Pediatric Continuous EEG Monitoring: Case Presentation December 5, 2011

Transcription

1 Pediatric Continuous EEG Monitoring: Case Presentation December 5, 2011 Sudha Kilaru Kessler M.D. Assistant Professor of Neurology and Pediatrics Children s Hospital of Philadelphia University of Pennsylvania American Epilepsy Society Annual Meeting

2 Disclosure No disclosures American Epilepsy Society Annual Meeting

3 Learning Objectives This case provides a framework for considering how continuous EEG monitoring is used in the pediatric intensive care setting. American Epilepsy Society Annual Meeting

4 Introduction 9 year old previously healthy girl. Presented to the emergency department after 3 days of headache, nausea, emesis. Examination: right hemianopsia. Increasingly somnolent within hours. Head CT, toxicology screen, blood count, basic metabolic panel were all unrevealing. Admitted to the pediatric intensive care unit. Is an EEG needed? EEG monitoring?

5 Non-Convulsive Seizures: Prevalence, Risk Factors and Indications for EEG Monitoring December 5, 2011 Nicholas Abend, MD Assistant Professor of Neurology & Pediatrics The Children s Hospital of Philadelphia & University of Pennsylvania School of Medicine American Epilepsy Society Annual Meeting American Epilepsy Society Annual Meeting

6 Disclosure None. American Epilepsy Society Annual Meeting

7 Learning Objectives List current indications for EEG monitoring in critically ill children. Discuss the incidence of non-convulsive seizures in critically ill children. Identify children at increased risk for non-convulsive seizures. Select how long to monitor children. American Epilepsy Society Annual Meeting

8 Seizures are the most common pediatric neuro-icu conditions leading to neurologic consultation (35%). Bell MJ, Carpenter J, Au AK, Keating RF, Myseros JS, Yaun A, Weinstein S. Neurocritical Care, % of PICU patients undergo continuous EEG (ceeg) monitoring Melbourne Shahwan A, Bailey C, Shekerdemian L, Harvey AS. Epilepsia, Philadelphia Abend NS, unpublished

9 De Georgia MA, Deogaonkar A. Neurologist, 2005 EEG ADVANTAGES Non-invasive. Extensive coverage. Available at bedside. Continuous data acquisition. Functional test. DISADVANTAGES Technical expertise. Interpretation expertise. Findings often non-specific. Expensive.

10 1. Current Practice - ceeg & NCS Management 2. Impact of ceeg on Management 3. Non-Convulsive Seizure Epidemiology

11 1. Current Practice - ceeg & NCS Management 2. Impact of ceeg on Management 3. Non-Convulsive Seizure Epidemiology

12 Yes, I d like to ask a very specific question that pertains to only me, and then go on and on and on

13 Responses from 47/50 US and 11/11 Canadian institutions. US News & World Report - 50 neurology/neurosurgery programs. 1 response per institution. 31 questions (5-10 minutes). Significant increase (~30%) in patients undergoing ceeg over 1 year. United States - median of 10 patients per month. Canada median 3 patients per month. Sanchez S, Carpenter J, Chapman KE, Dlugos DJ, Giza CC, Hahn CD, Kessler SK, Goldstein J, Loddenkemper T, Riviello JJ, Abend NS. For the Pediatric Critical Care EEG Consortium (PCCEG).

14 ceeg Indication % Event Characterization (movement, Δvital signs) 95% ΔMS after seizure or status epilepticus 97% ΔMS with acute primary neurologic disorder 88% ΔMS of unknown etiology 88% ΔMS & systemic disorder (no neurologic disorder) 72% Resuscitation from Cardiac Arrest 62% Traumatic Brain Injury 53% Extra Corporal Membrane Oxygenation (ECMO) 34%

15 EEG Review Frequency % Never 27% 1 per day 16% 2 per day 27% Technologist Review 3 per day 4% 4 per day 5% >4 per day 7% Continuously 14% 1 per day 19% 2 per day 37% Physician Review 3 per day 19% 4 per day 7% >4 per day 17% Continuously 2%

16 Technologists: Available 24/7: 79% (51% by call-back) Screen EEG: 50%.

17 330 physicians responded. Academic/Tertiary Care 85% ceeg Available 24/7 80% ceeg > 1 patient per month 83% Abend NS, Dlugos DJ, Hahn CD, Hirsch LJ, Herman ST. Neurocritical Care 2010.

18 Any NCS Multiple NCS Only NCSE Never Tolerate < 10 NCS per day Tolerate <5 NCS per day Terminate all NCS Induce Burst Suppression Induce Electrocerebral Silence % of Respondents Treatment Initiation Overall Treatment Goal

19 % of Respondents % of Respondents Anticonvulsant for NCSE Anticonvulsant for NCS

20 % of Respondents Persist Persist Persist Never if after 1st after 2nd after 3rd only NCS AED AED AED Persist Persist Persist after 1st after 2nd after 3rd AED AED AED Never if only NCSE NCS Coma Induction for NCS NCSE Coma Induction for NCSE

21 ceeg to screen for NCS in children with: Δ MS of unknown etiology, Δ MS and a known acute neurologic disorder. Δ MS following a convulsion. Screening twice per day is most common practice. Clinical uncertainty: overall NCS management approach and specific AED choices. Evidence-based pathways are needed. Abend NS, Dlugos DJ, Hahn CD, Hirsch LJ, Herman ST. Neurocritical Care Sanchez S, Carpenter J, Chapman KE, Dlugos DJ, Giza CC, Hahn CD, Kessler SK, Goldstein J, Loddenkemper T, Riviello JJ, Abend NS. For the Pediatric Critical Care EEG Consortium (PCCEG).

22 1. Current Practice - ceeg & NCS Management 2. Impact of ceeg on Management 3. Non-Convulsive Seizure Epidemiology

23 Off hand, I d say you re suffering from an arrow through your head, but just to play it safe, I m ordering a bunch of tests.

24 N=100, Prospective consecutive, Tertiary care PICU. ceeg if acute neurologic disorder with ΔMS. Median Age = 2.9 years Median ceeg Duration = 2 days Acute Encephalopathy Etiology: HIE 31 Epilepsy 24 CNS Infection 10 Other Non-Structural 10 TBI 7 Stroke 7 Other Structural 6 Neurosurgical 5 ceeg impact: Δ AED, Event not sz, Urgent imaging. Abend NS, Topjian AA, Gutierrez-Colina AM, Donnelly M, Clancy RR, Dlugos DJ. Neurocritical Care

25 ceeg impacted management in 60 of 100. Urgent Neuroimaging = 5 (3 impacted management) NCS identified = 39 Paroxysmal Event Not Seizure = 21 Movement = 16 (4 had unrelated NCS) Vital sign fluctuation = 5 (3 had unrelated NCS) Total of 46 had NCS AED changes = 47 Initiate=28 Escalate = 15 Discontinue = 4

26 Critically ill children: Retrospective, N=122 Seizures = 38% Non-Epileptic Events = 27% apnea, desats, ICP increases, tachycardia, abn movements. Williams K, Jarrar R, Buchhalter J. Epilepsia, Critically Ill adults: Retrospective, N=300 ceeg led to AED changes in 52% (Initiation 14%, Modification 33%, Discontinuation 5%) Kilbride RD, Costello DJ, Chiappa KH. Arch Neuro

27 1. Current Practice - ceeg & NCS Management 2. Impact of ceeg on Management 3. Non-Convulsive Seizure Epidemiology

28

29 NCS-NCSE in 7-100% of critically ill children. Age Etiology of Acute Neurologic Disorder ceeg Indication Study Design

30 Study Convulsive SE TBI ICH SAH Altered Mental Status Claassen % 8% 9% 13% 5% Medical ICU DeLorenzo % Trieman % Vespa % Vespa % Claassen % Alroughani % Towne % Kilbride % Oddo % McHugh %

31 Study Epilepsy Δ MS HIE TBI Tumor ICH Stroke CNS Infxn Toxic- Metab Alehan % 14% Hosain % Jette % 72% 54% 57% 66% 100% 66% 100% 55% Saengpattrachai % Hyllienmark % Abend % Shahwan % Abend % 39% 29% 40% 71% 70% 40% Williams % 21% 70% 33% McCoy % 40% 14%

32 Study Abend 2009 Abend 2011 Jette 2006 Williams 2011 McCoy 2011 Shahwan 2010 N Age 19 Ped 100 Ped 117 Neo+Ped 122 Neo+Ped 121 Neo+Ped 100 Ped EEG Indication % with Acute CNS Disorder NCS or NCSE s/p Cardiac Arrest with HIE 100% 48% ΔMS & acute CNS condition 100% 46% Critically ill and underwent ceeg >68% 39% Critically ill and underwent ceeg >62% 38% Critically ill and underwent ceeg 52% 29% Sustained depressed consciousness 50% 7%

33 Study Abend 2011 Jette 2006 Williams 2011 Hosain 2005 McCoy 2011 Saengpattrachai 2006 N Location 100 Ped 117 Neo+Ped 122 Neo+Ped 178 Neo+Ped 121 Neo+Ped 141 Ped EEG Indication Study Type NCS or NCSE ΔMS & acute CNS condition Pro 46% Critically ill and underwent ceeg Retro 39% Critically ill and underwent ceeg Retro 38% Persistently unresponsive Retro 33% Critically ill and underwent ceeg Retro 29% Unexplained ΔMS and underwent EEG Retro 16%

34 ceeg Indication: acute neurologic disorder with ΔMS 100 critically ill children Seizures 46 No Seizures 54 Non- Convulsive Seizures 27 Non- Convulsive Status Epilepticus 19 Non-Convulsive Only 20 Non-Convulsive & Convulsive 7 Non-Convulsive Only 12 Non-Convulsive & Convulsive Abend NS, Gutierrez-Colina AM, Topjian AA, Zhao H, Guo R, Donnelly M, Clancy RR, Dlugos DJ. Neurology

35 NCS Only: 29-75% of those with seizures. Jette N. et al., 2005 ; Abend NS et al., 2011; Williams K. et al., 2011 ; Shahwan A, et al. 2010; McCoy B et al., Many seizures would be missed without ceeg, even with optimal clinical observation. 6% receiving paralytics while NCS occurred. Abend NS, Gutierrez-Colina AM, Topjian AA, Zhao H, Guo R, Donnelly M, Clancy RR, Dlugos DJ. Neurology Electromechanical uncoupling/dissociation.

36 Clinical Risk Factors: Younger Age Abend et al., 2011; Williams et al., 2011 Convulsive SE Williams et al.,2011 Acute Seizures McCoy et al., 2011 Acute Structural Brain Injury McCoy et al., 2011 TBI Williams et al., 2011 Electrographic Risk Factors: Lack of Reactivity Jette et al., 2006 Epileptiform Discharges Williams et al. 2011; Jette et al., 2006; McCoy et al., 2011

37 13% Abend NS, Gutierrez-Colina AM, Topjian AA, Zhao H, Guo R, Donnelly M, Clancy RR, Dlugos DJ. Neurology % of NCS detected within 24 hours. Hyllienmark, L. et al., 2005 Jette N et al., 2006 Shahwan A et al., 2010 Williams K et al., 2011 McCoy B et al., 2011 Identifying the remaining 13% would require a tripling of ceeg monitoring days.

38 % of Respondents Comatose Obtunded/Lethargic PEDs Present Hr 3 Hrs 6 Hrs 12 Hrs 24 Hrs 48 Hrs 72 Hrs Hours of ceeg if No Seizures Detected Abend NS, Dlugos DJ, Hahn CD, Hirsch LJ, Herman ST. Neurocritical Care 2010.

39 Observational, N=200, NCS-NCSE=82, AEDs=80. 1st Anticonvulsant Effective Refractory ( 4 anticonvulsants) % Electrographic Seizures Electrographic Status Epilepticus Topjian AA, Sanchez S, Berg RA, Dlugos DJ, Abend NS. In preparation.

40 PHT-FOS PB LEV VPA PHT-FOS PB LEV VPA % Initial AC Administered ES ESE PHT- PB LEV VPA PHT- PB LEV VPA FOS FOS Initial Anticonvulsant Initial Anticonvulsant Administered Efficacy* Initial AC Efficacy *No difference (p=0.39) after controlling for age and acute neurologic disorder. Topjian AA, Sanchez S, Berg RA, Dlugos DJ, Abend NS. In preparation.

41 1. Current Practice - ceeg & NCS Management ceeg increasingly used to identify NCS in at-risk patients. Intermittent ceeg review is most common practice. 2. Impact of ceeg on Management Impacts management (60%): NCS identification, AED changes. 3. Non-Convulsive Seizure Epidemiology NCS-NCSE in 50% with ΔMS and acute neurologic disorder. 87% of NCS detected with 1 day ceeg. Younger, acute convulsions, acute structural brain injury and epileptiform discharges - increased risk of NCS. NCS can often be treated with standard AEDs.

42 Dennis Dlugos Robert Clancy, Gihan Tennekoon Alexis Topjian, Robert Berg Sudha Kessler, Courtney Wusthoff, Eric Marsh Ana Gutierrez-Colina, Sarah Sanchez CHOP Neurophysiology Service and Fellows Amir Pshytycky, Raji Mahalingam, Nicole Ryan, Courtney Wusthoff, Karen Skjie, Katie Taub, Saba Ahmad CHOP Neurology Consult Service CHOP Neurophysiology Technologists - Maureen Donnelly Support: NINDS NSADA CHOP Department of Pediatrics Institutional Development Fund NINDS K23 (NS )

43 Are seizures and status epilepticus associated with worse outcome? How can we more efficiently identify seizures? How do we best treat seizures in critically ill children? How can we implement ICU ceeg in an appropriate and feasible manner? Joshua Goldstein, MD Children s Memorial Hospital Northwestern University Cecil Hahn, MD Hospital for Sick Children University of Toronto James Riviello Jr., MD NYU Langone Medical Center New York University School of Medicine Susan Herman, MD Beth Israel Deaconess Medical Center Harvard Medical School