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Unstandardized treatment of electroencephalographic status epilepticus does not improve outcome of comatose patients after cardiac arrest.

ABSTRACT: OBJECTIVE:Electroencephalographic status epilepticus occurs in 9-35% of comatose patients after cardiac arrest. Mortality is 90-100%. It is unclear whether (some) seizure patterns represent a condition in which anti-epileptic treatment may improve outcome, or severe ischemic damage, in which treatment is futile. We explored current treatment practice and its effect on patients' outcome. METHODS:We retrospectively identified patients that were treated with anti-epileptic drugs from our prospective cohort study on the value of continuous electroencephalography (EEG) in comatose patients after cardiac arrest. Outcome at 6?months was dichotomized between "good" [cerebral performance category (CPC) 1 or 2] and "poor" (CPC 3, 4, or 5). EEG analyses were done at 24?h after cardiac arrest and during anti-epileptic treatment. Unequivocal seizures and generalized periodic discharges during more than 30?min were classified as status epilepticus. RESULTS:Thirty-one (22%) out of 139 patients were treated with anti-epileptic drugs (phenytoin, levetiracetam, valproate, clonazepam, propofol, midazolam), of whom 24 had status epilepticus. Dosages were moderate, barbiturates were not used, medication induced burst-suppression not achieved, and treatment improved electroencephalographic status epilepticus patterns temporarily (<6?h). Twenty-three patients treated for status epilepticus (96%) died. In patients with status epilepticus at 24?h, there was no difference in outcome between those treated with and without anti-epileptic drugs. CONCLUSION:In comatose patients after cardiac arrest complicated by electroencephalographic status epilepticus, current practice includes unstandardized, moderate treatment with anti-epileptic drugs. Although widely used, this does probably not improve patients' outcome. A randomized controlled trial to estimate the effect of standardized, aggressive treatment, directed at complete suppression of epileptiform activity during at least 24?h, is needed and in preparation.

SUBMITTER: Hofmeijer J

PROVIDER: S-EPMC3978332 | biostudies-literature | 2014

REPOSITORIES: biostudies-literature

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Unstandardized treatment of electroencephalographic status epilepticus does not improve outcome of comatose patients after cardiac arrest.

Hofmeijer Jeannette J Tjepkema-Cloostermans Marleen C MC Blans Michiel J MJ Beishuizen Albertus A van Putten Michel J A M MJ

Frontiers in neurology 20140331

<h4>Objective</h4>Electroencephalographic status epilepticus occurs in 9-35% of comatose patients after cardiac arrest. Mortality is 90-100%. It is unclear whether (some) seizure patterns represent a condition in which anti-epileptic treatment may improve outcome, or severe ischemic damage, in which treatment is futile. We explored current treatment practice and its effect on patients' outcome.<h4>Methods</h4>We retrospectively identified patients that were treated with anti-epileptic drugs from ...[more]

PMID: 24744748

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Project description:BackgroundThe prediction of neurological outcome in comatose patients after cardiac arrest has major ethical and socioeconomic implications. The purpose of this study was to assess the capability of serum neuron-specific enolase (NSE), a biomarker of hypoxic brain damage, to predict death or vegetative state in comatose cardiac-arrest survivors.MethodsWe conducted a prospective observational cohort study in one university hospital and one general hospital Intensive Care Unit (ICU). All consecutive patients who suffered cardiac arrest and were subsequently admitted from June 2007 to February 2009 were considered for inclusion in the study. Patients who died or awoke within the first 48 hours of admission were excluded from the analysis. Patients were followed for 3 months or until death after cardiopulmonary resuscitation. The Cerebral Performance Categories scale (CPC) was used as the outcome measure; a CPC of 4-5 was regarded as a poor outcome, and a CPC of 1-3 a good outcome. Measurement of serum NSE was performed at 24 h and at 72 h after the time of cardiac arrest using an enzyme immunoassay. Clinicians were blinded to NSE results.ResultsNinety-seven patients were included. All patients were actively supported during the first days following cardiac arrest. Sixty-five patients (67%) underwent cooling after resuscitation. At 3 months 72 (74%) patients had a poor outcome (CPC 4-5) and 25 (26%) a good outcome (CPC 1-3). The median and Interquartile Range [IQR] levels of NSE at 24 h and at 72 h were significantly higher in patients with poor outcomes: NSE at 24 h: 59.4 ng/mL [37-106] versus 28.8 ng/mL [18-41] (p < 0.0001); and NSE at 72 h: 129.5 ng/mL [40-247] versus 15.7 ng/mL [12-19] (p < 0.0001). The Receiver Operator Characteristics (ROC) curve for poor outcome for the highest observed NSE value for each patient determined a cut-off value for NSE of 97 ng/mL to predict a poor neurological outcome with a specificity of 100% [95% CI = 87-100] and a sensitivity of 49% [95% CI = 37-60]. However, an approach based on a combination of SSEPs, NSE and clinical-EEG tests allowed to increase the number of patients (63/72 (88%)) identified as having a poor outcome and for whom intensive treatment could be regarded as futile.ConclusionNSE levels measured early in the course of patient care for those who remained comatose after cardiac arrest were significantly higher in patients with outcomes of death or vegetative state. In addition, we provide a cut-off value for NSE (> 97 ng/mL) with 100% positive predictive value of poor outcome. Nevertheless, for decisions concerning the continuation of treatment in this setting, we emphasize that an approach based on a combination of SSEPs, NSE and clinical EEG would be more accurate for identifying patients with a poor neurological outcome.

Project description:BackgroundAmong cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors.MethodsA narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format.ResultsEleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors.ConclusionsThese guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.

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Unstandardized treatment of electroencephalographic status epilepticus does not improve outcome of comatose patients after cardiac arrest.

Publications

Unstandardized treatment of electroencephalographic status epilepticus does not improve outcome of comatose patients after cardiac arrest.

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