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The role of continuous EEG in therapeutic hypothermia

The role of continuous EEG in therapeutic hypothermia. Esther L. Young, D.O. Oakland Neurology Center September 27, 2013. Role of EEG. EEG has been used to assist in determining prognosis following cardiac arrest since the 1960s.

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The role of continuous EEG in therapeutic hypothermia

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  1. The role of continuous EEG in therapeutic hypothermia Esther L. Young, D.O. Oakland Neurology Center September 27, 2013

  2. Role of EEG • EEG has been used to assist in determining prognosis following cardiac arrest since the 1960s. • EEG rating scale can predict neurologic outcome with an accuracy of 80% • Malignant EEG patterns: myoclonus with EEG correlate, a nonreactive background, burst suppression and status epilepticus • Better prognosis: diffuse slow-wave activity

  3. Therapeutic hypothermia • Therapeutic hypothermia has been shown to improve neurologic outcome after out-of-hospital cardiac arrest due to ventricular fibrillation and is the standard of care. • Protective hypothermia lowers a patient’s body temperature in order to help reduce the risk of ischemic injury to tissue following a period of insufficient blood flow

  4. Seizures • Hypothermia has antiepileptic effects, yet seizures in cardiac arrest patients can occur despite therapeutic hypothermia. • The risk of seizures may increase during rewarming • Continuous EEG monitoring has been recommended during therapeutic hypothermia to provide prognostic information and monitor for subclinical seizures and nonconvulsive status epilepticus • Seizures and nonconvulsive status epilepticus have been reported at a rate of 10-12% and have been shown to be an independent risk factor for mortality

  5. EEG grading system for cEEG findings following cardiac arrest • Mild (grade 1) • Excess beta, theta slowing, anesthetic pattern • Moderate (grade 2) • Diffuse or focal delta slowing, SIRPIDS, ELAE, spindle coma, interictalepileptiform discharges, generalized triphasic waves, FIRDA, TIRDA, OIRDA, PLED • Severe (grade 3) • Burst suppression pattern, low voltage outpt pattern, alpha/theta coma, focal or generalized seizures, nonreactive to stimuli, GPED, status epilepticus

  6. FIRDA

  7. PLED

  8. Triphasic waves

  9. Burst suppression

  10. Alpha coma

  11. GPED

  12. Continuous EEG in therapeutic hypothermia after cardiac arrest • Retrospective study of all patients undergoing cEEG with hypothermia after cardiac arrest • Evaluate the prognostic significance of EEG abnormalities occurring during the course of therapeutic hypothermia and warming. • Used the EEG grading system • 54 patients treated under TH protocol included • Cooled for 24 hours • cEEG monitoring initiated after hypothermia established and continued until normothermia for a minimum of 2 hours

  13. EEG grade during 3 stages of therapeutic hypothermia • EEG TH rewarmingnormothermia grade 1 11% 13% 26% 2 56% 57% 43% 3 33% 30% 21%

  14. Results • Good neurologic outcome at hospital discharge was seen in 33 (61%) patients. • A total of 21 (39%) had a poor neurologic outcome • 19 (35%) died during the hospitalization • EEG severity during TH and NT had a strong association with neurologic outcome • A grade 3 EEG during TH and NT correlated with poor neurologic outcome • Of patients with a poor neurologic outcome, the majority (16/21) showed a grade 3 pattern during TH and 16/19 patients who died had a grade 3 EEG • None of the patients with seizures or status epilepticus achieved good outcome despite treatment

  15. Results • There was a trend favoring an association between the evolution of the EEG background during TH and prognosis • 9 patients showed improvement in EEG severity grade after rewarming • 8 had a good outcome • Of the 4 patients with worsening of the EEG, 3 had a poor outcome • The 3 showing worsening to a grade 3 EEG pattern died • The patient showing progressing to a maximum severity of grade 2 had a good recovery

  16. Discussion • EEG abnormalities graded as severe based on the EEG severity grading system were associated with poor outcome • A benign EEG (grade 1) during hypothermia and NT uniformly predicted good recovery • Moderate EEG severity (grade 2) showed less predictive value • The change of cEEG findings during the course of TH-rewarming-NT tended to mirror functional outcome • ¾ of patients had the same EEG grade through TH-rewarming-NT

  17. Discussion • EEG findings were one of several facotrs used to estimate prognosis and were never considered in isolation • Small cohort size • Is “spot-check” EEG as good as cEEG? (majority of patients did not have a change in grade of EEG) • Clear benefit from aggressively treating identified seizures needs to be established if cEEG is to be recommended for the indication of seizure detection in this population

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