Continuous EEG in therapeutic hypothermia after cardiac arrest

Crepeau, Amy Z.; Rabinstein, Alejandro A.; Fugate, Jennifer E.; Mandrekar, Jay; Wijdicks, Eelco F. M.; White, Roger D.; Britton, Jeffrey W.

doi:10.1212/wnl.0b013e31827f089d

Cited by 182 publications

(163 citation statements)

References 23 publications

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“…The ideal paradigm for prognosticating neurologic outcomes in comatose cardiac arrest survivors treated with TH is unknown despite several studies that have tried to shed light on this crucial question (12)(13)(14)(15)(16)(17)(18). These studies have several important flaws: a lack of blinding to the results of the prognostic markers being evaluated (13,16,(19)(20)(21)(22), the high proportion of patients who have withdrawal of life-sustaining therapy (WLST) (12,13,19,23), and a lack of understanding regarding the number of patients who die of a true neurologic cause defined brain death as opposed to WLST, cardiac, respiratory, infectious, or other causes.…”

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confidence: 99%

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Mulder

Gibbs

Smith

et al. 2015

Survey of Anesthesiology

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Objectives-To characterize the prevalence of withdrawal of life-sustaining treatment, as well as the time to awakening, short-term neurologic outcomes, and cause of death in comatose survivors of out-of-hospital resuscitated cardiopulmonary arrests treated with therapeutic hypothermia.Design-Single center, prospective observational cohort study of consecutive patients with outof-hospital cardiopulmonary arrests. Setting-Academic HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptPatients-Adults with witnessed, nontraumatic, out-of-hospital cardiopulmonary arrests regardless of initial electrocardiographic rhythm with return of spontaneous circulation who were admitted to an ICU. Interventions-None.Measurements and Main Results-The study cohort included 154 comatose survivors of witnessed out-of-hospital cardiopulmonary arrests who were admitted to an ICU during the 54-month study period. One hundred eighteen patients (77%) were treated with therapeutic hypothermia. The mean age was 59 years, 104 (68%) were men, and 83 (54%) had an initial rhythm of ventricular tachycardia or fibrillation. Only eight of all 78 patients (10%) who died qualified as brain dead; and 81% of all patients (63 of 78) who died did so after withdrawal of lifesustaining treatment. Twenty of 56 comatose survivors (32%) treated with hypothermia who awoke (as defined by Glasgow Motor Score of 6) and had good neurologic outcomes (defined as Cerebral Performance Category 1-2) did so after 72 hours.Conclusions-Our study supports delaying prognostication and withdrawal of life-sustaining treatment to beyond 72 hours in cases treated with therapeutic hypothermia. Larger multicenter prospective studies are needed to better define the most appropriate time frame for prognostication in comatose cardiac arrest survivors treated with therapeutic hypothermia. These data are also consistent with the notion that a majority of out-of-hospital cardiopulmonary arrest survivors die after a decision to withdrawal of life-sustaining treatment and that very few of these survivors progress to brain death. Keywordsbrain death; cardiac arrest; outcome; prognostication; therapeutic hypothermia; withdrawal of lifesustaining treatmentOut-of-hospital cardiopulmonary arrests (OHCA) pose a significant public health burden, with an estimated annual prevalence of over 380,000 arrests evaluated by emergency medical services in the United States alone (1-4). In the decade following the 2002 landmark trials of therapeutic hypothermia (TH) to improve outcomes in comatose cardiac arrest survivors, little additional progress has been made in finding and implementing successful new neuroprotective interventions (5, 6). Therefore, TH remains the only proven neuroprotective strategy available and the focus of the resuscitation community. A number of factors explain this lack of progress: a lack of understanding of the mechanisms and circumstances leading to poor outcomes, lead time and selection biases, as well as funding and ethical co...

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confidence: 99%

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Mulder

Gibbs

Smith

et al. 2015

Survey of Anesthesiology

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“…7 The evidence for cEEG has focused on rates of seizure detection in specific patient populations, 8 and the significance of particular EEG patterns. [9][10][11] Meaningful improvement in patient outcomes has yet to be demonstrated. 12,13 The literature regarding costs, charges, or cost-effectiveness of cEEG is more limited.…”

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Continuous and routine EEG in intensive care

et al. 2013

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Objectives: To evaluate the effect of intensive care unit continuous EEG (cEEG) monitoring on inpatient mortality, hospital charges, and length of stay.Methods: A retrospective cross-sectional study was conducted using the Nationwide Inpatient Sample, a dataset representing 20% of inpatient discharges in nonfederal US hospitals. Adult discharge records reporting mechanical ventilation and EEG (routine EEG or cEEG) were included. cEEG was compared with routine EEG alone in association with the primary outcome of in-hospital mortality and secondary outcomes of total hospital charges and length of stay. Demographics, hospital characteristics, and medical comorbidity were used for multivariate adjustments of the primary and secondary outcomes.Results: A total of 40,945 patient discharges in the weighted sample met inclusion criteria, of which 5,949 had reported cEEG. Mechanically ventilated patients receiving cEEG were younger than routine EEG patients (56 vs 61 years; p , 0.001). There was no difference in the 2 groups in income or medical comorbidities. cEEG was significantly associated with lower in-hospital mortality in both univariate (odds ratio 5 0.54, 95% confidence interval 0.45-0.64; p , 0.001) and multivariate (odds ratio 5 0.63, 95% confidence interval 0.51-0.76; p , 0.001) analyses. There was no significant difference in costs or length of stay for patients who received cEEG relative to those receiving only routine EEG. Sensitivity analysis showed that adjusting for diagnosis-related groups (DRGs) for any neurologic diagnoses, DRGs for neurologic procedures, and specific DRGs for epilepsy/ convulsions did not substantially alter the association of cEEG with reduced inpatient mortality.Conclusions: cEEG is favorably associated with inpatient survival in mechanically ventilated patients, without adding significant charges to the hospital stay. Continuous EEG (cEEG) is increasingly utilized in critically ill patients with abnormal neurologic function. cEEG can detect convulsive and nonconvulsive seizures, brain ischemia, and other disturbances as they occur, prompting adjustment of anticonvulsants 1,2 or interventions to reverse focal ischemia.3,4 For seizures, only cEEG can provide this diagnostic information; for detection of focal ischemia, cEEG may be more sensitive than imaging 5 and gives uninterrupted bedside appraisal. Encephalopathic patients may benefit from cEEG 6 even in the absence of known acute brain injury. 7The evidence for cEEG has focused on rates of seizure detection in specific patient populations, 8 and the significance of particular EEG patterns.9-11 Meaningful improvement in patient outcomes has yet to be demonstrated. 12,13The literature regarding costs, charges, or cost-effectiveness of cEEG is more limited. A singlecenter study showed that cEEG was responsible for only 1% of total hospital charges for From the Departments of Neurology (J.P.N.) and Health Services (L.N.),

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“…[41][42][43] But as seizures may lead to secondary brain injury, treatment of recurrent seizures could be considered as standard therapy in comatose patients with PCAS.…”

Section: Cbf and Metabolismmentioning

confidence: 99%

Critical Care Management Focused on Optimizing Brain Function After Cardiac Arrest

Nakashima

Hifumi

Kawakita

et al. 2017

Circ J

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The discussion of neurocritical care management in post-cardiac arrest syndrome (PCAS) has generally focused on target values used for targeted temperature management (TTM). There has been less attention paid to target values for systemic and cerebral parameters to minimize secondary brain damage in PCAS. And the neurologic indications for TTM to produce a favorable neurologic outcome remain to be determined. Critical care management of PCAS patients is fundamental and essential for both cardiologists and general intensivists to improve neurologic outcome, because definitive therapy of PCAS includes both special management of the cause of cardiac arrest, such as coronary intervention to ischemic heart disease, and intensive management of the results of cardiac arrest, such as ventilation strategies to avoid brain ischemia. We reviewed the literature and the latest research about the following issues and propose practical care recommendations. Issues are (1) prediction of TTM candidate on admission, (2) cerebral blood flow and metabolism and target value of them, (3) seizure management using continuous electroencephalography, (4) target value of hemodynamic stabilization and its method, (5) management and analysis of respiration, (6) sedation and its monitoring, (7) shivering control and its monitoring, and (8) glucose management. We hope to establish standards of neurocritical care to optimize brain function and produce a favorable neurologic outcome.

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Continuous EEG in therapeutic hypothermia after cardiac arrest

Abstract: Grades 1 and 3 on our EEG severity grading scale during TH and NT correlated with outcome. Treating seizures did not improve outcome in our cohort.

Cited by 182 publications

References 23 publications

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Continuous and routine EEG in intensive care

Critical Care Management Focused on Optimizing Brain Function After Cardiac Arrest

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