Prevalence of Seizures in Pediatric Extracorporeal Membrane Oxygenation Patients as Measured by Continuous Electroencephalography

Abstract

Objectives: Standards for neuromonitoring during extracorporeal membrane oxygenation support do not currently exist, and there is wide variability in practice. We present our institutional experience at an academic children’s hospital since establishment of a continuous electroencephalography monitoring protocol for extracorporeal membrane oxygenation patients. Design: Retrospective, single-center study. Setting: Neonatal ICU and PICU in an urban, quaternary care center. Patients: All neonatal and pediatric patients requiring extracorporeal membrane oxygenation. Interventions: None. Measurements and Main Results: During the study period, 70 patients were cannulated for extracorporeal membrane oxygenation and had continuous electroencephalography monitoring for greater than 24 hours. Electroencephalographic seizures were observed in 16 of 70 patients (23%), including five patients (7%) who were in status epilepticus. Among patients with continuous electroencephalography seizures, nine (56%) had subclinical nonconvulsive status epilepticus and eight (50%) had seizures in the initial 24 hours of extracorporeal membrane oxygenation support. Survival to hospital discharge was significantly greater for extracorporeal membrane oxygenation patients without seizures (74% vs 44%; p = 0.02). Conclusions: Seizures occur in a significant proportion of pediatric and neonatal extracorporeal membrane oxygenation patients, frequently in the initial 24 hours after extracorporeal membrane oxygenation cannulation. Because seizures are associated with significantly decreased survival, neuromonitoring early in the extracorporeal membrane oxygenation course is important and useful. Further studies are needed to correlate electroencephalography findings with neurologic outcome.

EEG is A Predictor of Neuroimaging Abnormalities in Pediatric Extracorporeal Membrane Oxygenation

“…In our study seizures occurred in 12 of the 50 patients (24%) which is similar to other studies. Three recent studies using continuous EEG monitoring have demonstrated that the risk for seizures in ECMO patients is substantial, with seizures detected in 18%-23% of children and 50%-83% of those having electrographic only seizures [2,16,24]. Our study further supports the indication for long-term EEG monitoring of these patients due to the high risk for electrographic only seizures.…”

“…Cannulation of the major vessels has a greater risk of ischemic and thromboembolic events which may account for higher neurologic injuries with VA ECMO [22,23]. However, single-center studies in both neonatal and pediatric patients have not found differences between VA, VV ECMO, and occurrence of seizures during EEG [16]. Our results may have been influenced by the fact that more than 70% of our patients were on VA ECMO.…”

“…The severity of EEG abnormalities during ECMO that corresponded with severity of neuroimaging abnormalities has been partly supported in recent studies where seizures during EEG were linked to brain hemorrhage and brain injury [2,16,17]. A prior study where only a combination of HUS and EEG was highly predictive of abnormal neuroimaging findings may be secondary to the use of routine EEG, as opposed to LTM, lack of scoring system for neuroimaging abnormalities, and proximity of neuroimaging to the ECMO run [18].…”

Neurologic Complications and Neuromonitoring on ECMO

“…A study of children and neonates undergoing ECMO revealed that 18% of patients had electrographic seizures, with 61% of those patients having electrographic status epilepticus and 83% having exclusively electrographic seizures [39]. Another recent study of neonatal and pediatric patients found electrographic seizures in 23% of their patients, especially within the first 24 hours of ECMO [40]. Patients with seizures had decreased survival to discharge (44% versus 74%).…”

Population Pharmacokinetics of Phenobarbital in Neonates and Infants on Extracorporeal Membrane Oxygenation and the Influence of Concomitant Renal Replacement Therapy

“…[10][11][12] Electrographic seizures are common in neonates and children undergoing extracorporeal membrane oxygenation (ECMO) and are associated with poor shortand long-term outcomes. 13,14 There are limited data to guide optimal dosing of antiseizure medications in pediatric patients undergoing ECMO, including disposition in critically ill children on ECMO. 16 Therefore, dosing adjustment may be needed.…”