Pediatric MNM bedside reference
Designed for printing or rapid bedside lookup. Pediatric values are evidence-graded; adult-extrapolated values are flagged.
Print this page double-sided on A4 / letter and laminate. The printed version omits the navigation, theme toggle, and tooltips; use your browser's print command (Ctrl+P, or Cmd+P on Mac). The doses below are starting points; always cross-check against your unit's pediatric formulary.
1 · Age-band normative values
| Age | CPP floor | ICP threshold | NIRS rSO₂ | TCD MFV | NPi |
|---|---|---|---|---|---|
| Term newborn | 30–40 | > 10 | 65–85% | ~24 | > 3 |
| Infant (1–12 mo) | 40–50 | > 15 | 60–80% | ~50–80 | > 3 |
| Toddler (1–3 yr) | 40–50 | > 20 | 60–80% | ~80–95 | > 3 |
| School-age (4–11 yr) | 50–60 | > 20 | 60–80% | ~85–110 | > 3 |
| Adolescent | 60–70 | > 20 | 60–80% | ~70 | > 3 |
Sources: PBTF / Kochanek 2019 · O'Brien 2015 · SafeBoosC 2015 · expert consensus. Treat as floors, not goals; individualize with PRx/CPPopt where available.
2 · Hyperosmolar dosing, interactive
3 · Raised ICP, escalation ladder
- Tier 0, confirm signal. Transducer level (foramen of Monro), no damping, clean cardiac waveform. Re-zero. Verify ICP > threshold sustained > 5 min before escalating.
- Tier 1, first-line. Head-up 30° (neck neutral, no jugular compression), adequate analgesia + sedation, normocapnia (PaCO₂ 35–40 mmHg), normoxia (SpO₂ 94–98%), normothermia (core 36–37 °C, treat fever aggressively), Na⁺ 145–150 mmol/L, glucose 5–10 mmol/L. Drain CSF if EVD in situ.
- Tier 2, hyperosmolar. 3% NaCl 3–5 mL/kg over 10–20 min (preferred first-line in most pediatric TBI guidelines) or mannitol 0.25–1 g/kg over 20–30 min. Re-dose for ICP > threshold. Ceilings: Na⁺ 155–160 mmol/L (HTS), serum osmolality 320 mOsm/kg or osmolar gap < 20 (mannitol).
- Tier 3, deeper sedation / neuromuscular blockade. Increase midazolam / fentanyl. Add neuromuscular blockade (rocuronium or vecuronium) if shivering, coughing, or asynchrony are driving ICP, confirm sedation depth first. Avoid prolonged propofol infusion in patients < 16 yr (PRIS risk).
- Tier 4, bridge therapies. Targeted mild hypothermia (35–36 °C) or brief, targeted hyperventilation (PaCO₂ 30–35 mmHg) only as a bridge to definitive therapy. Avoid prophylactic deep hyperventilation (PaCO₂ < 30), risk of ischaemia. Avoid sustained hypothermia < 32 °C; current evidence does not support prophylactic deep hypothermia for outcome.
- Tier 5, last-line. Barbiturate coma (pentobarbital or thiopental, titrated to cEEG burst-suppression, full haemodynamic and infection surveillance) or decompressive craniectomy (early surgical decompression in selected patients with refractory ICP). Both require neurosurgical and PICU consensus.
Adapted from PBTF / Kochanek 2019 pediatric severe-TBI guidelines (3rd edition) and current pediatric NCS / ESPNIC consensus. Defer to your unit's pathway. Each tier is a 30–60 minute trial: re-evaluate ICP, pupils, NIRS, and clinical exam before escalating.
4 · PbtO₂-targeted CPP escalation (BOOST-style)
- Confirm signal. Probe equilibrated > 1 h, not in contusion (CT-confirmed), no CSF wicking on probe.
- Check the easy levers. PaO₂ > 80, PaCO₂ 35–40, Hgb > 9, normothermia.
- Raise CPP toward upper end of age-band; titrate noradrenaline. Re-check PbtO₂ in 30 min.
- Raise FiO₂ to 60% if PbtO₂ still < 20 mmHg.
- Transfuse to Hgb 9–10 g/dL.
- Reduce CMRO₂, deepen sedation, target normothermia 36 °C, exclude seizures (cEEG).
- Microdialysis if available, distinguishes ischaemia (low PbtO₂ + low glucose + high L/P) from mitochondrial dysfunction (normal PbtO₂ + high L/P).
5 · Pupillometry, what the NPi means
| NPi | Interpretation |
|---|---|
| > 3 | Brisk reactive, normal range. |
| 2.5–3 | Sluggish, sedation, mild encephalopathy, or early herniation. Trend hourly. |
| < 2 | Severely abnormal. Image. Re-examine. |
| 0 | Non-reactive. Catastrophic in absence of mydriatic / sedation effect. |
| L≠R ≥ 0.7 | Asymmetry. Uncal herniation differential, emergency. |
BIS < 40 reduces NPi by ~0.8 × ((40 − BIS) / 40). Cooling to 33 °C reduces NPi by ~0.5–0.8.
6 · Status epilepticus & NCSE, pediatric pathway
SE = status epilepticus (continuous seizure ≥ 5 min, or recurrent seizures without recovery between). NCSE = non-convulsive status epilepticus, electrographic seizure without overt convulsive activity.
Suspect NCSE if any of:
- Unexplained altered consciousness lasting > 30 min.
- Subtle motor signs: face / hand twitching, gaze deviation, nystagmus, automatisms.
- aEEG bandwidth narrowing without explanation.
- Post-convulsive failure to wake within 10–20 min.
- Acute ischaemic / haemorrhagic injury with new neurology.
- Post-arrest, encephalitis / autoimmune encephalopathy, severe TBI.
Pediatric SE pathway (timed from seizure onset):
- 0–5 min · stabilisation. Airway, breathing, circulation. IV access. Glucose, electrolytes, ABG. Pulse oximetry, end-tidal CO₂. Time the seizure.
- 5–20 min · first-line benzodiazepine. Midazolam 0.2 mg/kg IM (max 10 mg) or 0.1 mg/kg IV (max 4 mg per dose). Alternatives: lorazepam 0.1 mg/kg IV (max 4 mg) or diazepam 0.2–0.5 mg/kg IV/PR. May repeat ×1 if seizure persists at 5 min.
- 20–40 min · second-line (established SE). Choose one and load: levetiracetam 60 mg/kg IV (max 4500 mg) over 5–15 min, fosphenytoin 20 mg PE/kg IV (max 1500 mg PE) at ≤ 150 mg PE/min with cardiac monitoring, or valproate 40 mg/kg IV (max 3000 mg) over 10 min. Avoid valproate in known/suspected mitochondrial disease (POLG). ESETT showed all three roughly equivalent at first second-line attempt.
- > 40 min · refractory SE → continuous infusion. Intubate. Start continuous EEG. Midazolam infusion 0.2 mg/kg load then 0.05–0.4 mg/kg/h (preferred first-line continuous in children). Alternatives: ketamine 1–2 mg/kg load then 1–10 mg/kg/h (NMDA antagonist; useful when GABAergic resistance), pentobarbital 5 mg/kg load then 1–5 mg/kg/h, or thiopental. Titrate to seizure suppression or burst-suppression on cEEG.
- > 24 h refractory or recurrent on weaning · super-refractory SE. Repeat workup for cause: encephalitis (HSV PCR, autoimmune panel, NMDAR, LGI1, GAD), CNS infection, metabolic, structural (MRI). Add adjuncts: pyridoxine trial in young children, methylprednisolone + IVIG if autoimmune suspected, ketogenic diet (1/3 response in super-refractory pediatric SE), plasma exchange, therapeutic hypothermia 33–34 °C (research-grade), inhalational anaesthetic (last-line, requires ICU-OR setup).
- Wean criteria. 24 h of seizure freedom on cEEG before reducing infusion. Wean adjuncts first (ketamine), then primary infusion (midazolam) over 12–24 h with cEEG vigilance for breakthrough.
Critical points:
- aEEG cannot diagnose NCSE, it can flag (envelope narrowing) but full-montage cEEG is the only diagnostic.
- Time-to-cEEG < 60 min is the pediatric refractoriness target.
- Avoid prolonged propofol infusion in patients < 16 yr, PRIS risk; midazolam, ketamine, or pentobarbital preferred.
- Continue cEEG 24–48 h after seizure cessation to detect re-emergence on weaning.
- Up to 50% of children with controlled motor activity after benzodiazepines have ongoing electrographic seizures, clinical exam alone misses NCSE.
Adapted from ESETT 2019 (pediatric subgroup), ACNS 2021 critical-care EEG terminology, NCS / Brophy 2012 management consensus, AES 2016 guideline, and current pediatric NCS expert recommendations. Pediatric electrographic seizure prevalence in critically ill / unexplained altered consciousness: 10–46% across cohorts (higher in HIE, post-arrest, and acute encephalitis).
7 · Discordance triage, three-step framework
- Confirm both signals. Transducer level / damping / impedance / probe contact. A clean signal disagreeing with a dirty one isn't a discordance, it's artifact.
- Think about what each samples. Most discordances are anatomical: global vs. regional, arterial vs. venous, electrical vs. flow. Knowing what each monitor samples lets you predict what should diverge.
- When physiology and bedside diverge, image. CT or MR anchors physiology to anatomy.
See /integration/discordance-triage/ for worked examples.
8 · Post-arrest prognostication, multimodal timeline
Multimodal anchors over time: aEEG / NIRS / pupillometry early, SSEP / BAER at 72 h after sedation washout, MRI at day 4–7. Convergent abnormality across two or more modalities at 72 h is the strongest pediatric prognostic signal.
9 · "When the kit isn't there"
Available in most PICUs globally:
- Clinical exam, GCS / FOUR / pediatric scales.
- Bedside pupillometer (or a torch and a ruler, note manual pupil size + reactivity).
- Intermittent or fixed TCD; ONSD with a linear probe.
- Bilateral NIRS (most modern PICU monitors integrate).
- Bedside aEEG / reduced-montage EEG.
- Fontanelle US in infants.
Often only at tertiary centres:
- Continuous full-montage cEEG with neurophysiology cover.
- Invasive ICP / PRx / CPPopt with ICM+.
- PbtO₂ probes, microdialysis, brain thermistor.
- DC-coupled ECoG strips, two-depth TCD, Hemedex CBF.
The mental model holds at every level. Use what you have; reason about what each tool samples; do not skip the convergence step.