Cardiac Arrest Hans Friberg, Associate professor Center for Resuscitation Science Lund University Sweden CENTER FOR RESUSCITATION SCIENCE IN THE ØRESUND REGION The 42nd Annual Meeting of The Japanese Society of Intensive Care Medicine
/ Date Natural course of brain recovery following cardiac arrest COMA Vegetative state Cardiac arrest Brain stem recovery Recovery of cortical function Brain Dead hours – days (– weeks)
/ Date Nielsen et al. CCM 2011 Jan;39(1):57-64 1000 patients – clinical or electrographic seizures in 24% • Good outcome in 17% at 6 months Seizures after cardiac arrest – The Hypothermia Registry –
/ Date Seder et al. CCM 2015, e-pub ahead of print 2500 patients – myoclonic seizures in 18% • Epileptiform activity in 55% • Good outcome in 9% Seizures after cardiac arrest – International Cardiac Arrest Registry –
/ Date Rundgren et al. CCM 2010;38:1838 Electrographic seizures in 26/95 patients – 27% • 2/26 patients (8%) good outcome Seizures after cardiac arrest
/ Date EEG after cardiac arrest • Recommends EEG during hypothermia and within 24h after rewarming to rule out non-convulsive seizures • Suggests EEG to assist with prognostication, particularly in patients treated with hypothermia • Suggests continuous EEG to assist with prognostication of coma Further data are necessary to understand its full potential Claassen J et al. ICM 2013
/ Date EEG after cardiac arrest – limitations • Different grading systems, definitions & terminology • EEG can be affected by sedation • Inter-rater variability • Cost – continuous multichannel EEG • Lack of large prospective studies on the prevalence and predictive value of EEG-changes
/ Date Objective: Standardize terminology of EEG-patterns in the critically ill Goal: Aid communication and facilitate future research Hirsch LJ et al. J Clin Neurophysiol 2012 Critical Care EEG terminology – ACNS
/ Date • Traditional multichannel montage • Simplified montage, few channels • Trend curves with compressed time scale • Simplified montage and trend curves – aEEG Continuous EEG – cEEG Friedman et al. Anesthesia and Analgesia 2009
/ Date aEEG amplitude integrated electroencephalography Established method in neonatal ICUs! Preferred method in adult ICUs! • simplified EEG – few channels • trend analysis – to facilitate!
/ Date Friberg H et al. Critical Care 2013 Seizures are common after cardiac arrest…. …clinical signs of recovery or deterioration, which previously could be observed, are now concealed by sedation, analgesia, and muscle paralysis. cEEG can be made more simple by reducing the number of electrodes and by adding trend analysis to the original EEG curves…
/ Date • To reach general use, cEEG needs to be – Simple • Reduce the number of leads • Add trend analysis to the original EEG curves – Possible to apply bedside, preferably by ICU-staff – Cost-effective Continuous EEG (cEEG) after cardiac arrest
/ Date Simplified interpretation 4 dominating EEG patterns after CA 1.Flat 2.Continuous background 3.Suppression-burst (SB) 4.Electrographic status epilepticus (ESE) Rundgren et al. CCM 2010
/ Date Prognostic value of simplified aEEG monitoring after CA • 95 adult comatose patients • Primary cardiac arrest • Hypothermia treated Rundgren et al. Crit Care Med 2010 Prospective study Lund 2004-2008
/ Date • 57/95 patients recovered consciousness • An initial flat pattern is common – no correlation to outcome • Recovery of a continuous background pattern is a good early predictor of recovery of consciousness – PPV 0.87 • All other patterns than a continuous background at normo- thermia are strong predictors of poor outcome – NPV 0.91 • Electrographic SE develops from two different background patterns, which may have therapeutic implications Rundgren et al. CCM 2010 Simplified aEEG monitoring after CA
/ Date Late Cont. Prolonged Suppr-Burst Early Cont. Early Flat Late Flat Early ESE Late ESE from Cont. 8h 36h 60h Hypotherma aEEG-mon 2 channels Uncertain Malignant Benign
/ Date The rationale: • Simple to apply and simple to use • A trend monitor of brain function – Aids in prognostication – Seizure detection • Guide anticonvulsive treatment • Early and continuous prognostic information – good as well as poor outcome Simplified aEEG monitoring after CA
/ Date A patient with late debut of ESE, 3 weeks in the ICU and good outcome Continuous background Flat Electrographic status epilepticus Hours after cardiac arrest: 6 24 72 48 12 18 30 36 42 54 60 66 EEG pattern: No registration No registration ** Normothermia 1 sec 100μV Westhall et al. Ther Hypothermia Temp Manag 2013
/ Date Electrographic seizures Our treatment strategy: I. Continuous evaluation (simplified aEEG) II. Suppression of electrographic seizures – 24 h III. In selected cases – prolonged treatment 1-2 w I. ESE from a continuous pattern II. Preserved N20 potentials III. Low Neuron Specific Enolase (NSE) IV. Patience…
/ Date • aEEG is feasible to perform and a valuable tool after cardiac arrest – prognosis, seizure detection • Needs to be validated against gold standard • Collaboration with neurophysiologists and education of staff are keys to sucess Conclusions II
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