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Mazzio EL, Topjian AA, Reeder RW, Sutton RM, Morgan RW, Berg RA, Nadkarni VM, Wolfe HA, Graham K, Naim MY, Friess SH, Abend NS, Press CA. Association of EEG characteristics with outcomes following pediatric ICU cardiac arrest: A secondary analysis of the ICU-RESUScitation trial. Resuscitation 2024; 201:110271. [PMID: 38866233 DOI: 10.1016/j.resuscitation.2024.110271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/27/2024] [Accepted: 06/05/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND AND OBJECTIVES There are limited tools available following cardiac arrest to prognosticate neurologic outcomes. Prior retrospective and single center studies have demonstrated early EEG features are associated with neurologic outcome. This study aimed to evaluate the prognostic value of EEG for pediatric in-hospital cardiac arrest (IHCA) in a prospective, multicenter study. METHODS This cohort study is a secondary analysis of the ICU-Resuscitation trial, a multicenter randomized interventional trial conducted at 18 pediatric and pediatric cardiac ICUs in the United States. Patients who achieved return of circulation (ROC) and had post-ROC EEG monitoring were eligible for inclusion. Patients < 90 days old and those with pre-arrest Pediatric Cerebral Performance Category (PCPC) scores > 3 were excluded. EEG features of interest included EEG Background Category, and presence of focal abnormalities, sleep spindles, variability, reactivity, periodic and rhythmic patterns, and seizures. The primary outcome was survival to hospital discharge with favorable neurologic outcome. Associations between EEG features and outcomes were assessed with multivariable logistic regression. Prediction models with and without EEG Background Category were developed and receiver operator characteristic curves compared. RESULTS Of the 1129 patients with an index cardiac arrest who achieved ROC in the parent study, 261 had EEG within 24 h of ROC, of which 151 were evaluable. The cohort included 57% males with a median age of 1.1 years (IQR 0.4, 6.8). EEG features including EEG Background Category, sleep spindles, variability, and reactivity were associated with survival with favorable outcome and survival, (all p < 0.001). The addition of EEG Background Category to clinical models including age category, illness category, PRISM score, duration of CPR, first documented rhythm, highest early post-arrest arterial lactate improved the prediction accuracy achieving an AUROC of 0.84 (CI 0.77-0.92), compared to AUROC of 0.76 (CI 0.67-0.85) (p = 0.005) without EEG Background Category. CONCLUSION This multicenter study demonstrates the value of EEG, in the first 24 h following ROC, for predicting survival with favorable outcome after a pediatric IHCA.
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Affiliation(s)
- Emma L Mazzio
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Stuart H Friess
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Craig A Press
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Massey SL, Weinerman B, Naim MY. Perioperative Neuromonitoring in Children with Congenital Heart Disease. Neurocrit Care 2024; 40:116-129. [PMID: 37188884 DOI: 10.1007/s12028-023-01737-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
Although neonates and children with congenital heart disease are primarily hospitalized for cardiac and pulmonary diseases, they are also at an increased risk for neurologic injury due to both empiric differences that can exist in their nervous systems and acquired injury from cardiopulmonary pathology and interventions. Although early efforts in care focused on survival after reparative cardiac surgery, as surgical and anesthetic techniques have evolved and survival rates accordingly improved, the focus has now shifted to maximizing outcomes among survivors. Children and neonates with congenital heart disease experience seizures and poor neurodevelopmental outcomes at a higher rate than age-matched counterparts. The aim of neuromonitoring is to help clinicians identify patients at highest risk for these outcomes to implement strategies to mitigate these risks and to also help with neuroprognostication after an injury has occurred. The mainstays of neuromonitoring are (1) electroencephalographic monitoring to evaluate brain activity for abnormal patterns or changes and to identify seizures, (2) neuroimaging to reveal structural changes and evidence of physical injury in and around the brain, and (3) near-infrared spectroscopy to monitor brain tissue oxygenation and detect changes in perfusion. This review will detail the aforementioned techniques and their use in the care of pediatric patients with congenital heart disease.
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Affiliation(s)
- Shavonne L Massey
- Division of Neurology, Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - Bennett Weinerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbia University Irving Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Maryam Y Naim
- Division of Cardiac Critical Care Medicine, Department of Anesthesiology, Critical Care Medicine, and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Waak M, Laing J, Nagarajan L, Lawn N, Harvey AS. Continuous electroencephalography in the intensive care unit: A critical review and position statement from an Australian and New Zealand perspective. CRIT CARE RESUSC 2023; 25:9-19. [PMID: 37876987 PMCID: PMC10581281 DOI: 10.1016/j.ccrj.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objectives This article aims to critically review the literature on continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU) from an Australian and New Zealand perspective and provide recommendations for clinicians. Design and review methods A taskforce of adult and paediatric neurologists, selected by the Epilepsy Society of Australia, reviewed the literature on cEEG for seizure detection in critically ill neonates, children, and adults in the ICU. The literature on routine EEG and cEEG for other indications was not reviewed. Following an evaluation of the evidence and discussion of controversial issues, consensus was reached, and a document that highlighted important clinical, practical, and economic considerations regarding cEEG in Australia and New Zealand was drafted. Results This review represents a summary of the literature and consensus opinion regarding the use of cEEG in the ICU for detection of seizures, highlighting gaps in evidence, practical problems with implementation, funding shortfalls, and areas for future research. Conclusion While cEEG detects electrographic seizures in a significant proportion of at-risk neonates, children, and adults in the ICU, conferring poorer neurological outcomes and guiding treatment in many settings, the health economic benefits of treating such seizures remain to be proven. Presently, cEEG in Australian and New Zealand ICUs is a largely unfunded clinical resource that is subsequently reserved for the highest-impact patient groups. Wider adoption of cEEG requires further research into impact on functional and health economic outcomes, education and training of the neurology and ICU teams involved, and securement of the necessary resources and funding to support the service.
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Affiliation(s)
- Michaela Waak
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Joshua Laing
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Comprehensive Epilepsy Program, Alfred Health, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, Perth, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Australia
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Sir Charles Gardiner Hospital, Perth, Australia
| | - A. Simon Harvey
- Department of Neurology, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Neurosciences Research Group, Murdoch Children's Research Institute, Melbourne, Australia
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The Role of Electroencephalography in the Prognostication of Clinical Outcomes in Critically Ill Children: A Review. CHILDREN 2022; 9:children9091368. [PMID: 36138677 PMCID: PMC9497701 DOI: 10.3390/children9091368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022]
Abstract
Electroencephalography (EEG) is a neurologic monitoring modality that allows for the identification of seizures and the understanding of cerebral function. Not only can EEG data provide real-time information about a patient’s clinical status, but providers are increasingly using these results to understand short and long-term prognosis in critical illnesses. Adult studies have explored these associations for many years, and now the focus has turned to applying these concepts to the pediatric literature. The aim of this review is to characterize how EEG can be utilized clinically in pediatric intensive care settings and to highlight the current data available to understand EEG features in association with functional outcomes in children after critical illness. In the evaluation of seizures and seizure burden in children, there is abundant data to suggest that the presence of status epilepticus during illness is associated with poorer outcomes and a higher risk of mortality. There is also emerging evidence indicating that poorly organized EEG backgrounds, lack of normal sleep features and lack of electrographic reactivity to clinical exams portend worse outcomes in this population. Prognostication in pediatric critical illness must be informed by the comprehensive evaluation of a patient’s clinical status but the utilization of EEG may help contribute to this assessment in a meaningful way.
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Hordijk JA, Verbruggen SC, Buysse CM, Utens EM, Joosten KF, Dulfer K. Neurocognitive functioning and health-related quality of life of children after pediatric intensive care admission: a systematic review. Qual Life Res 2022; 31:2601-2614. [PMID: 35357629 PMCID: PMC9356943 DOI: 10.1007/s11136-022-03124-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study systematically reviewed recent findings on neurocognitive functioning and health-related quality of life (HRQoL) of children after pediatric intensive care unit admission (PICU). DATA SOURCES Electronic databases searched included Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar. The search was limited to studies published in the last five years (2015-2019). STUDY SELECTION Original studies assessing neurocognitive functioning or HRQoL in children who were previously admitted to the PICU were included in this systematic review. DATA EXTRACTION Of the 3649 identified studies, 299 met the inclusion criteria based on title abstract screening. After full-text screening, 75 articles were included in the qualitative data reviewing: 38 on neurocognitive functioning, 33 on HRQoL, and 4 on both outcomes. DATA SYNTHESIS Studies examining neurocognitive functioning found overall worse scores for general intellectual functioning, attention, processing speed, memory, and executive functioning. Studies investigating HRQoL found overall worse scores for both physical and psychosocial HRQoL. On the short term (≤ 12 months), most studies reported HRQoL impairments, whereas in some long-term studies HRQoL normalized. The effectiveness of the few intervention studies during and after PICU admission on long-term outcomes varied. CONCLUSIONS PICU survivors have lower scores for neurocognitive functioning and HRQoL than children from the general population. A structured follow-up program after a PICU admission is needed to identify those children and parents who are at risk. However, more research is needed into testing interventions in randomized controlled trials aiming on preventing or improving impairments in critically ill children during and after PICU admission.
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Affiliation(s)
- José A Hordijk
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - Sascha C Verbruggen
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - Corinne M Buysse
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - Elisabeth M Utens
- Research Institute of Child Development and Education, University of Amsterdam, Nieuwe Achtergracht 127, 1018 WS, Amsterdam, The Netherlands.,Academic Center for Child Psychiatry the Bascule/Department of Child and Adolescent Psychiatry, Academic Medical Center, Rijksstraatweg 145, 1115 AP, Amsterdam, The Netherlands.,Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC - Sophia Children's Hospital, Wytemaweg 8, 3015 CN, Rotterdam, The Netherlands
| | - Koen F Joosten
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - Karolijn Dulfer
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
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Ko MSM, Poh PF, Heng KYC, Sultana R, Murphy B, Ng RWL, Lee JH. Assessment of Long-term Psychological Outcomes After Pediatric Intensive Care Unit Admission: A Systematic Review and Meta-analysis. JAMA Pediatr 2022; 176:e215767. [PMID: 35040918 PMCID: PMC8767488 DOI: 10.1001/jamapediatrics.2021.5767] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE The pediatric intensive care unit (PICU) exposes children to stressful experiences with potential long-term psychological repercussions. However, current understanding of post-PICU psychological outcomes is incomplete. OBJECTIVE To systematically review and evaluate reported long-term psychological outcomes among children previously admitted to the PICU. DATA SOURCES A systematic search of the Cumulative Index to Nursing and Allied Health Literature, Embase, MEDLINE (PubMed), and PsycINFO was conducted from database inception to June 2021. Search terms included phrases related to intensive care (eg, intensive care units and critical care) and terms for psychological disorders (eg, posttraumatic stress disorder, depressive disorder, conduct disorder, and neurodevelopmental disorder) limited to the pediatric population. STUDY SELECTION This systematic review and meta-analysis included randomized clinical trials and observational studies reporting psychological disorders among children younger than 18 years who were admitted to the PICU with follow-up for at least 3 months. Psychological disorders were defined using the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Children were excluded if they were admitted to the PICU for primary brain conditions (eg, traumatic brain injury, meningoencephalitis, and brain tumors) or discharged to the home for palliative care. DATA EXTRACTION AND SYNTHESIS Titles and abstracts were independently screened by 2 reviewers, with data extraction conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Data were pooled using a random-effects model during meta-analysis. MAIN OUTCOMES AND MEASURES Age-corrected IQ scores and long-term psychological outcomes measured by scales such as the Child Behavior Checklist (higher scores indicate more behavioral problems) among children admitted to the PICU. RESULTS Of 9193 records identified, 31 independent studies (5 randomized clinical trials and 26 observational studies) involving 7786 children (mean age, 7.3 years [95% CI, 6.2-8.4 years]; 4267 boys [54.8%]; race and ethnicity were not reported by all studies) admitted to the PICU were included. Overall, 1 of 19 children (5.3%) to 14 of 16 children (88.0%) previously admitted to the PICU were reported to have at least 1 psychological disorder. Studies that examined posttraumatic stress disorder reported that 6 of 60 children (10.0%) to 31 of 102 children (30.4%) met the diagnostic criteria for the disorder at 3 to 6 months of follow-up. Compared with healthy children, those admitted to the PICU had lower IQ scores at 1 to 2 years of follow-up (mean, 89.40 points [95% CI, 88.33-90.47 points] vs 100.70 points [95% CI, 99.43-101.97 points]; P < .001) and 3 to 5 years of follow-up (mean, 88.54 points [95% CI, 83.92-93.16 points] vs 103.18 [95% CI, 100.36-105.99 points]; P < .001) and greater total emotional and behavioral problems at 4 years of follow-up (mean, 51.69 points [95% CI, 50.37-53.01 points] vs 46.66 points [95% CI, 45.20-48.13 points]; P < .001). CONCLUSIONS AND RELEVANCE This systematic review and meta-analysis found a high burden of psychological sequelae among children previously admitted to the PICU, suggesting that risk stratification and early interventions are needed for high-risk groups.
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Affiliation(s)
| | - Pei-Fen Poh
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | | | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Beverly Murphy
- Medical Center Library and Archives, Duke University, Durham, North Carolina
| | - Regina Wan Leng Ng
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Jan Hau Lee
- MD Programme, Duke-NUS Medical School, Singapore,Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
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Lalgudi Ganesan S, Hahn CD. Spectrograms for Seizure Detection in Critically Ill Children. J Clin Neurophysiol 2022; 39:195-206. [PMID: 34510096 DOI: 10.1097/wnp.0000000000000868] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Electrographic seizures are common in critically ill children and a significant proportion of these seizures are nonconvulsive. There is an association between electrographic seizures and neurophysiological disturbances, worse short- and long-term neurologic outcomes, and mortality in critically ill patients. In this context, timely diagnosis and treatment of electrographic seizures in critically ill children becomes important. However, most institutions lack the resources to support round-the-clock or frequent review of continuous EEG recordings causing significant delays in seizure diagnosis. Given the current gaps in review of continuous EEG across institutions globally, use of visually simplified, time-compressed quantitative EEG trends such as spectrograms has the potential to enhance timeliness of seizure diagnosis and treatment in critically ill children.
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Affiliation(s)
- Saptharishi Lalgudi Ganesan
- Paediatric Critical Care Medicine, Children's Hospital of Western Ontario, London Health Sciences Centre, London, ON, Canada
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Cecil D Hahn
- Division of Paediatric Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada; and
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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8
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Continuous EEG for Diagnosis of Electrographic Seizures in the Pediatric Cardiac Critical Care Unit: Using a Precious Resource Wisely. Neurocrit Care 2021; 36:13-15. [PMID: 34331204 DOI: 10.1007/s12028-021-01314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
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Alterations in coordinated EEG activity precede the development of seizures in comatose children. Clin Neurophysiol 2021; 132:1505-1514. [PMID: 34023630 DOI: 10.1016/j.clinph.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 02/21/2021] [Accepted: 03/12/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We aimed to test the hypothesis that computational features of the first several minutes of EEG recording can be used to estimate the risk for development of acute seizures in comatose critically-ill children. METHODS In a prospective cohort of 118 comatose children, we computed features of the first five minutes of artifact-free EEG recording (spectral power, inter-regional synchronization and cross-frequency coupling) and tested if these features could help identify the 25 children who went on to develop acute symptomatic seizures during the subsequent 48 hours of cEEG monitoring. RESULTS Children who developed acute seizures demonstrated higher average spectral power, particularly in the theta frequency range, and distinct patterns of inter-regional connectivity, characterized by greater connectivity at delta and theta frequencies, but weaker connectivity at beta and low gamma frequencies. Subgroup analyses among the 97 children with the same baseline EEG background pattern (generalized slowing) yielded qualitatively and quantitatively similar results. CONCLUSIONS These computational features could be applied to baseline EEG recordings to identify critically-ill children at high risk for acute symptomatic seizures. SIGNIFICANCE If confirmed in independent prospective cohorts, these features would merit incorporation into a decision support system in order to optimize diagnostic and therapeutic management of seizures among comatose children.
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Bauer Huang SL, Said AS, Smyser CD, Lin JC, Guilliams KP, Guerriero RM. Seizures Are Associated With Brain Injury in Infants Undergoing Extracorporeal Membrane Oxygenation. J Child Neurol 2021; 36:230-236. [PMID: 33112194 PMCID: PMC8086759 DOI: 10.1177/0883073820966917] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Determine seizure frequency and association with neurologic outcomes in infants undergoing extracorporeal membrane oxygenation. Identify patient or clinical factors associated with seizures or brain injury on imaging. METHODS Retrospective, single-center study including infants less than 1 year of age, who underwent extracorporeal membrane oxygenation between 2012 and 2017. RESULTS A total of 104 infants met study criteria including 45 patients with continuous electroencephalographic (EEG) monitoring during their extracorporeal membrane oxygenation run and 59 infants without EEG. Seizures (electrographic-only or electro-clinical) were identified in 18 of the 45 (40%). Among the 18 infants with seizures, 14 (78%) had moderate to severe brain injury, whereas only 44% of those without seizures (12 of 27) on EEG had moderate to severe brain injury (P = .03). Cardiopulmonary resuscitation prior to extracorporeal membrane oxygenation (ECPR), mode of extracorporeal membrane oxygenation, length of stay, survival to discharge, and congenital heart disease were not associated with seizures. One of 10 patients with cyanotic congenital heart disease due to hypoplastic left heart syndrome had seizures compared with 7 of 10 patients with non-hypoplastic left heart syndrome lesions (P = .02). Seizures were associated with moderate to severe brain injury, after adjusting for ECPR and congenital heart disease (P = .04). CONCLUSIONS Electrographic seizures were common in patients undergoing extracorporeal membrane oxygenation and higher than previously reported. Seizures were associated with moderate to severe abnormalities on imaging, after adjusting for ECPR and congenital heart disease. This study adds to recent literature describing the risk of seizures in patients on extracorporeal membrane oxygenation and highlights the presence of brain injuries that may be identified by routine EEG surveillance.
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Affiliation(s)
- Sarah L Bauer Huang
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
| | - Ahmed S Said
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Christopher D Smyser
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
- Department of Radiology, 7548Washington University in St Louis, MO, USA
| | - John C Lin
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Kristin P Guilliams
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Réjean M Guerriero
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
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Ghossein J, Alnaji F, Webster RJ, Bulusu S, Pohl D. Continuous EEG in a Pediatric Intensive Care Unit: Adherence to Monitoring Criteria and Barriers to Adequate Implementation. Neurocrit Care 2020; 34:519-528. [PMID: 32696100 DOI: 10.1007/s12028-020-01053-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Subclinical seizures are common in critically ill children and are best detected by continuous EEG (cEEG) monitoring. Timely detection of seizures requires pediatric intensive care unit (PICU) physicians to identify patients at risk of seizures and request cEEG monitoring. A recent consensus statement from the American Clinical Neurophysiology Society (ACNS) outlines the indications for cEEG monitoring in critically ill patients. However, adherence to these cEEG monitoring criteria among PICU physicians is unknown. Our project had two goals: 1. To assess adherence to cEEG monitoring indications and barriers toward their implementation; 2. To improve compliance with the ACNS cEEG monitoring criteria in our PICU. METHODS This is a single-institution study. A total of 234 PICU admissions (183 unique patients) were studied. A 6-month retrospective chart review identified PICU patients meeting ACNS criteria for cEEG monitoring, and patients for whom monitoring was requested. This was followed by an 8-week quality improvement project. During this mentorship period, a didactic 15-min lecture and summary handouts regarding the ACNS indications for cEEG monitoring were provided to all PICU physicians. Requests for cEEG monitoring during the mentorship period were compared to baseline adherence to cEEG monitoring recommendations, and barriers toward timely cEEG monitoring were assessed. RESULTS Nearly every fifth PICU patient met cEEG monitoring indications, and prevalences of patients meeting those indications were similar in the retrospective and the prospective mentorship period (18% vs. 19%). Almost all patients (98%) requiring cEEG as per ACNS criteria met the indication for monitoring already at the time of their PICU admission. During the retrospective period, 23% of patients meeting ACNS criteria had a request for cEEG monitoring, which increased to 83% during the mentorship period. The median delay to cEEG initiation was 16.7 h during the mentorship period, largely due to limited hours of EEG technician availability. Electrographic seizures were identified in 36% of patients monitored, all within the first 120 min of cEEG recording. The majority (79%) of cEEGs informed clinical management. CONCLUSIONS A brief teaching intervention supplemented by pictographic handouts significantly increased adherence to cEEG monitoring recommendations, and cEEGs guided clinical management. However, there were long delays to cEEG initiation. In order to promptly recognize subclinical seizures in critically ill children, we strongly advocate for a routine screening for cEEG monitoring indications as part of the PICU admission process, and a care model allowing for cEEG initiation around-the-clock.
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Affiliation(s)
- Jamie Ghossein
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Fuad Alnaji
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.,CHEO Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Richard J Webster
- CHEO Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Srinivas Bulusu
- Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Daniela Pohl
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada. .,CHEO Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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Electrographic Seizures and Brain Injury in Children Requiring Extracorporeal Membrane Oxygenation. Pediatr Neurol 2020; 108:77-85. [PMID: 32299743 DOI: 10.1016/j.pediatrneurol.2020.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/23/2020] [Accepted: 03/01/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Single-center studies suggest that up to 30% of children undergoing extracorporeal membrane oxygenation have electrographic seizures. The aim of this study was to characterize seizure prevalence, seizure risk factors, and brain injury prevalence in the pediatric extracorporeal membrane oxygenation population at a tertiary care children's hospital. METHODS We performed a retrospective systematic review of medical records for 86 consecutive children (neonates to age 21 years) who received Neurology consults and continuous video electroencephalography while undergoing extracorporeal membrane oxygenation from November 2015 to September 2018. RESULTS Continuous video electroencephalography was initiated in 86 of 170 children who required extracorporeal membrane oxygenation (51%); median duration of continuous vodeo electroencephalography was four days. Nineteen of 86 had electroencephalography-confirmed seizures (22%). Sixteen of 19 had seizures within the first 48 hours on continuous video electroencephalography. Interictal epileptiform discharges were a significant risk factor for seizures; 89% of those with seizures versus 46% of those without had interictal epileptiform discharges (P < 0.001, Fisher's exact test). Children with seizures also had higher pericannulation lactate (median 6.7, interquartile range of 4.3 to 19.0 for those with, and median 4.0, interquartile range of 2.0 to 7.3 for those without; P = 0.02, Mann-Whitney U test). Seizures were associated with hemorrhage on neuroimaging (68% of children with seizures had intracranial hemorrhage versus 34% of those without, P = 0.01, chi-square test). CONCLUSION Approximately half the children undergoing extracorporeal membrane oxygenation received continuous video electroencephalography during the study period, and 22% had seizures. Interictal epileptiform discharges and elevated pre-extracorporeal membrane oxygenation lactate levels were risk factors for seizures; seizures were associated with intracranial hemorrhage.
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Abstract
PURPOSE We aimed to determine which early EEG features and feature combinations most accurately predicted short-term neurobehavioral outcomes and survival in children resuscitated after cardiac arrest. METHODS This was a prospective, single-center observational study of infants and children resuscitated from cardiac arrest who underwent conventional EEG monitoring with standardized EEG scoring. Logistic regression evaluated the marginal effect of each EEG variable or EEG variable combinations on the outcome. The primary outcome was neurobehavioral outcome (Pediatric Cerebral Performance Category score), and the secondary outcome was mortality. The authors identified the models with the highest areas under the receiver operating characteristic curve (AUC), evaluated the optimal models using a 5-fold cross-validation approach, and calculated test characteristics maximizing specificity. RESULTS Eighty-nine infants and children were evaluated. Unfavorable neurologic outcome (Pediatric Cerebral Performance Category score 4-6) occurred in 44 subjects (49%), including mortality in 30 subjects (34%). A model incorporating a four-level EEG Background Category (normal, slow-disorganized, discontinuous or burst-suppression, or attenuated-flat), stage 2 Sleep Transients (present or absent), and Reactivity-Variability (present or absent) had the highest AUC. Five-fold cross-validation for the optimal model predicting neurologic outcome indicated a mean AUC of 0.75 (range, 0.70-0.81) and for the optimal model predicting mortality indicated a mean AUC of 0.84 (range, 0.76-0.97). The specificity for unfavorable neurologic outcome and mortality were 95% and 97%, respectively. The positive predictive value for unfavorable neurologic outcome and mortality were both 86%. CONCLUSIONS The specificity of the optimal model using a combination of early EEG features was high for unfavorable neurologic outcome and mortality in critically ill children after cardiac arrest. However, the positive predictive value was only 86% for both outcomes. Therefore, EEG data must be considered in overall clinical context when used for neuroprognostication early after cardiac arrest.
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14
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Electrographic seizure burden and outcomes following pediatric status epilepticus. Epilepsy Behav 2019; 101:106409. [PMID: 31420288 DOI: 10.1016/j.yebeh.2019.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Pediatric status epilepticus carries a substantial risk for morbidity and mortality, but the relationship between seizure burden, treatment, and outcome remains incompletely understood. This review summarizes the evidence linking seizure burden and outcomes among critically ill children in the intensive care unit (ICU), a population in whom accurate quantification of seizure burden is possible using continuous electroencephalographic monitoring. Several high-quality observational studies among critically ill children have reported an association between higher seizure burden and worse outcome, even after adjusting for potential confounders such as age, etiology, and illness severity. Although these studies support the hypothesis that seizures contribute to brain injury and worsen outcome, a causal link between seizures and outcome remains to be proven. The relationship between seizures and outcome is likely complex, and dependent on factors such as etiology, preexisting neurological disability, medication exposure, and possibly individual genetic factors. Studies attempting to define this complex relationship will need to measure and account for these factors in their analyses. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Oh A, Olson LD, Chern JJ, Kim H. Clinical Characteristics and Nonconvulsive Seizures in Young Children With Abusive Head Trauma. J Child Neurol 2019; 34:713-719. [PMID: 31185789 DOI: 10.1177/0883073819853973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM We aimed to evaluate putative predictors of symptoms and signs at admission for nonconvulsive seizure and to examine the impact of nonconvulsive seizures on short-term outcomes. METHOD We retrospectively collected consecutive abusive head trauma patients (<36 months of age) from the trauma registry at Children's Healthcare of Atlanta between 2009 and 2014. Multiple logistic regression was performed to assess the putative predictors for the occurrence of nonconvulsive seizures including clinical seizures, altered mental status, respiratory difficulty, and cardiac arrest at admission, while controlling for age, sex, and injury severity. The Mann-Whitney U test and the Fisher exact test were used to compare the short-term outcomes between patients with and without nonconvulsive seizures. RESULTS Two hundred seventy patients with abusive head trauma were identified (male = 55.6%). The median age was 4 months (interquartile range = 2-8 months). Among 70 patients who underwent continuous electroencephalography (EEG), 40 had nonconvulsive seizures (57%) and 21 developed nonconvulsive status epilepticus (30%). Altered mental status at admission was associated with the occurrence of nonconvulsive seizures (odds ratio = 6.8, 95% confidence interval = 1.2-38.2, P = .03). Comparing patients with no seizures, those with nonconvulsive seizures were more likely to stay longer at hospital (9 days vs 14 days, P = .04) and to need rehabilitation (50.0% vs 63.2%, P = .03). CONCLUSIONS Nonconvulsive seizures and nonconvulsive status epilepticus was highly prevalent in young pediatric patients with abusive head trauma. Presenting with altered mental status at admission was found to predict the occurrence of nonconvulsive seizures. Nonconvulsive seizures had an unfavorable impact on short-term outcomes.
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Affiliation(s)
- Ahyuda Oh
- 1 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Larry D Olson
- 1 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,2 Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Joshua J Chern
- 2 Children's Healthcare of Atlanta, Atlanta, GA, USA.,3 Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Hyunmi Kim
- 1 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,2 Children's Healthcare of Atlanta, Atlanta, GA, USA.,4 Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Williams CN, Hartman ME, Guilliams KP, Guerriero RM, Piantino JA, Bosworth CC, Leonard SS, Bradbury K, Wagner A, Hall TA. Postintensive Care Syndrome in Pediatric Critical Care Survivors: Therapeutic Options to Improve Outcomes After Acquired Brain Injury. Curr Treat Options Neurol 2019; 21:49. [PMID: 31559490 DOI: 10.1007/s11940-019-0586-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Children surviving the pediatric intensive care unit (PICU) with neurologic illness or injury have long-term morbidities in physical, cognitive, emotional, and social functioning termed postintensive care syndrome (PICS). In this article, we review acute and longitudinal management strategies available to combat PICS in children with acquired brain injury. RECENT FINDINGS Few intervention studies in this vulnerable population target PICS morbidities. Small studies show promise for both inpatient- and outpatient-initiated therapies, mainly focusing on a single domain of PICS and evaluating heterogeneous populations. While evaluating the effects of interventions on longitudinal PICS outcomes is in its infancy, longitudinal clinical programs targeting PICS are increasing. A multidisciplinary team with inpatient and outpatient presence is necessary to deliver the holistic integrated care required to address all domains of PICS in patients and families. While PICS is increasingly recognized as a chronic problem in PICU survivors with acquired brain injury, few interventions have targeted PICS morbidities. Research is needed to improve physical, cognitive, emotional, and social outcomes in survivors and their families.
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Affiliation(s)
- Cydni N Williams
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA.
- Department of Pediatrics, Division of Pediatric Critical Care, Oregon Health and Science University, Portland, OR, USA.
| | - Mary E Hartman
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Kristin P Guilliams
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
- Department of Neurology, Division of Pediatric and Developmental Neurology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Rejean M Guerriero
- Department of Neurology, Division of Pediatric and Developmental Neurology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Juan A Piantino
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA
- Department of Pediatrics, Division of Pediatric Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Christopher C Bosworth
- Department of Psychology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Skyler S Leonard
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health and Science University, Portland, OR, USA
| | - Kathryn Bradbury
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health and Science University, Portland, OR, USA
| | - Amanda Wagner
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health and Science University, Portland, OR, USA
| | - Trevor A Hall
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA
- Department of Pediatrics, Division of Pediatric Psychology, Oregon Health and Science University, Portland, OR, USA
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Fung FW, Jacobwitz M, Vala L, Parikh D, Donnelly M, Xiao R, Topjian AA, Abend NS. Electroencephalographic seizures in critically ill children: Management and adverse events. Epilepsia 2019; 60:2095-2104. [PMID: 31538340 DOI: 10.1111/epi.16341] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Guidelines recommend that encephalopathic critically ill children undergo continuous electroencephalographic (CEEG) monitoring for electrographic seizure (ES) identification and management. However, limited data exist on antiseizure medication (ASM) safety for ES treatment in critically ill children. METHODS We performed a single-center prospective observational study of encephalopathic critically ill children undergoing CEEG. Clinical and EEG features and ASM utilization patterns were evaluated. We determined the incidence, types, and risk factors for adverse events associated with ASM administration. RESULTS A total of 472 consecutive critically ill children undergoing CEEG were enrolled. ES occurred in 131 children (28%). Clinicians administered ASM to 108 children with ES (82%). ES terminated after the initial ASM in 38% of patients who received one ASM, after the second ASM in 35% of patients who received two ASMs, after the third ASM in 50% of patients who received three ASMs, and after the fourth ASM in 53% of patients who received four ASMs. Thirty patients (28%) received anesthetic infusions for ES management. Adverse events occurred in 18 patients (17%). Adverse effects were expected and resolved in all patients, and they were generally serious (in 15 patients) and definitely related (in 12 patients). Adverse events were rare in patients with acute symptomatic seizures requiring only one to two ASMs for treatment, but were more common in children with epilepsy, ictal-interictal continuum EEG patterns, or patients requiring more extensive ASM management. SIGNIFICANCE ES ceased after one ASM in only 38% of critically ill children but ceased after two ASMs in 73% of critically ill children. Thus, ES management was often accomplished with readily available medications, but optimization of multistep ES management strategies might be beneficial. Adverse events were rare and manageable in children with acute symptomatic seizures requiring only one to two ASMs for treatment. Future studies are needed to determine whether management of acute symptomatic ES improves neurobehavioral outcomes.
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Affiliation(s)
- France W Fung
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia,, Philadelphia, PA, USA.,Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marin Jacobwitz
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia,, Philadelphia, PA, USA
| | - Lisa Vala
- Department of Neurodiagnostics, Children's Hospital of Philadelphia,, Philadelphia, PA, USA
| | - Darshana Parikh
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia,, Philadelphia, PA, USA.,Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maureen Donnelly
- Department of Neurodiagnostics, Children's Hospital of Philadelphia,, Philadelphia, PA, USA
| | - Rui Xiao
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicholas S Abend
- Department of Pediatrics (Division of Neurology), Children's Hospital of Philadelphia,, Philadelphia, PA, USA.,Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Neurodiagnostics, Children's Hospital of Philadelphia,, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Anesthesia & Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Towards Successes in the Management of Nonconvulsive Status Epilepticus: Tracing the Detection-to-Needle Trajectories. J Clin Neurophysiol 2019; 37:253-258. [PMID: 31490288 DOI: 10.1097/wnp.0000000000000630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Data on the timeliness of emergent medication delivery for nonconvulsive status epilepticus (NCSE) are currently lacking. METHODS Retrospective chart reviews (between 2015 and 2018) and analyses of all patients with NCSE were performed at the University of Nebraska Medical Center, a level 4 epilepsy center, to determine the latencies to order and administration of the first, second, and third antiepileptic drugs (AEDs). Recurrent NCSE cases were considered independently and classified as comatose and noncomatose. RESULTS There were 77 occurrences of NCSE in 53 patients. The first, second, and third AEDs were delivered with substantial delays at median times of 80 (25%-75% interquartile range, 44-166), 126 (interquartile range, 67-239), and 158 minutes (interquartile range, 89-295), respectively, from seizure detection. The median times to the order of the first and second AEDs were 33 and 134.5 minutes longer in comatose NCSE patients compared with those with noncomatose forms, respectively (P = 0.001 and 0.004, respectively). The median times between the AED orders and their administration in these two groups were the same (P = 0.60 and 0.37, respectively). With bivariate analysis, the median latencies to administration of the first, second, and third AEDs were significantly increased by 33, 109.5, and 173 minutes, respectively, in patients who died within 30 days compared with those who survived (P = 0.047, P = 0.02, P = 0.0007, respectively). CONCLUSIONS The administration of the first, second, and third AEDs for NCSE was delayed. Slow initiation of acute treatment in comatose patients was caused by delays in the placement of the medication order.
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Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e194-e233. [DOI: 10.1161/cir.0000000000000697] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.
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20
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Xu Q, Uliel-Sibony S, Dunham C, Sarnat H, Flores-Sarnat L, Brunga L, Davidson S, Lo W, Shlien A, Connolly M, Boelman C, Datta A. mTOR Inhibitors as a New Therapeutic Strategy in Treatment Resistant Epilepsy in Hemimegalencephaly: A Case Report. J Child Neurol 2019; 34:132-138. [PMID: 30514132 DOI: 10.1177/0883073818813238] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hemimegalencephaly is a hamartomatous malformation of one hemisphere. Functional hemispherectomy, the definitive treatment, is associated with significant morbidity and mortality in early infancy. Dysregulation of the mTOR pathway can result in malformations of cortical development, and mTOR inhibitors can effectively reduce seizures in tuberous sclerosis complex. We report a 6-day-old female with hemimegalencephaly and frequent seizures despite 9 antiseizure medications. At 3 months of age, while awaiting hemispherectomy, an mTOR inhibitor, rapamycin, was initiated by the neurologist. After 1 week of treatment, there was >50% reduction in seizures and total seizure burden, and after 2 weeks, development improved, resulting in deferral of surgery by 2.5 months with an increased body weight. Pathology demonstrated cortical dysplasia with upregulation of the mTOR pathway. Deep-sequencing of brain tissue demonstrated 16% mosaicism for a pathogenic de novo MTOR gene mutation. This case exemplifies how mTOR inhibitors could be considered for seizure reduction in patients with hemimegalencephaly while awaiting surgery.
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Affiliation(s)
- Qi Xu
- 1 Division of Neurology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Shimrit Uliel-Sibony
- 1 Division of Neurology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Christopher Dunham
- 2 Department of Pathology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Harvey Sarnat
- 3 Division of Pediatric Neurology, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada
| | - Laura Flores-Sarnat
- 3 Division of Pediatric Neurology, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada
| | - Ledia Brunga
- 4 University of Toronto, Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, ON, Canada
| | - Scott Davidson
- 4 University of Toronto, Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, ON, Canada
| | - Winnie Lo
- 4 University of Toronto, Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, ON, Canada
| | - Adam Shlien
- 4 University of Toronto, Program in Genetics and Genome Biology, the Hospital for Sick Children, Toronto, ON, Canada
| | - Mary Connolly
- 1 Division of Neurology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Cyrus Boelman
- 1 Division of Neurology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Anita Datta
- 1 Division of Neurology, University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
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21
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Benedetti GM, Silverstein FS, Rau SM, Lester SG, Benedetti MH, Shellhaas RA. Sedation and Analgesia Influence Electroencephalography Monitoring in Pediatric Neurocritical Care. Pediatr Neurol 2018; 87:57-64. [PMID: 30049426 DOI: 10.1016/j.pediatrneurol.2018.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/01/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We assessed neuroactive medication use in critically ill children who require neurological consultation and evaluated the associations between administration of these medications and continuous electroencephalography (cEEG) utilization and seizure frequency. METHODS We evaluated exposure to sedatives, analgesics, anesthetics, and paralytics in consecutive patients (0 days to 18 years) for whom neurological consultation was requested in three intensive care units (ICUs) [neonatal (NICU), pediatric (PICU), and cardiothoracic (PCTU)]) at one children's hospital. We assessed cEEG usage and seizure incidence in relation to drug exposure. RESULTS From November 2015 to November 2016, 300 consecutive patients were evaluated (93 NICU, 139 PICU, and 68 PCTU). Ninety-seven (32%) were receiving ≥1 sedative infusion at the time of consultation [NICU 7 (8%), PICU 50(36%), PCTU 40 (58%%]; 91 (30%) received ≥1 paralytic agent within the preceding 24 hours. Continuous electroencephalography was performed more often for patients treated with sedative infusions (81 of 97 versus 133 of 203, P = 0.001) and paralytic medications (80 of 91 versus 134 of 209, P < 0.001) within 24 hours preceding consultation than those who were not. Sixty-eight of 214 (32%) had electrographic seizures (65 of 68 within initial 24 hours of monitoring); seizures were less common among patients who had received sedative infusions (18 of 81 versus 51 of 133, P = 0.014). In multivariable analysis of seizure likelihood, only younger age was associated with increased risk (P = 0.037). CONCLUSIONS Critically ill infants and children are frequently treated with sedatives, anesthetics, analgesics, and paralytics. Neuroactive medications limit bedside neurological assessments and, in this cohort, were associated with increased cEEG usage. Our data underscore the need to study the effect of these medications on clinical care and long-term outcomes.
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Affiliation(s)
- Giulia M Benedetti
- Department of Pediatrics, Division of Pediatric Neurology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Faye S Silverstein
- Department of Pediatrics, Division of Pediatric Neurology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Stephanie M Rau
- Department of Pediatrics, Division of Pediatric Neurology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Shannon G Lester
- Department of Pediatrics, Division of Pediatric Neurology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Marco H Benedetti
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Renée A Shellhaas
- Department of Pediatrics, Division of Pediatric Neurology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan.
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22
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Abend NS, Xiao R, Kessler SK, Topjian AA. Stability of Early EEG Background Patterns After Pediatric Cardiac Arrest. J Clin Neurophysiol 2018; 35:246-250. [PMID: 29443794 DOI: 10.1097/wnp.0000000000000458] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE We aimed to determine whether EEG background characteristics remain stable across discrete time periods during the acute period after resuscitation from pediatric cardiac arrest. METHODS Children resuscitated from cardiac arrest underwent continuous conventional EEG monitoring. The EEG was scored in 12-hour epochs for up to 72 hours after return of circulation by an electroencephalographer using a Background Category with 4 levels (normal, slow-disorganized, discontinuous/burst-suppression, or attenuated-featureless) or 2 levels (normal/slow-disorganized or discontinuous/burst-suppression/attenuated-featureless). Survival analyses and mixed-effects ordinal logistic regression models evaluated whether the EEG remained stable across epochs. RESULTS EEG monitoring was performed in 89 consecutive children. When EEG was assessed as the 4-level Background Category, 30% of subjects changed category over time. Based on initial Background Category, one quarter of the subjects changed EEG category by 24 hours if the initial EEG was attenuated-featureless, by 36 hours if the initial EEG was discontinuous or burst-suppression, by 48 hours if the initial EEG was slow-disorganized, and never if the initial EEG was normal. However, regression modeling for the 4-level Background Category indicated that the EEG did not change over time (odds ratio = 1.06, 95% confidence interval = 0.96-1.17, P = 0.26). Similarly, when EEG was assessed as the 2-level Background Category, 8% of subjects changed EEG category over time. However, regression modeling for the 2-level category indicated that the EEG did not change over time (odds ratio = 1.02, 95% confidence interval = 0.91-1.13, P = 0.75). CONCLUSIONS The EEG Background Category changes over time whether analyzed as 4 levels (30% of subjects) or 2 levels (8% of subjects), although regression analyses indicated that no significant changes occurred over time for the full cohort. These data indicate that the Background Category is often stable during the acute 72 hours after pediatric cardiac arrest and thus may be a useful EEG assessment metric in future studies, but that some subjects do have EEG changes over time and therefore serial EEG assessments may be informative.
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Affiliation(s)
- Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - Rui Xiao
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - Sudha Kilaru Kessler
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - Alexis A Topjian
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, U.S.A
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Abstract
PURPOSE We aimed to determine whether conventional standardized EEG features could be consolidated into a more limited number of factors and whether the derived factor scores changed during the acute period after pediatric cardiac arrest. METHODS Children resuscitated after cardiac arrest underwent conventional continuous EEG monitoring. The EEG was scored in 12-hour epochs for up to 72-hours after return of circulation by an electroencephalographer using standardized critical care EEG terminology. We performed a polychoric factor analysis to determine whether numerous observed EEG features could be represented by a smaller number of derived factors. Linear mixed-effects regression models and heat maps evaluated whether the factor scores remained stable across epochs. RESULTS We performed EEG monitoring in 89 consecutive children, which yielded 453 EEG segments. We identified two factors, which were not correlated. The background features were factor loaded with the features continuity, voltage, and frequency. The intermittent features were factor loaded with the features of seizures, periodic patterns, and interictal discharges. Factor scores were calculated for each EEG segment. Linear, mixed-effect, regression results indicated that the factor scores did not change over time for the background features factor (coefficient, 0.18; 95% confidence interval, 0.04-0.07; P = 0.52) or the intermittent features factor (coefficient, -0.003; 95% confidence interval, -0.02 to 0.01; P = 0.70). However, heat maps showed that some individual subjects did experience factor score changes over time, particularly if they had medium initial factor scores. CONCLUSIONS Subsequent studies assessing whether EEG is informative for neurobehavioral outcomes after pediatric cardiac arrest could combine numerous EEG features into two factors, each reflecting multiple background and intermittent features. Furthermore, the factor scores would be expected to remain stable during the acute period for most subjects.
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Abstract
PURPOSE OF REVIEW All critical care is directed at maintaining brain health, but recognizing neurologic complications of critical illness in children is difficult, and limited data exist to guide practice. This article discusses an approach to the recognition and management of seizures, stroke, and cardiac arrest as complications of other critical illnesses in the pediatric intensive care unit. RECENT FINDINGS Convulsive and nonconvulsive seizures occur frequently in children after cardiac arrest or traumatic brain injury and during extracorporeal membrane oxygenation. Seizures may add to neurologic morbidity, and continuous EEG monitoring is needed for up to 24 hours for detection. Hypothermia has not been shown to improve outcome after cardiac arrest in children, but targeted temperature management with controlled normothermia and prevention of fever is a mainstay of neuroprotection. SUMMARY Much of brain-directed pediatric critical care is empiric. Recognition of neurologic complications of critical illness requires multidisciplinary care, serial neurologic examinations, and an appreciation for the multiple risk factors for neurologic injury present in most patients in the pediatric intensive care unit. Through attention to the fundamentals of neuroprotection, including maintaining or restoring cerebral perfusion matched to the metabolic needs of the brain, combined with anticipatory planning, these complications can be prevented or the neurologic injury mitigated.
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Interrater Agreement of EEG Interpretation After Pediatric Cardiac Arrest Using Standardized Critical Care EEG Terminology. J Clin Neurophysiol 2018; 34:534-541. [PMID: 29023307 DOI: 10.1097/wnp.0000000000000424] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE We evaluated interrater agreement of EEG interpretation in a cohort of critically ill children resuscitated after cardiac arrest using standardized EEG terminology. METHODS Four pediatric electroencephalographers scored 10-minute EEG segments from 72 consecutive children obtained 24 hours after return of circulation using the American Clinical Neurophysiology Society's (ACNS) Standardized Critical Care EEG terminology. The percent of perfect agreement and the kappa coefficient were calculated for each of the standardized EEG variables and a predetermined composite EEG background category. RESULTS The overall background category (normal, slow-disorganized, discontinuous, or attenuated-featureless) had almost perfect agreement (kappa 0.89).The ACNS Standardized Critical Care EEG variables had agreement that was (1) almost perfect for the seizures variable (kappa 0.93), (2) substantial for the continuity (kappa 0.79), voltage (kappa 0.70), and sleep transient (kappa 0.65) variables, (3) moderate for the rhythmic or periodic patterns (kappa 0.55) and interictal epileptiform discharge (kappa 0.60) variables, and (4) fair for the predominant frequency (kappa 0.23) and symmetry (kappa 0.31) variables. Condensing variable options led to improved agreement for the continuity and voltage variables. CONCLUSIONS These data support the use of the standardized terminology and the composite overall background category as a basis for standardized EEG interpretation for subsequent studies assessing EEG background for neuroprognostication after pediatric cardiac arrest.
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Outcomes following electrographic seizures and electrographic status epilepticus in the pediatric and neonatal ICUs. Curr Opin Neurol 2018; 30:156-164. [PMID: 28118303 DOI: 10.1097/wco.0000000000000425] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Increasing recognition of electrographic seizures and electrographic status epilepticus in critically ill neonates and children has highlighted the importance of identifying their potential contributions to neurological outcomes to guide optimal management. RECENT FINDINGS Recent studies in children and neonates have found an independent association between increasing seizure burden and worse short-term and long-term outcomes, even after adjusting for other important contributors to outcome such as seizure cause and illness severity. The risk of worse neurological outcome has been shown to increase above a seizure burden threshold of 12-13 min/h, which is considerably lower than the conventional definition of status epilepticus of 30 min/h. Randomized controlled trials in neonates have demonstrated that electroencephalography-targeted therapy can successfully reduce seizure burden, but due to their small size these trials have not been able to demonstrate that more aggressive electroencephalography-targeted treatment of both subclinical and clinical seizures results in improved outcome. SUMMARY Despite mounting evidence for an independent association between increasing seizure burden and worse outcome, further study is needed to determine whether early seizure identification and aggressive antiseizure treatment can improve neurodevelopmental outcomes.
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Massey S, Banwell B. Clinical implications of status epilepticus in children. THE LANCET. CHILD & ADOLESCENT HEALTH 2018; 2:81-83. [PMID: 30169239 DOI: 10.1016/s2352-4642(17)30175-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 06/08/2023]
Affiliation(s)
- Shavonne Massey
- Department of Neurology and Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Brenda Banwell
- Department of Neurology and Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Nguyen The Tich S. Place de l’électroencéphalogramme dans la prise en charge de l’accident vasculaire ischémique artériel du nouveau-né. Arch Pediatr 2017; 24:9S41-9S45. [DOI: 10.1016/s0929-693x(17)30330-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Caprarola SD, Kudchadkar SR, Bembea MM. Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit. ACTA ACUST UNITED AC 2017; 3:193-207. [PMID: 29218262 DOI: 10.1007/s40746-017-0092-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose of review With increasing survival of children requiring admission to pediatric intensive care units (PICU), neurodevelopmental outcomes of these patients are an area of increased attention. Our goal was to systematically review recently published literature on neurologic outcomes of PICU patients. Recent Findings Decline in neurofunctional status occurs in 3%-20% of children requiring PICU care. This proportion varies based on primary diagnosis and severity of illness, with children admitted for primary neurologic diagnosis, children who suffer cardiac arrest or who require invasive interventions during the PICU admission, having worse outcomes. Recent research focuses on early identification and treatment of modifiable risk factors for unfavorable outcomes, and on long-term follow-up that moves beyond global cognitive outcomes and is increasingly including tests assessing multidimensional aspects of neurodevelopment. Summary The pediatric critical care research community has shifted focus from survival to survival with favorable neurologic outcomes of children admitted to the PICU.
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Affiliation(s)
- Sherrill D Caprarola
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, 6621 Fannin St, Houston, TX, United States, 77030
| | - Sapna R Kudchadkar
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, United States, 21287
| | - Melania M Bembea
- Departments of Anesthesiology and Critical Care Medicine, and Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD, United States, 21287
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Shinnar RC, Shinnar S, Hesdorffer DC, O'Hara K, Conklin T, Cornett KM, Miazga D, Sun S. Parental stress, pediatric quality of life, and behavior at baseline and one-year follow-up: Results from the FEBSTAT study. Epilepsy Behav 2017; 69:95-99. [PMID: 28236729 PMCID: PMC5423815 DOI: 10.1016/j.yebeh.2017.01.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 11/17/2022]
Abstract
UNLABELLED Febrile status epilepticus is a serious and frightening event in the life of the child and parent. It is regarded as a medical emergency with potential long lasting consequences. The purpose of this study was to look at the immediate and long term effects of such an event on parental stress and parents' perception of their child's physical and psychosocial wellbeing. METHODS From 2003 to 2010, 199 subjects, age 1 month to 5 years, were recruited as part of a prospective, multicenter study (FEBSTAT) of consequences of febrile status epilepticus (FSE). At one month and one year after the episode of FSE, parents were asked to complete the Parenting Stress Index, short form (PSI/SF), the Pediatric Quality of Life Inventory (PedsQL) and the Child Behavior Checklist (CBCL). In addition to PedsQL and CBCL in the FEBSTAT subjects only, a comparison was made between Columbia Study of First Febrile Seizures subjects with a first simple febrile seizure (SFS) and the FEBSTAT group, including 15 subjects with FSE from the Columbia group, in the area of parental stress which was administered at the same time intervals in both studies. RESULTS At baseline, the PSI/SF was statistically significantly higher for SFS versus FSE on the parent-child dysfunctional score and the total raw score, however at one year this difference resolved. In the FSE group, significantly higher parental stress over one year was reported in children with abnormal versus normal prior development (p= 0.02). Prior abnormal development was a risk factor at 1 year for lower total PEDSQL (p=0.01) versus prior normal development. Mean scores on the CBCL at baseline and 1 year were within the normal range for both empirically based scales and major risk factors. CONCLUSIONS Parents of children experiencing a SFS experienced more stress at baseline than those with FSE. Families of children in the FEBSTAT cohort with identified development problems at baseline that continued, or progressed over the one year period, reported decreasing QOL.
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Affiliation(s)
- Ruth C Shinnar
- Neurology and Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
| | - Shlomo Shinnar
- Neurology and Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Dale C Hesdorffer
- GH Sergievsky Center, and Department of Epidemiology, Columbia University, New York, NY 10032, USA
| | - Kathryn O'Hara
- Pediatric Neurology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Terrie Conklin
- Neurology, Children's Hospital of The King's Daughter, Norfolk, VA 23507, USA
| | | | - Diana Miazga
- Neurology, Lurie Children's Hospital, Chicago, IL 60611, USA
| | - Shumei Sun
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA 23298, USA
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Sánchez Fernández I, Sansevere AJ, Guerriero RM, Buraniqi E, Pearl PL, Tasker RC, Loddenkemper T. Time to electroencephalography is independently associated with outcome in critically ill neonates and children. Epilepsia 2017; 58:420-428. [PMID: 28130784 DOI: 10.1111/epi.13653] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To identify factors associated with in-hospital mortality in neonates and children undergoing continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU). METHODS We performed a retrospective observational study in patients from birth to 21 years of age who underwent clinically indicated cEEG in the ICU from 2011 to 2013. The main outcome measure was in-hospital mortality. RESULTS Six-hundred and twenty-five patients (54.2% male) met eligibility criteria, of whom 211 were neonates (55% male, 24.8% premature) and 414 were pediatric patients (53.9% male). Electrographic seizures occurred in 176 patients (28.2%) and status epilepticus (SE) occurred in 20 (11.4%). The time from ICU admission to cEEG initiation was 16.7 (5.1-94.4) h. Eighty-nine patients (14.2%) (30 [14.2%] neonates, and 59 [14.3%] pediatric patients) died in the hospital. In neonates-after controlling for gender and prematurity-independent factors associated with mortality were prematurity (odds ratio [OR] 2.63. 95% confidence interval [CI] 1.06-6.5, p = 0.037), presence of status epilepticus (SE); OR 8.82, 95% CI 1.74-44.57, p = 0.008), and time from ICU admission to initiation of cEEG (OR 1.002, 95% CI 1.001-1.004 per hour, p = 0.008]. In pediatric patients-after controlling for gender and age-independent factors associated with mortality were the absence of seizures factors associated with mortality were absence of seizures (OR = 4.3, (95% CI: 1.5-12.4), p = 0.007), the presence of SE (OR 7.76, 95% CI 1.47-40.91, p = 0.016), and the time from ICU admission to initiation of cEEG (OR 1.001, 95% CI 1.0002-1.001, per hour, p = 0.005]. SIGNIFICANCE Both presence of electrographic SE and time from ICU admission to cEEG initiation were independent factors associated with mortality in neonates and pediatric patients with cEEG in the ICU.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Child Neurology, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Arnold J Sansevere
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Rejean M Guerriero
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ersida Buraniqi
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Phillip L Pearl
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Robert C Tasker
- Division of Critical Care, Departments of Neurology, Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
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Abstract
PURPOSE OF REVIEW Approximately one in five children admitted to a pediatric ICU have a new central nervous system injury or a neurological complication of their critical illness. The spectrum of neurologic insults in children is diverse and clinical practice is largely empirical, as few randomized, controlled trials have been reported. This lack of data poses a substantial challenge to the practice of pediatric neurocritical care (PNCC). PNCC has emerged as a novel subspecialty, and its presence is expanding within tertiary care centers. This review highlights the recent advances in the field, with a focus on traumatic brain injury (TBI), cardiac arrest, and stroke as disease models. RECENT FINDINGS Variable approaches to the structure of a PNCC service have been reported, comprising multidisciplinary teams from neurology, critical care, neurosurgery, neuroradiology, and anesthesia. Neurologic morbidity is substantial in critically ill children and the increased use of continuous electroencephalography monitoring has highlighted this burden. Therapeutic hypothermia has not proven effective for treatment of children with severe TBI or out-of-hospital cardiac arrest. However, results of studies of severe TBI suggest that multidisciplinary care in the ICU and adherence to guidelines for care can reduce mortality and improve outcome. SUMMARY There is an unmet need for clinicians with expertise in the practice of brain-directed critical care for children. Although much of the practice of PNCC may remain empiric, a focus on the regionalization of care, creating defined training paths, practice within multidisciplinary teams, protocol-directed care, and improved measures of long-term outcome to quantify the impact of such care can provide evidence to direct the maturation of this field.
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Early Electroencephalographic Background Features Predict Outcomes in Children Resuscitated From Cardiac Arrest. Pediatr Crit Care Med 2016; 17:547-57. [PMID: 27097270 PMCID: PMC5201170 DOI: 10.1097/pcc.0000000000000740] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To determine 1) whether early electroencephalographic background features were associated with survival and neurologic outcomes among children resuscitated from cardiac arrest and not treated with therapeutic hypothermia and 2) if addition of electroencephalographic background to commonly used clinical criteria is more predictive of outcome than clinical criteria alone. DESIGN Retrospective study. SETTING PICU and Cardiac ICUs of a tertiary children's hospital. PATIENTS Patients resuscitated from in-hospital or out-of-hospital cardiac arrest who underwent clinically indicated electroencephalographic monitoring and were not treated with therapeutic hypothermia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-hundred twenty-eight patients underwent electroencephalographic monitoring within 1 day of return of spontaneous circulation. Background category was normal in four subjects (3%), slow-disorganized in 58 subjects (45%), discontinuous-burst suppression in 24 subjects (19%) and attenuated-flat in 42 subjects (33%). Forty-six subjects (36%) had a reactive electroencephalography. Twenty subjects (15%) had a seizure during electroencephalographic monitoring. Absence of reactivity (p < 0.001) and seizures (p = 0.04) were associated with worse electroencephalographic background category. After controlling for covariates, for each incrementally worse background score, the odds of death was 3.63 (95% CI, 2.18-6.0; p < 0.001) and the odds of unfavorable neurologic outcome was 4.38 (95% CI, 2.51-7.17; p = 0.001). CONCLUSIONS Worse electroencephalographic background early after resuscitation from both in-hospital and out-of-hospital cardiac arrest is associated with increased odds of death and unfavorable neurologic outcomes at hospital discharge. These electroencephalographic background patterns may be used in addition to clinical criteria to support prognostic decision making.
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Williams RP, Banwell B, Berg RA, Dlugos DJ, Donnelly M, Ichord R, Kessler SK, Lavelle J, Massey SL, Hewlett J, Parker A, Topjian A, Abend NS. Impact of an ICU EEG monitoring pathway on timeliness of therapeutic intervention and electrographic seizure termination. Epilepsia 2016; 57:786-95. [PMID: 26949220 PMCID: PMC4862885 DOI: 10.1111/epi.13354] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVES We aimed to determine whether implementation of a structured multidisciplinary electroencephalography (EEG) monitoring pathway improved the timeliness of administration of antiseizure medication in response to electrographic seizures in encephalopathic critically ill children. METHODS A multidisciplinary team developed a pathway to standardize EEG monitoring and seizure management in encephalopathic critically ill children, aiming to decrease the time from electrographic seizure onset to antiseizure medication administration. Data were collected to inform the team of improvement opportunities, which were then provided by an institutional pathway, staff education, and streamlined communication. Measurements were obtained before and after pathway implementation to assess for improvement. RESULTS We collected data on 41 patients before and 21 after pathway implementation. There were no differences between the baseline and pathway groups in demographic characteristics, acute encephalopathy etiologies, or antiseizure medications utilized. The median duration [interquartile range, IQR] from seizure onset to antiseizure medication administration was shorter for patients treated with the pathway (64 min [50, 101]) compared to patients treated prior to pathway implementation (139 min [71, 189]; p = 0.0006). The median [IQR] interval from seizure onset to antiseizure medication order was shorter for the pathway group (31 min [20, 49]) than the baseline group (71 min [33, 131]; p = 0.003). The median [IQR] interval from antiseizure medication order to administration was shorter for the pathway group (30 min [19, 40]) than the baseline group (40 min [17, 68]) (p = 0.047). Seizure termination was more likely to occur following initial antiseizure medication administration in the pathway than baseline group (67% vs. 27%, p = 0.002). SIGNIFICANCE Implementation of the pathway resulted in a significant reduction in the duration between electrographic seizure onset and antiseizure medication administration, and a significant increase in the rate of electrographic seizure termination following an initial antiseizure medication. Further study is needed to determine whether these changes are associated with improved outcomes.
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Affiliation(s)
- Ryan P. Williams
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Brenda Banwell
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Robert A. Berg
- Department of Critical Care Medicine, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Dennis J. Dlugos
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | | | - Rebecca Ichord
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Sudha Kilaru Kessler
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Jane Lavelle
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Shavonne L. Massey
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Jennifer Hewlett
- Department of Pharmacy Services, The Children’s Hospital of Philadelphia
| | - Allison Parker
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Alexis Topjian
- Department of Critical Care Medicine, The Children’s Hospital of Philadelphia and the University of Pennsylvania
| | - Nicholas S. Abend
- Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Department of Neurology, The Children’s Hospital of Philadelphia and the University of Pennsylvania
- Neurodiagnostics, The Children’s Hospital of Philadelphia
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Wilson CA. Continuous electroencephalogram detection of non-convulsive seizures in the pediatric intensive care unit: review of the utility and impact on management and outcomes. Transl Pediatr 2015; 4:283-9. [PMID: 26835390 PMCID: PMC4728999 DOI: 10.3978/j.issn.2224-4336.2015.10.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Non-convulsive seizures (NCS) are common among critically ill children with acute encephalopathy. Continuous electroencephalogram (CEEG) monitoring is an indispensable tool to detect NCS, which is essential to guiding management and assessing prognosis. Risk factors for NCS are highest in pediatric intensive care unit (PICU) patients with altered mental status (AMS) and a recently witnessed clinical seizure, acute changes on neuroimaging, and/or interictal abnormalities on CEEG. Screening for at least 24 hours in at risk pediatric populations is ideal, but around half of NCS may be detected within the first hour. Rapid treatment of prolonged seizures or status epilepticus is critical, as higher seizure burdens have been associated with poorer outcomes in critically ill children. This review integrates current information on critically ill children with AMS and the use of CEEGs, risk factors for NCS, duration of CEEG monitoring, and how the detection of NCS impacts management and outcomes.
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Affiliation(s)
- Carey A Wilson
- Department of Child Neurology, University of Utah School of Medicine, UT 84113, USA
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