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Research Article

The yield of continuous EEG monitoring in the intensive care unit at a tertiary care hospital in Saudi Arabia: A retrospective study

[version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]
PUBLISHED 15 May 2019
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Abstract

Background: The practice of continuous EEG monitoring (CEEG) in the intensive care unit (ICU) has been spreading over the past decade. Building an effective ICU CEEG program with sufficient quality demands adequate EEG equipment and significant human resources. While this is available in large tertiary care centers where the practice of CEEG has developed, it may not be available in developing healthcare systems. This study sought to provide data generated from a CEEG program in the adult ICU at a tertiary healthcare center in Saudi Arabia, shedding light on the real-life utility of CEEG in a developing healthcare system.
Methods: This is a retrospective review of CEEG findings, along with mortality and duration of hospitalization of patients who had CEEG during a 12-month period at the adult ICU at the King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia.
Results: A total of 202 CEEG records were identified. A total of 52 patients had non-convulsive seizures (NCS); 10 clearly fulfilled criteria for non-convulsive status epilepticus. There were 120 patients that had clinical seizures upon presentation. Among them, 36 (30%) had NCS on EEG. The proportion of patients who were deceased at 60 days was higher in patients who had NCS (42%) than those who didn’t (26%, χ(2, n=200)= 4.4, p=0.03). The duration of hospital stay was longer for those who had periodic or rhythmic CEEG patterns (χ2 (2, n=200)= 7.6, p=0.02) but there was no significant relationship with mortality at 60 days.
Conclusion: This study demonstrates a real-world experience from a tertiary care center in Saudi Arabia, a developing healthcare system. Findings are consistent with prior experience with ICU CEEG, demonstrating that finding ictal, rhythmic or periodic patterns is associated with morbidity and mortality. Further studies are needed to demonstrate how the practice of CEEG may alter patient outcomes.

Keywords

Neurocritical care, EEG, non-convulsive seizures, status epilepticus, Saudi Arabia

Introduction

Continuous electroencephalography (CEEG), the practice of continuously recording an electroencephalogram and a time-synchronized video of the patient, is commonly utilized to monitor critically ill patients with acute brain injury or altered mental status1. CEEG is instrumental in the diagnosis and management of nonconvulsive seizures (NCS) and status epilepticus, detection of cerebral ischemia, prognostication of outcomes after cardiorespiratory arrest, and evaluation of abnormal movements and altered mental status1. The practice of CEEG monitoring of critically ill patients in the intensive care unit (ICU) has been spreading over the past decade, particularly in Europe and North America1,2. Building an effective ICU CEEG program with sufficient quality demands not only adequate EEG equipment but also significant human resources2. This includes trained electroencephalographers and technologists who have enough time to devote to reviewing the large amounts of EEG data that are generated through continuous monitoring2. While this is available in large tertiary care centers where the practice of CEEG has developed, it may not be available in developing healthcare systems. Most of the published CEEG data also come from these advanced centers in North America and Europe.

This study sought to provide data generated from a CEEG program in the adult ICU at a tertiary healthcare center in Saudi Arabia, aiming to shed light on the real-life utility of CEEG in a developing healthcare system outside North America and Europe.

Methods

Data gathering

This is a retrospective review of ICU CEEG findings, as well as mortality status and duration of hospitalization of all patients who underwent CEEG monitoring during a 12-month period from September 2016 to August 2017 at the adult ICU at the King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. This is an academic, tertiary-care, 600-bed hospital. Its adult ICU is comprised of 30 beds and is divided into medical and surgical divisions. CEEGs are requested by ICU physician or neurologists according to the clinical needs. An EEG technologist is available during the day time to set up ICU CEEGs. EEG leads are placed using the 10–20 international system of lead placement. CEEGs are digitally recorded, including synchronized video recording of the patient. The duration of CEEG monitoring is decided by the neurology consultation or ICU physicians. Studies whose duration was less than 2 hours were not included in the study as they were considered extended but not long-term studies. An epileptologist with fellowship training in CEEG interpretation reviewed the records on daily basis and reported them using the American Clinical Neurophysiology Society (ACNS) ICU EEG consortium proposed nomenclature for ICU EEG reporting, and the Salzburg criteria for non-convulsive status epilepticus3. Management decisions were made by the physicians in the ICU and neurology services.

Data analysis

Reports of CEEGs performed in the adult ICU during the study period were retrieved from the hospital’s electronic medical records (EMR). The author extracted key data from the reports, including background characteristics, the presence of rhythmic and periodic patterns or NCS. The author retrieved relevant demographic and clinical patient data from the hospital’s EMR, including diagnoses, ICU and hospital stay, and mortality status at 60 days. Frequencies, percentages, means, standard deviation, and Chi square were performed using the IBM SPSS Statistics for Windows, version 20.0.

Ethical approval

This study was approved by the Institutional Review Board of KAUH as a retrospective study of anonymized clinical data with waiver of additional patient consent.

Results

A total of 202 CEEG records fulfilling the criteria were identified; complete, raw figures are available as Underlying data4. There were 116 female patients. The mean age was 53 (standard deviation=21). The duration of CEEG recording varied, with 48 (24%) recorded for 2–6 hours and 154 (76%) recorded for 6–24 hours. Table 1 shows the frequency of clinical diagnoses of our patients. The most common diagnostic categories were cerebrovascular disease and epilepsy. Table 2 shows the frequency of CEEG findings. Among the 52 patients that had NCS on CEEG, 10 patients clearly fulfilled criteria for non-convulsive status epilepticus. There were 120 patients that had clinical seizures upon presentation prior to CEEG monitoring. Among them, 36 (30%) had NCS on EEG. The proportion of patients who were deceased at 60 days was significantly higher in patients who had NCS (42%) than those who didn’t (27%, χ2 (2, n=200)= 4.4, p=0.03) (Table 3). There was no significant difference in the duration of hospital stay between those who had seizures and those who didn’t (p=0.2) (Table 3). The duration of hospital stay was longer for those who had periodic or rhythmic CEEG patterns (χ2 (2, n=200)= 7.6, p=0.02) but there was no significant relationship with mortality at 60 days (Table 3).

Table 1. Frequencies and percentages of relevant clinical diagnoses in the study sample.

Diagnosisn (%)
Cerebrovascular disease53 (26%)
Epilepsy50 (25%)
Sepsis/Metabolic40 (20%)
Brain tumor8 (4%)
CNS infections24 (12%)
Post arrest10 (5%)
Traumatic brain injury6 (3%)

Table 2. Frequencies and percentages of non-convulsive seizures (NCS), generalized periodic discharges (GPD), lateralized periodic discharges (LPD), GRDA (generalized rhythmic delta activity), and LRDA (lateralized rhythmic delta activity) in the study sample.

Variablen (%)
NCS52 (26%)
GPD22 (11%)
LPD20 (10%)
GRDA22 (11%)
LRDA14 (7%)

Table 3. Cross-tabulation of mortality and duration of hospital stay in relation to the presence of seizures and periodic or rhythmic patterns on CEEG.

VariableMortalityHospital Stay
Death within 60 days<1 week1 week-1month>1month
EEG SeizuresNo40 (27%)44 (30%)60 (40%)44 (30%)
Yes22 (42%)*12 (23%)20 (39%)20 (39%)
Periodic or rhythmic patternsNo16 (25%)26 (40%)20 (31%)18 (28%)
Yes46 (33%)30 (22%)60 (44%)46 (34%)*

*p<0.05.

Discussion

The practice of using CEEG in the ICU has developed rapidly over the past decade, particularly in North America and Europe1,5. This study is one of the first to report the experience of using ICU CEEG in Saudi Arabia, a country with a rapidly developing healthcare system that faces economic constraints. The data are consistent with prior knowledge and experience from other countries that CEEG is effective in detecting NCS and other likely harmful subclinical EEG patterns on the ictal-interictal continuum5,6. This study also shows a significant association between NCS and mortality. In addition, having periodic or rhythmic patterns was significantly associated with longer hospital stays.

Prior studies have not definitively proven that utilizing CEEG leads to better outcomes2,5. This, coupled with the significant resources required to effectively run an ICU CEEG program2, may lead decision makers in healthcare systems to hesitate to support the development of CEEG practices. This study presents local data that demonstrate the need for CEEG. The data also raises questions whether CEEG is being utilized optimally. For example, few patients with brain tumors had CEEG, even though this is a patient population at risk of NCS. This suggests a need for a protocol for CEEG in the ICU, with focus on indications, required duration of monitoring, and management of NCS.

This study is a retrospective analysis with limitations. Data extracted from the EMR did not allow clarity with regards to the mental status of patients, use of sedatives, and other management decisions. Physicians did not follow a clear protocol when deciding the duration of the CEEG study. Longer studies may lead to higher detection rates of relevant CEEG patterns. The number of cases in some diagnostic categories was not high enough to permit subgroup analyses. The clinical setting is that of a developing program with limited resources and must be interpreted in this context. Further studies from developing healthcare systems like Saudi Arabia’s are needed to illuminate how the practice of CEEG monitoring may be integrated in the region.

Data availability

Open Science Framework: The yield of continuous EEG monitoring in the ICU at a tertiary care hospital in Saudi Arabia: A retrospective study. https://doi.org/10.17605/OSF.IO/Q56J34.

This project contains all raw de-identified data associated with this study.

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

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Tayeb HO. The yield of continuous EEG monitoring in the intensive care unit at a tertiary care hospital in Saudi Arabia: A retrospective study [version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]. F1000Research 2019, 8:663 (https://doi.org/10.12688/f1000research.19237.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 15 May 2019
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Reviewer Report 18 Sep 2019
Yara Mikhaeil-Demo, University of Illinois at Chicago, Chicago, USA 
Elizabeth E Gerard, Department of Neurology, Feinberg School of Medicine, Northwestern University (NU), Chicago, IL, 60611​, USA 
Approved with Reservations
VIEWS 15
This paper describes a one-year experience using continuous EEG monitoring in a developing healthcare system. The authors experience with a growing cEEG program is a valuable addition to the literature. We have some comments and questions to better understand the results ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Mikhaeil-Demo Y and Gerard EE. Reviewer Report For: The yield of continuous EEG monitoring in the intensive care unit at a tertiary care hospital in Saudi Arabia: A retrospective study [version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]. F1000Research 2019, 8:663 (https://doi.org/10.5256/f1000research.21080.r54081)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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39
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Reviewer Report 23 Jul 2019
Robert C. Tasker, Department of Neurology, Harvard Medical School, Boston, MA, USA 
Not Approved
VIEWS 39
The author has described a practice of continuous EEG monitoring in an intensive care unit in a University Hospital in Jeddah, Saudi Arabia.

I have a number of comments that will help readers better understand what these ... Continue reading
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CITE
HOW TO CITE THIS REPORT
Tasker RC. Reviewer Report For: The yield of continuous EEG monitoring in the intensive care unit at a tertiary care hospital in Saudi Arabia: A retrospective study [version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]. F1000Research 2019, 8:663 (https://doi.org/10.5256/f1000research.21080.r51103)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 27 Aug 2019
    Haythum Tayeb, Division of Neurology, Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
    27 Aug 2019
    Author Response
    Dear Dr. Tasker,

    Thank you very much for your time and detailed review of my manuscript entitled: “The yield of continuous EEG monitoring in the intensive care unit at a tertiary ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 27 Aug 2019
    Haythum Tayeb, Division of Neurology, Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
    27 Aug 2019
    Author Response
    Dear Dr. Tasker,

    Thank you very much for your time and detailed review of my manuscript entitled: “The yield of continuous EEG monitoring in the intensive care unit at a tertiary ... Continue reading
Views
29
Cite
Reviewer Report 23 May 2019
Peter W Kaplan, Department of Neurology, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA 
Approved
VIEWS 29
How many of the NCSE were focal versus generalized? 

Did not the mortality vary with etiology of NCSE and PDs?

I would add in the final section on limitations of the study that there is ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Kaplan PW. Reviewer Report For: The yield of continuous EEG monitoring in the intensive care unit at a tertiary care hospital in Saudi Arabia: A retrospective study [version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]. F1000Research 2019, 8:663 (https://doi.org/10.5256/f1000research.21080.r48822)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 27 Aug 2019
    Haythum Tayeb, Division of Neurology, Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
    27 Aug 2019
    Author Response
    Dear Dr. Kaplan,

    Thank you very much for kindly reviewing my manuscript entitled: “The yield of continuous EEG monitoring in the intensive care unit at a tertiary care hospital in Saudi ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 27 Aug 2019
    Haythum Tayeb, Division of Neurology, Department of Internal Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
    27 Aug 2019
    Author Response
    Dear Dr. Kaplan,

    Thank you very much for kindly reviewing my manuscript entitled: “The yield of continuous EEG monitoring in the intensive care unit at a tertiary care hospital in Saudi ... Continue reading

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 15 May 2019
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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