Keywords
Neurocritical care, EEG, non-convulsive seizures, status epilepticus, Saudi Arabia
Neurocritical care, EEG, non-convulsive seizures, status epilepticus, Saudi Arabia
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.
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.
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.
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).
Diagnosis | n (%) |
---|---|
Cerebrovascular disease | 53 (26%) |
Epilepsy | 50 (25%) |
Sepsis/Metabolic | 40 (20%) |
Brain tumor | 8 (4%) |
CNS infections | 24 (12%) |
Post arrest | 10 (5%) |
Traumatic brain injury | 6 (3%) |
Variable | n (%) |
---|---|
NCS | 52 (26%) |
GPD | 22 (11%) |
LPD | 20 (10%) |
GRDA | 22 (11%) |
LRDA | 14 (7%) |
Variable | Mortality | Hospital Stay | |||
---|---|---|---|---|---|
Death within 60 days | <1 week | 1 week-1month | >1month | ||
EEG Seizures | No | 40 (27%) | 44 (30%) | 60 (40%) | 44 (30%) |
Yes | 22 (42%)* | 12 (23%) | 20 (39%) | 20 (39%) | |
Periodic or rhythmic patterns | No | 16 (25%) | 26 (40%) | 20 (31%) | 18 (28%) |
Yes | 46 (33%) | 30 (22%) | 60 (44%) | 46 (34%)* |
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.
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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Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
No
If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
No
If applicable, is the statistical analysis and its interpretation appropriate?
No
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: Researcher in the 'Pediatric Status Epilepticus Research Group' (PSERG); Journal reviewer; Senior Editor
Reviewer Expertise: Pediatric Neurocritical Care; Pediatric ICU
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Yes
Are sufficient details of methods and analysis provided to allow replication by others?
Yes
If applicable, is the statistical analysis and its interpretation appropriate?
I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: EEG
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