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Prognosis of neurologic complications in critical illness. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190446 DOI: 10.1016/b978-0-444-63599-0.00041-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Neurologic complications of critical illness require extensive clinical and neurophysiologic evaluation to establish a reliable prognosis. Many sequelae of intensive care unit (ICU) treatment, such as delirium and ICU-acquired weakness, although highly associated with adverse outcomes, are less suitable for prognostication, but should rather prompt clinicians to seek previously unnoticed persisting underlying illnesses. Prognostication can be confounded by drug administration particularly because its clearance is abnormal in critical illness. Some neurological complications are severe, and can last for months or years after discharge from ICU. The most important ethical aspects regarding neurologic complications in critically ill patients are prevention, recognition, and identification, and prevention of self-fulfilling prophecies. This chapter summarizes the tool of prognostication of major neurological complications of critical illness.
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252
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Tsetsou S, Novy J, Pfeiffer C, Oddo M, Rossetti AO. Multimodal Outcome Prognostication After Cardiac Arrest and Targeted Temperature Management: Analysis at 36 °C. Neurocrit Care 2017; 28:104-109. [DOI: 10.1007/s12028-017-0393-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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253
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Taccone FS, Baar I, De Deyne C, Druwe P, Legros B, Meyfroidt G, Ossemann M, Gaspard N. Neuroprognostication after adult cardiac arrest treated with targeted temperature management: task force for Belgian recommendations. Acta Neurol Belg 2017; 117:3-15. [PMID: 28168412 DOI: 10.1007/s13760-017-0755-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/25/2017] [Indexed: 12/27/2022]
Abstract
The prognosis of patients who are admitted to the hospital after cardiac arrest often relies on neurological examination, which could be significantly influenced by the use of sedative drugs or the implementation of targeted temperature management. The need for early and accurate prognostication is crucial as up to 15-20% of patients could be considered as having a poor outcome and may undergo withdrawal of life-sustaining therapies while a complete neurological recovery is still possible. As current practice in Belgium is still based on a very early assessment of neurological function in these patients, the Belgian Society of Intensive Care Medicine created a multidisciplinary Task Force to provide an optimal approach for monitoring and refine prognosis of CA survivors. This Task Force underlined the importance to use a multimodal approach using several additional tools (e.g., electrophysiological tests, neuroimaging, biomarkers) and to refer cases with uncertain prognosis to specialized centers to better evaluate the extent of brain injury in these patients.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Ingrid Baar
- Department of Neurology, Antwerp University Hospital, 2650, Edegem, Belgium
| | - Cathy De Deyne
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg ZOL, Schiepse Bos 6, 3600, Genk, Belgium
| | - Patrick Druwe
- Department of Intensive Care, Ghent University Hospital, De Pintelaan, 185, 9000, Ghent, Belgium
| | - Benjamin Legros
- Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Geert Meyfroidt
- Department of Intensive Care, UZ Leuven, Herestraat 49, box 7003 63, 3000, Leuven, Belgium
| | - Michel Ossemann
- Department of Neurology, CHU UCL Namur, Université Catholique de Louvain, Avenue Gaston Thérasse, 1, 5530, Yvoir, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
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254
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Excellent neurologic recovery after prolonged coma in a cardiac arrest patient with multiple poor prognostic indicators. Resuscitation 2017; 113:e11-e12. [PMID: 28189599 DOI: 10.1016/j.resuscitation.2017.01.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 01/23/2017] [Accepted: 01/27/2017] [Indexed: 11/24/2022]
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255
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Zubler F, Steimer A, Kurmann R, Bandarabadi M, Novy J, Gast H, Oddo M, Schindler K, Rossetti AO. EEG synchronization measures are early outcome predictors in comatose patients after cardiac arrest. Clin Neurophysiol 2017; 128:635-642. [PMID: 28235724 DOI: 10.1016/j.clinph.2017.01.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/22/2017] [Accepted: 01/24/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Outcome prognostication in comatose patients after cardiac arrest (CA) remains a major challenge. Here we investigated the prognostic value of combinations of linear and non-linear bivariate EEG synchronization measures. METHODS 94 comatose patients with EEG within 24h after CA were included. Clinical outcome was assessed at 3months using the Cerebral Performance Categories (CPC). EEG synchronization between the left and right parasagittal, and between the frontal and parietal brain regions was assessed with 4 different quantitative measures (delta power asymmetry, cross-correlation, mutual information, and transfer entropy). 2/3 of patients were used to assess the predictive power of all possible combinations of these eight features (4 measures×2 directions) using cross-validation. The predictive power of the best combination was tested on the remaining 1/3 of patients. RESULTS The best combination for prognostication consisted of 4 of the 8 features, and contained linear and non-linear measures. Predictive power for poor outcome (CPC 3-5), measured with the area under the ROC curve, was 0.84 during cross-validation, and 0.81 on the test set. At specificity of 1.0 the sensitivity was 0.54, and the accuracy 0.81. CONCLUSION Combinations of EEG synchronization measures can contribute to early prognostication after CA. In particular, combining linear and non-linear measures is important for good predictive power. SIGNIFICANCE Quantitative methods might increase the prognostic yield of currently used multi-modal approaches.
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Affiliation(s)
- Frédéric Zubler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Andreas Steimer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rebekka Kurmann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mojtaba Bandarabadi
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Novy
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Heidemarie Gast
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mauro Oddo
- Department of Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kaspar Schindler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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256
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The Benefit of Neuromuscular Blockade in Patients with Postanoxic Myoclonus Otherwise Obscuring Continuous Electroencephalography (CEEG). Crit Care Res Pract 2017; 2017:2504058. [PMID: 28265468 PMCID: PMC5317108 DOI: 10.1155/2017/2504058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/08/2017] [Accepted: 01/18/2017] [Indexed: 12/04/2022] Open
Abstract
Introduction. Myoclonus status epilepticus is independently associated with poor outcome in coma patients after cardiac arrest. Determining if myoclonus is of cortical origin on continuous electroencephalography (CEEG) can be difficult secondary to the muscle artifact obscuring the underlying CEEG. The use of a neuromuscular blocker can be useful in these cases. Methods. Retrospective review of CEEG in patients with postanoxic myoclonus who received cisatracurium while being monitored. Results. Twelve patients (mean age: 53.3 years; 58.3% male) met inclusion criteria of clinical postanoxic myoclonus. The initial CEEG patterns immediately prior to neuromuscular blockade showed myoclonic artifact with continuous slowing (50%), burst suppression with myoclonic artifact (41.7%), and continuous myogenic artifact obscuring CEEG (8.3%). After intravenous administration of cisatracurium (0.1 mg–2 mg), reduction in artifact improved quality of CEEG recordings in 9/12 (75%), revealing previously unrecognized patterns: continuous EEG seizures (33.3%), lateralizing slowing (16.7%), burst suppression (16.7%), generalized periodic discharges (8.3%), and, in the patient who had an initially uninterpretable CEEG from myogenic artifact, continuous slowing. Conclusion. Short-acting neuromuscular blockade is useful in determining background cerebral activity on CEEG otherwise partially or completely obscured by muscle artifact in patients with postanoxic myoclonus. Fully understanding background cerebral activity is important in prognostication and treatment, particularly when there are underlying EEG seizures.
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257
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Fantaneanu TA, Sarkis R, Avery K, Scirica BM, Hurwitz S, Henderson GV, Lee JW. Delayed Deterioration of EEG Background Rhythm Post-cardiac Arrest. Neurocrit Care 2016; 26:411-419. [DOI: 10.1007/s12028-016-0355-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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258
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Amorim E, Rittenberger JC, Zheng JJ, Westover MB, Baldwin ME, Callaway CW, Popescu A. Continuous EEG monitoring enhances multimodal outcome prediction in hypoxic-ischemic brain injury. Resuscitation 2016; 109:121-126. [PMID: 27554945 PMCID: PMC5124407 DOI: 10.1016/j.resuscitation.2016.08.012] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 07/17/2016] [Accepted: 08/03/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Hypoxic brain injury is the largest contributor to disability and mortality after cardiac arrest. We aim to identify electroencephalogram (EEG) characteristics that can predict outcome on cardiac arrest patients treated with targeted temperature management (TTM). METHODS We retrospectively examined clinical, EEG, functional outcome at discharge, and in-hospital mortality for 373 adult subjects with return of spontaneous circulation after cardiac arrest. Poor outcome was defined as a Cerebral Performance Category score of 3-5. Pure suppression-burst (SB) was defined as SB not associated with status epilepticus (SE), seizures, or generalized periodic discharges. RESULTS In-hospital mortality was 68.6% (N=256). Presence of both unreactive EEG background and SE was associated with a positive predictive value (PPV) of 100% (95% confidence interval: 0.96-1) and a false-positive rate (FPR) of 0% (95% CI: 0-0.11) for poor functional outcome. A prediction model including demographics data, admission exam, presence of status epilepticus, pure SB, and lack of EEG reactivity had an area under the curve of 0.92 (95% CI: 0.87-0.95) for poor functional outcome prediction, and 0.96 (95% CI: 0.94-0.98) for in-hospital mortality. Presence of pure SB (N=87) was confounded by anesthetics use in 83.9% of the cases, and was not an independent predictor of poor functional outcome, having a FPR of 23% (95% CI: 0.19-0.28). CONCLUSIONS An unreactive EEG background and SE predicted poor functional outcome and in-hospital mortality in cardiac arrest patients undergoing TTM. Prognostic value of pure SB is confounded by use of sedative agents, and its use on prognostication decisions should be made with caution.
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Affiliation(s)
- Edilberto Amorim
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Julia J Zheng
- Department of Neurosciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Maria E Baldwin
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandra Popescu
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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259
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Rush B, Ashkanani M, Romano K, Hertz P. Utilization of electroencephalogram post cardiac arrest in the United States: A nationwide retrospective cohort analysis. Resuscitation 2016; 110:141-145. [PMID: 27886947 DOI: 10.1016/j.resuscitation.2016.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 08/14/2016] [Accepted: 11/07/2016] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The use of electroencephalogram (EEG) has been demonstrated to have diagnostic and prognostic value in cardiac arrest patients. The use of this modality across the United States in this population is unknown. METHODS The Nationwide Inpatient Sample (NIS) is a federal database capturing 20% of all US hospital admissions. A cohort of patients who suffered both in and out of hospital cardiac arrests from the 2006 to 2012 NIS datasets was created. RESULTS The records of 55,208,382 hospitalizations were analyzed, of which 207,703 patients suffered a cardiac arrest. There were 2952 (1.42%) patients who also had an EEG. Patients who had an EEG compared to those who did not were: younger (62.2 years SD 16.6 vs 66.9 years SD 16.2, p<0.01), were less likely to have insurance coverage (89.9% vs 91.6%, p=0.03) and had significantly longer length of stay (8.6days IQR 3.7-17.1 vs 4.1days IQR 1.0-10.5, p<0.01). Patients treated at urban teaching hospitals were more likely to receive an EEG than patients treated at urban non-teaching and rural hospitals (p<0.01). The rate of EEG in survivors of cardiac arrest increased from 1.03% in 2006 to 2.16% in 2012, a relative increase of 110% (p<0.02). The median time to performance of an EEG was 1.6days IQR 0.33-4.53 days. CONCLUSION EEG is performed on approximately 2% of patients who suffer cardiac arrest in the United States. The treatment hospital and patient characteristics of those who received an EEG different from those who did not.
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Affiliation(s)
- Barret Rush
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC V5Z 1M9, Canada; Harvard T.H. Chan School of Public Health, Harvard University, 677 Huntington Ave., Boston, MA 02115, USA.
| | - Mohammad Ashkanani
- Division of Epilepsy, Department of Neurology, University of British Columbia, Vancouver, BC, Canada.
| | - Kali Romano
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC V5Z 1M9, Canada; Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
| | - Paul Hertz
- Division of General Internal Medicine, Department of Medicine, University Health Network, Toronto, Ontario, Canada.
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260
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Cold But Not Dead: The Role of EEG in Predicting the Outcome After Cardiac Arrest. Epilepsy Curr 2016; 16:389-390. [PMID: 27857619 DOI: 10.5698/1535-7511-16.6.389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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261
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Vanhatalo S. Testing brains with burst suppressions. Clin Neurophysiol 2016; 127:2919-2920. [PMID: 27212117 DOI: 10.1016/j.clinph.2016.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/23/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Sampsa Vanhatalo
- Department of Clinical Neurophysiology, HUS Medical Imaging, University of Helsinki and Helsinki University Hospital, Finland. http://www.babacenter.fi
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262
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Cortical somatosensory evoked high-frequency (600Hz) oscillations predict absence of severe hypoxic encephalopathy after resuscitation. Clin Neurophysiol 2016; 127:2561-9. [PMID: 27291874 DOI: 10.1016/j.clinph.2016.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/09/2016] [Accepted: 04/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Following cardiac arrest (CA), hypoxic encephalopathy (HE) frequently occurs and hence reliable neuroprognostication is crucial to decide on the extent of intensive care. Several investigations predict severe HE leading to persistent unresponsive wakefulness or death, with high specificity. Only few studies attempted to predict absence of severe HE. Cortical somatosensory evoked high-frequency (600Hz) oscillation (HFO) bursts indicate the presence of highly synchronized spiking activity in the primary somatosensory cortex. Since global neuronal damage characterizes severe HE preserved cortical HFOs may early exclude severe HE. METHODS We determined amplitudes of early and late HFO bursts in 302 comatose CA patients after median nerve somatosensory evoked potential (SSEPs) and clinical outcome upon intensive care unit discharge using the cerebral performance category (CPC) scale. RESULTS We detected significant early HFO bursts in 146 patients and late HFO bursts in 95 patients. Only one of 27 unresponsive wakefulness patients had a late HFO burst amplitude above 70nV and all seventeen patients who died despite higher amplitudes died from non-neurological causes. CONCLUSIONS High-frequency SSEP components can reliably be studied in comatose CA patients using standard equipment. SIGNIFICANCE Late HFO burst amplitudes above 70nV largely exclude severe HE incompatible with regaining consciousness.
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