; escalate]
Q2 -->|Yes > 30 with RAP plateau at +1| Tx[Active treatment per ICP pathway]
Warn --> Pre[Pre-empt next stimulus; deeper sedation; HOB; ready hyperosmolar]
8. Try it: interactive widgets
9. RAP-driven management decisions
9.1 Pre-emption rather than reaction
The defining use case. A rising RAP toward +0.7 in a patient with ICP still "in range" justifies a pre-emptive management response:
- Deeper sedation if appropriate; avoid stimulating manoeuvres.
- Optimised head position: 30° head-of-bed, neutral neck, no abdominal compression.
- Ventilator harmony: PEEP minimal but safe, normocapnia, avoid coughing.
- Pre-empt the next perturbation: warn the bedside team that ICP is likely to spike with suction, posture change, or fluid bolus.
- Have hyperosmolar therapy at the bedside ready for rapid administration.
9.2 Avoiding the "false reassurance" of in-range ICP
A patient with sustained ICP 18 and RAP +0.7 is not in a safe place even though ICP is below the guideline treatment threshold (Kochanek 2019: treat ICP above 20 mmHg, all pediatric ages). RAP is the bedside signal that says "this ICP is on the steep part of the curve; one perturbation away from crisis."
9.3 The decompensation conversation
A patient with very high sustained ICP and a falling RAP that crosses zero into negative territory is decompensating. This is not improvement; it is cerebrovascular collapse. The bedside team should:
- Escalate ICP management to maximum: deep sedation, paralysis if needed, deeper hyperosmolar, hypothermia if not already, hyperventilation as a temporising measure.
- Consider decompressive craniectomy if salvageable and appropriate to the case.
- Prepare for the brain-death conversation if maximal therapy is exhausted.
- Engage family early with structured, honest communication.
9.4 Pairing with PRx
PRx and RAP are derived from the same probe but address different physiologies. PRx is the slow-wave correlation of ICP with MAP, an autoregulation index. RAP is the AMP-vs-mean-ICP correlation, a compensatory-reserve index. Both can be impaired in severe TBI; both can be useful for prognostication and management.
9.5 Pairing with the ICP waveform
The ICP waveform morphology (P1, P2, P3 peaks) gives the same compliance information as RAP but at a different time scale. A P2 > P1 pattern on the bedside waveform is the visual signature of low compliance, often correlating with elevated RAP. The two together strengthen the case for active management. See the ICP page for waveform morphology detail.
Teaching, not protocol. RAP thresholds (+0.7 warning, decompensation at falling RAP with very high ICP) are heuristics derived from observational adult data with limited pediatric validation. Local protocols and clinical judgment govern. Defer to your unit's senior neurocritical care team for RAP-driven decisions.
10. Clinical contexts: RAP across acute brain injuries
10.1 Severe TBI
The primary indication. RAP rises and falls predictably with the evolution of pediatric and adult severe TBI; it complements PRx and ICP-dose analyses for prognostication. Howells 2017 reported the largest RAP outcome dataset in adult TBI. Lewis 2014 the pediatric TBI feasibility data.
10.2 Aneurysmal SAH
Useful in SAH for the same reason: a rising RAP in a stable-looking patient warns of impending ICP crisis from rebleed, hydrocephalus, or DCI-related oedema. Less validated than in TBI but conceptually similar.
10.3 Pediatric AIS
ICP monitoring is uncommon in pediatric AIS unless malignant oedema is suspected. When ICP is monitored, RAP can supplement the bedside picture.
10.4 HIE and post-cardiac arrest
ICP monitoring in HIE is selective. When present, RAP adds compensatory-reserve information to the bedside picture, especially during the rewarming and reperfusion windows.
10.5 Pediatric ECMO
ICP monitoring on ECMO is uncommon (anticoagulation precludes safe bolt placement in most cases). RAP is therefore rarely available in ECMO. When EVD is in place for a specific surgical indication, RAP can be computed.
10.6 Meningitis and encephalitis with raised ICP
Fulminant meningitis or encephalitis with cerebral oedema may require EVD or parenchymal monitoring. RAP supports the bedside management when invasive monitoring is in place.
10.7 Brain-death determination
Not a brain-death tool. The decompensation pattern (RAP falling below 0 at very high ICP) is the bedside signature of cerebrovascular collapse and is consistent with impending brain death, but the formal diagnosis is clinical + apnoea + ancillary per local protocol.
10.8 DKA cerebral oedema
ICP monitoring in DKA is rare (the cerebral oedema is usually managed empirically with osmotherapy). In selected centres with EVD placement for fulminant DKA-CO, RAP would supplement the management.
10.9 Hydrocephalus / EVD-managed patients
A common chronic use case: pediatric patients with EVD for hydrocephalus or post-haemorrhagic hydrocephalus can have RAP computed continuously. Rising RAP in this context can indicate impending shunt failure or developing increased ICP.
10.10 Refractory raised ICP escalation
In refractory raised ICP requiring tier-3 therapies (decompressive craniectomy, barbiturate coma, hypothermia), RAP is part of the bedside data informing the escalation decisions. Decompensating RAP supports the case for surgical decompression where appropriate.
11. Multimodal integration: RAP in the MMM/MNM stack
| Pair with… | What you gain | Worked scenario |
|---|---|---|
| Mean ICP | The substrate; RAP complements ICP | ICP 16 + RAP +0.7 vs ICP 16 + RAP +0.1: very different patients |
| ICP waveform (P1, P2, P3) | Same compliance physiology, different time scale | P2 > P1 + RAP +0.8: concordant low compliance |
| PRx | Autoregulation vs reserve; two different physiologies | TBI with high RAP and high PRx: bad on both indices |
| CPP | The downstream consequence of high ICP | RAP rising + CPP falling = crisis approaching |
| Mx / COx | Non-invasive autoregulation companions | Multimodal picture of brain stress |
| Clinical exam | The gate | RAP rising + GCS falling = act now |
| TCD | PI rises with raised ICP; complements RAP | Both indicating decompensation: high RAP + high PI |
| NIRS | Tissue oxygenation alongside compensatory reserve | Multimodal evidence of secondary injury |
12. Setup and technique
12.1 Equipment
- Parenchymal ICP probe (Codman, Camino, Raumedic) or EVD with transducer placed by neurosurgery.
- High-sample-rate digital input to the bedside platform (100 Hz minimum).
- Bedside platform with RAP computation: ICM+, Sickbay, custom Python pipeline, or vendor-integrated.
- Synchronised ECG (optional but helpful for beat detection).
- Clean ICP waveform with crisp P1-P2-P3 morphology.
12.2 Setup workflow
- Confirm ICP probe is placed and zeroed per local protocol.
- Verify waveform quality: P1-P2-P3 morphology visible, respiratory variation clean, no electrode noise.
- Sample rate at 100 to 200 Hz; some platforms accept lower rates with degraded RAP precision.
- Beat detection running (manual review of detection accuracy in first minutes).
- Start RAP computation: typically 10-s averages over 5-min window, updated every 1 min.
- Display RAP, AMP, mean ICP, PRx (if computed) on a single bedside trend strip.
- Set alarms: rising RAP, sustained RAP > 0.7, decompensation pattern (falling RAP at very high ICP).
12.3 Interpretation in clinical context
- Always read RAP alongside mean ICP and AMP. RAP without context is unreliable.
- Trend over hours: a single RAP value is less informative than the trajectory over 4 to 12 hours.
- Pair with clinical exam, CPP, PRx, ICP waveform morphology. The multimodal picture is the working unit.
- Document at bedside rounds: RAP trend, current zone, planned response to specific perturbations.
12.4 Quality control
- Waveform quality is the leading determinant of RAP reliability. Probe drift, broken connections, and electrode noise all degrade AMP detection.
- Beat detection accuracy affects AMP; manual review during initial setup.
- Filtering: appropriate high-pass and low-pass to isolate the cardiac-frequency pulse; over-filtering degrades AMP, under-filtering admits noise.
- Re-zero ICP per local protocol; drift in mean ICP corrupts RAP.
12.5 Pediatric-specific considerations
- Smaller pulse amplitudes in young children; the AMP signal-to-noise ratio is lower; RAP precision suffers slightly.
- Higher heart rates (toddlers, infants): more beats per 10-second window; AMP averaging is more robust but FFT-based AMP extraction needs adjusted parameters.
- Pediatric reference data sparse: treat pediatric RAP thresholds as adult-extrapolated.
- Confounders are the same: sedation, posture, ventilator, suction, fluid boluses all influence ICP and AMP and therefore RAP.
12.6 When RAP is not the right tool
- Inadequate waveform quality: damped, noisy, or disconnected ICP probe.
- EVD draining continuously: open EVD vents the ICP wave, suppressing AMP and corrupting RAP.
- Very low ICP (over-drainage): AMP is small, RAP is poorly defined.
- Very high ICP with cerebrovascular collapse: RAP itself becomes a decompensation marker; interpret in clinical context.
13. Pitfalls
- Open EVD vents the ICP wave: AMP drops, RAP is corrupt. Close the EVD to atmosphere (or clamp briefly) when reading RAP.
- Waveform damping from probe drift or wedge artefact reduces AMP and lowers RAP, mimicking improvement.
- Over-filtering degrades the pulse amplitude; under-filtering admits noise.
- Single-snapshot RAP: trend is the signal.
- Confusing decompensation with recovery: a falling RAP at very high ICP is decompensation, not improvement.
- Adult thresholds in children: most pediatric RAP work uses adult thresholds; pediatric-specific normative data are limited.
- Sedation changes: deep sedation lowers CMRO2, reduces cerebral vascular volume, can shift the patient down the PV curve; RAP can improve transiently with sedation increase.
- Posture changes: HOB up reduces cerebral venous pressure, can drop ICP and AMP; RAP shifts.
- Pairing with ICP waveform morphology: when RAP and P2 > P1 disagree, look harder; the two should usually agree.
- Ignoring AMP: AMP itself (without the correlation) is informative; large AMP at "in range" ICP is a low-compliance signature even when RAP has not fully risen.
14. Combine with…
- ICP: the parent modality; RAP is one of its derived indices.
- PRx: the autoregulation index sibling, also from the ICP probe.
- CPP: the downstream variable that decompensating RAP threatens.
- Mx: the TCD-based autoregulation index.
- COx: the NIRS-based autoregulation index.
- Foundations: Monro-Kellie doctrine: the physiology behind RAP.
- Foundations: Marmarou PV curve: the direct conceptual underpinning.
15. Evidence summary
| Topic | Source | Grade |
|---|---|---|
| Original RAP description | B | |
| Kim 2009 RAP review | review | |
| Howells 2017 large adult RAP cohort | B | |
| Kazimierska 2021 compliance / RAP | C | |
| Lewis 2014 pediatric RAP | C | |
| Marmarou pressure-volume curve | foundational | |
| Hawthorne ICP biomarkers review | review | |
| PRx (the autoregulation companion) | A | |
| Pediatric BTF (TBI) | expert | |
| SAH AHA guidelines | expert | |
| Pediatric MMM consensus | expert | |
| LeRoux 2014 neurocritical consensus | expert | |
| Pediatric PCCM review | review | |
| Pediatric MMM PCCM review | review | |
| Pediatric post-arrest brain injury | review | |
| Pediatric brain-death criteria | expert |
16. Recent literature (2022 to 2025)
- Kazimierska 2021 compliance index analyses: extended the RAP / compliance framework with novel ICP-waveform-derived indices in adult TBI.
- Hawthorne 2014 ICP biomarkers review (still the standard primer): positions RAP, AMP, and pulse-waveform-derived indices in the broader ICP-monitoring framework.
- Tasker 2023 PCCM review: includes RAP in the pediatric severe TBI MNM toolkit.
- Figaji 2025 pediatric MMM consensus: RAP recognised as tier-2 (specialist centre) modality in pediatric MNM stacks.
- Helbok 2024 pediatric MMM: bedside operationalisation of RAP in pediatric multimodal monitoring.
- Continued adult RAP literature: refinements in waveform-based AMP extraction, FFT-based RAP, and ML-augmented compliance index work in selected research centres.
17. Self-check
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