Continuous Electroencephalogram in Comatose Postcardiac Arrest Syndrome Patients Treated With Therapeutic Hypothermia

Abstract

Purpose:

Therapeutic Hypothermia (TH) is the only therapeutic intervention proven to significantly improve survival and neurologic outcome in comatose postcardiac arrest patients and is now considered standard of care. When we discuss prognostication with regard to comatose survivors postcardiac arrest, we should look for tools that are both reliable and accurate and that achieve a false-positive rate (FPR) equal to or very closely approaching zero.

Methods:

We retrospectively reviewed data that were prospectively collected on all cardiac arrest patients admitted to our ICU. Continuous electroencephalogram (cEEG) monitoring was performed as part of our protocol for therapeutic hypothermia in comatose postcardiac arrest patients. The primary outcome measure was the best score on hospital discharge on the 5-point Glasgow-Pittsburgh cerebral performance category (CPC) scores.

Results:

A total of 58 patients were included in this study. Twenty five (43%) patients had a good neurologic outcome (CPC score of 1-2). Three (5.2%) patients had nonconvulsive status epilepticus, all of whom had poor outcome (CPC = 5). Seventeen (29%) patients had burst suppression (BS); all had poor outcome. Both nonconvuslsive seizures (NCS) and BS had a specificity of 100% (95% confidence interval [CI], 84%-100%), positive predictive values of 100% (95% CI, 31%-100%), and 100% (95% CI, 77%-100%), respectively. Both NCS and BS had FPRs of zero (95% CI, 0.0-0.69, and 0.0-0.23, respectively).

Conclusions:

In comatose postcardiac arrest patients treated with hypothermia, EEG during the maintenance and rewarming phase of hypothermia can contribute to prediction of neurologic outcome. Pending large multicenter prospective studies evaluating the role of cEEG in prognostication, our study adds to the existing evidence that cEEG can play a potential role in prediction of outcome in postcardiac arrest patients treated with hypothermia.

Keywords

coma cardiac arrest prognostication EEG electroencephalogram continuous EEG therapeutic hypothermia

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References

Stiell

Wells

Field

. Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med. 2004;351(7):647–656.

Keenan

Dodek

Martin

Priestap

Norena

Wong

. Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are. Crit Care Med. 2007;35(3):836–841.

Mashiko

Otsuka

Shimazaki

. An outcome study of out-of-hospital cardiac arrest using the Utstein template: a Japanese experience. Resuscitation. 2002;55(3):241–246.

Nolan

Laver

Welch

Harrison

Gupta

Rowan

. Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC case mix programme database. Anaesthesia. 2007;62(12):1207–1216.

Langhelle

Tyvold

Lexow

Hapnes

Sunde

Steen

. In-hospital factors associated with improved outcome after out-ofhospital cardiac arrest: a comparison between four regions in Norway. Resuscitation. 2003;56(3):247–263.

Herlitz

Engdahl

Svensson

Angquist

Silfverstolpe

Holmberg

. Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest. Resuscitation. 2006;70(3):404–409.

Neumar

Nolan

Adrie

. Post– cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication: a consensus statement from the international Liaison committee on resuscitation (American heart association, Australian and New Zealand council on resuscitation, European resuscitation council, heart and stroke foundation of Canada, InterAmerican heart foundation, resuscitation council of Asia, and the resuscitation council of Southern Africa); the American heart association emergency cardiovascular care committee; the council on cardiovascular surgery and anesthesia; the council on cardiopulmonary, perioperative, and critical care; the council on clinical cardiology; and the stroke council. Circulation. 2008;118(23):2452–2483.

Eisenberg

Mengert

. Cardiac resuscitation. N Engl J Med. 2001;334(17):1304–1313.

Bunch

White

Smith

. Long-term subjective memory function in ventricular fibrillation out-of-hospital cardiac arrest survivors resuscitated by early defibrillation. Resuscitation. 2004;60(2):189–195.

10.

Laver

Farrow

Turner

Nolan

. Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med. 2004;30(11):2126–2128.

11.

Jacobs

Nadkarni

Bahr

. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the international Liaison committee on resuscitation (American heart association, European resuscitation council, Australian resuscitation council, New Zealand resuscitation council, Heart and stroke foundation of Canada, InterAmerican heart foundation, resuscitation council of Southern Africa). Resuscitation. 2004;63(3):233–249.

12.

Peberdy

Callaway

Neumar

. Part 9: post– cardiac arrest care: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122 (suppl 3):S768–S786.

13.

Sunde

Pytte

Jacobsen

. Implementation of a standardized treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation. 2007;73(1):29–39.

14.

Rundgren

Rosen

Fribert

. Amplitude integrated EEG (aEEG) predicts outcome after ardiac arrest and induced hypothermia. Intensive Care Med. 2006;32(6):836–842.

15.

Legriel

Bruneel

Sediri

. Early EEG monitoring for detecting postanoxic status epilepticus during therapeutic hypothermia: a pilot study. Neurocrit Care. 2009;11(3):383–344.

16.

Rossetti

Oddo

Liaudet

Kaplan

. Predictors of awakening from postanoxic status epilepticus after therapeutic hypothermia. Neurology. 2009;72(8):744–749.

17.

Oddo

Rossetti

. Predicting neurological outcome after cardiac arrest. Curr Opin Crit Care. 2011;17(3):254–259.

18.

Ely

Truman

Shintani

. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond agitation-sedation scale (RASS). JAMA. 2003;289(22):2983–2991.

19.

Cummins

Chamberlain

Abramson

. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. a statement for health professionals from a task force of the American heart association, the European resuscitation council, the Heart and stroke foundation of Canada, and the Australian resuscitation council. Circulation. 1991;84(2):960–975.

20.

The Hypothermia After Cardiac Arrest (HACA) study group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346(8):549–556.

21.

Bernard

Gray

Buist

. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346(8):557–563.

22.

Van der Wal

Brinkman

Bisschops

. Influence of mild therapeutic hypothermia after cardiac arrest on hospital mortality. Crit Care Med. 2011;39(1):84–88.

23.

Cloostermans

van Meulen

Eertman

Hom

van Putten

. Continuous electroencephalography monitoring for early prediction of neurological outcome in postanoxic patients after cardiac arrest: a prospective cohort study. Crit Care Med. 2012;40(10):2867–2875.

24.

Rittenberger

Popescu

Brenner

Guyette

Callaway

. Frequency and timing of nonconvulsive status epilepticus in comatose post-cardiac arrest subjects treated with hypothermia. Neurocrit Care. 2012;16(1):114–22.

25.

Wijdicks

Hijdra

Young

Bassetti

Wiebe

Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the quality standards subcommittee of the American academy of neurology. Neurology. 2006;67(2):203–210.

26.

Rossetti

Urbano

Delodder

Kaplan

Oddo

. Prognostic value of continuous EEG monitoring during therapeutic hypothermia after cardiac arrest. Crit Care. 2010;14(5):R173.

27.

Crepeau

Rabinstein

Fugate

. Continuous EEG in therapeutic hypothermia after cardiac arrest: prognostic and clinical value. Neurology. 2013;80(4):339–344.

28.

Phelps

Dumas

Maynard

Silver

Rea

. Cerebral Performance Category and long-term prognosis following out-of-hospital cardiac arrest. Crit Care Med. 2013;41(5):1252–1257.