INTENSIVE CARE UNIT / CONTINOUS EEG MONITORING

STAFFING AND IMPLEMENTATION

Maria Lucia Furtado de Mendonça Iodete Carneiro do PradoElizabeth Maria D’Almeida RibeiroElizabeth Maria D’Almeida RibeiroAna Cláucida T. Mattos

WHY MONITOR THE BRAIN

IN I.C.U. ???

?

� Physiophatological changes are dynamic

� Information must be dynamic

� Neurophysiological abnormalities are detectedbefore clinical deterioration

CRITICAL CARE PATIENT:

� Intervention before clinical deterioration

� Therapeutic control

� Early prognostic information

� Differential diagnosis of conscience disturbances

DOPPLER DOPPLER TRANSCRANIANOTRANSCRANIANO

SUPORTE NEUROLÓGICO EM U.T.I.SUPORTE NEUROLÓGICO EM U.T.I.

PRESSÃOPRESSÃOINTRACRANIANAINTRACRANIANA

EEG CONTINUO EEG CONTINUO

SjVO2SjVO2

MICRODIÁLISEMICRODIÁLISEPOTENCIAISPOTENCIAISEVOCADOSEVOCADOS

JULGAMENTO MÉDICOJULGAMENTO MÉDICO

� Cobertura cortical ampla

� Relação direta e dinâmica com anormalidades de perfusão

ELETRENCEFALOGRAMA:

sensível a anestesia, temperatura e sensível a anestesia, temperatura e distúrbios metabólicosdistúrbios metabólicos

� Resistente a anestésicos e hipotermia

� Correlação estabelecida com isquemia cerebral

POTENCIAL EVOCADO SÔMATO SENSITIVO:

Limitado a uma via neuralLimitado a uma via neural

� Detecta e quantifica sinais de microembolização (MES)

� Detecta anormalidades hemodinâmicas intracranianas em tempo real

DOPPLER TRANSCRANIANO:

Não avalia função cerebral diretamenteNão avalia função cerebral diretamente

INDICATIONS FOR ICU - CEEG :

� Unexplained decrease in LOC

�Detection of subclinical seizures

�Unstable cerebral ischaemia�Unstable cerebral ischaemia

�Early detection of vasospasm in SAH

�Increased ICP with decrease in LOC

�Prognosis

Uninformative bedside assessment:

INDICATIONS FOR ICU - CEEG :cont.

�Medication - induced coma with/without NMB use

1. SENSITIVE TO CARDIAC ISCHEMIA

SENSITIVE TO CEREBRAL ISCHEMIA

2. DETECTS CARDIAC ISCHEMIA DETECTS CEREBRAL ISCHEMIA

EKG EEG

CEEG = “EKG MONITORING” OF THE BRAIN

Courtesy KG Jordan ,MD. 2006KG Jordan ,MD. 2006

2. DETECTS CARDIAC ISCHEMIA AT A REVERSIBLE STAGE

DETECTS CEREBRAL ISCHEMIA AT A REVERSIBLE STAGE

3. CORRELATES WITH CARDIAC BLOOD FLOW

CORRELATES WITH CEREBRAL BLOOD FLOW

4. RAPIDLY AND ACCURATELY DETECTS CARDIAC ARRHYTHMIAS

RAPIDLY AND ACCURATELY DETECTS EPILEPTIC ACTIVITY

Are nonconvulsive seizures a significant problem in the ICU ??

�� 35%35% of NeuroICU patients found to have seizures (Jordan 1992)

�� 22%22% of TBI patients have seizures, ½ of which are nonconvulsive (Vespa 1999)

YES!!!

22%22%nonconvulsive (Vespa 1999)

�� 28%28% of ICH patients have seizures, ½ of which are nonconvulsive (Vespa 2003)

�� 15%15% of SAH patients have seizures (Claassen 2004)

�� 44%44% of pediatric ICU patients have seizures on cEEG (Jette, Hirsch 2006)

CEEG findings – 570 patients Claassen, 2004 :

MORTALIDADE - EMENC•• Retardo no diagnóstico:Retardo no diagnóstico:

– <0.5 h: 36% (5/14)– >1 <24 h: 39% (7/18) – ≥24 h: 75% (6/8)

•• Duração da criseDuração da crise::

– <10 h: 10% (3/30)

* Young GB, Jordan KG., Doig G. Neurology, 1996

•• Duração da criseDuração da crise– <10 h: 10% (3/30) – 10-20 h: 33% (2/6) – >20 h: 85% (11/13)

•• Etiologia:Etiologia:– Lesão crônica : 16% (4/25)– Lesão aguda : 46% (11/24)

MOST CRITICAL CARE PATIENTS HAD EXCLUSIVELY

NONCONVULSIVE SEIZURES

WITHOUT CEEG, THE RECOGNITION OF NCSE

IS DELAYED OR MISSED

INCREASE RATES OF MORBIDITY AND MORTALITY

74a74aPassado de AVE Passado de AVE Sepse urináriaSepse urináriaInsuficiência renal agudaInsuficiência renal agudaUso de quinolonaUso de quinolonaDeterioração do nível de consciênciaDeterioração do nível de consciência

TORPOROSA ACORDOU APÓS 1 mg MIDAZOLAM

Quanto tempo um paciente agudo

necessita ficar monitorizado paranecessita ficar monitorizado para

detecção de crises epilépticas ?

Tempo para gravar a primeira crise, comparando os pacientes comatososTempo para gravar a primeira crise, comparando os pacientes comatosose não comatosos e não comatosos

Neurology 2004;62:1743-1748

48 horas ou mais podem ser necessários para detecção de crises epilépticasnão convulsivas em pacientes comatosos

DETECTING AND MONITORING

CEREBRAL ISCHAEMIA

“The singular focus inneurocritical care is

to prevent or rapidly identifyneurocritical care is

to prevent or rapidly identifyand then reversebrain ischemiaif it occurs”

CBF CBF LEVELLEVEL

(ml/100gm/min)(ml/100gm/min)

EEG CHANGEEEG CHANGE DEGREE OF DEGREE OF NEURONAL INJURYNEURONAL INJURY

35-70 NORMAL NO INJURY

25-35 LOSS OF FAST BETA FREQUENCIES

USUALLY REVERSIBLEEEG reveals a “window of reversibility”

18-25 SLOWING OF BACKGROUND T0 5-7HZ THETA

POTENTIALLY REVERSIBLE

12-18 SLOWING TO 1-4HZ DELTA POTENTIALLY REVERSIBLE

< 8-10 SUPRESSION OF ALL FREQUENCIES

NEURONAL DEATH

Jordan K. JCN 2004

“window of reversibility”of

ischaemic cerebral injury

38a38aPO DISSECÇÃO AÓRTICAPO DISSECÇÃO AÓRTICA2h PARADA CIRCULATÓRIA2h PARADA CIRCULATÓRIAAVE HCDAVE HCD

PAM: 63 mmHg PAM: 95 mmHg

AVALIAÇÃO PROGNÓSTICA DOS COMASAVALIAÇÃO PROGNÓSTICA DOS COMAS

ELEMENTOS FISIOLÓGICOS DO SONO

REATIVIDADE

VARIABILIDADE

PADRÕES DE BOM PROGNÓSTICOPADRÕES DE BOM PROGNÓSTICO

PADRÕES DE MAU PROGNÓSTICO PADRÕES DE MAU PROGNÓSTICO

M O N Ó T O N O

LENTO E NÃO REATIVOLENTO E NÃO REATIVOCRISES EPILÉPTICASCRISES EPILÉPTICAS

PADRÕES DE MAU PROGNÓSTICO PADRÕES DE MAU PROGNÓSTICO

INATIVIDADE ELÉTRICA CEREBRALINATIVIDADE ELÉTRICA CEREBRALSURTO SUPRESSÃO SURTO SUPRESSÃO

ESPEC. = 100%

LANCET 1998 , 352 : 1808-12

POTENCIAL EVODACO SÔMATO SENSITIVO CURTA LATÊNCIA POTENCIAL EVODACO SÔMATO SENSITIVO CURTA LATÊNCIA –– N. MEDIANON. MEDIANO

APÓS 72 HORASAPÓS 72 HORAS

NORMALNORMAL ANORMALANORMAL

COMPONENTE CORTICAL SEM COMPONENTE CORTICAL

ML1

Slide 27

ML1 Pacientes comatosos com CC bilat. tem o prognóstico incertoDra. Malu; 20/10/2003

POTENCIAL EVODACO SÔMATO SENSITIVO POTENCIAL EVODACO SÔMATO SENSITIVO –– N. MEDIANO N. MEDIANO -- RCPRCP

2 50

3 0 0

N= 572N= 572

ÓBITO OU EVPÓBITO OU EVP

251229

J Clin Neurophysiol 2000 17 (5) 486-97

Ted L. Rothstein

D 3 EM DIANTE

0

50

10 0

150

2 0 0

PESS PESS C/ CCC/ CC

PESS PESS S/ CCS/ CC

RECUPERAÇÃORECUPERAÇÃO

ÓBITO OU EVPÓBITO OU EVP

144

0

PESS S/ CC BILATERAL APÓS PCR - SENS 68% VPP: 100% VPP: 100%

ML2

Slide 28

ML2 META ANÁLISE DE COMA ANÓXICO ISQUÊMICOE COMPONENTE COETICAL DA VIA SOMATO SENSITIVA EM 572 PACIENTESDra. Malu; 2/8/2003

DURING THE PAST 10 YEARS :

ICU/cEEG is becoming a

STANDART OF CARE

BUT...

SO...

�Very few neurointensivists read EEG

�There is a very shortage of EEGers to serve this unmet patient need 24/7

BUT...

Interdependence become increasingly important among all who are involved in the patient care

TEAMWORK

CONTINUOUS EEG MONITORING IN ICUCONTINUOUS EEG MONITORING IN ICU

��NEUROPHYSIOLOGY TEAMNEUROPHYSIOLOGY TEAM

��REAL TIME OBSERVATION “24/7”REAL TIME OBSERVATION “24/7”

��ICU TEAM BASIC AND CONTINUOUS TRAININGICU TEAM BASIC AND CONTINUOUS TRAINING

ICU/cEEG program most successful with

collaboration of all who areinvolved in the patient care

•Neurointensivist•Neurointensivist•Intensivist•Neurosurgeons•Fellows/Residents•ICU nurse•Neurophysiologist•Technologists

ICUICU--CEEG WORKSHOPCEEG WORKSHOP

Basic and advanced training of ICU team includes:

�Neuroanatomy

�Neurophysiology

ICUICU--CEEG WORKSHOPCEEG WORKSHOP

�Neurophysiology

�Technical application

�Computer application

�Waveform recognition

�Clinical correlation

FUNDAMENTAL POINTS - BASIC TRAINING

- Computer application :

�Bedside acquisition unit trainning

�Long distance real time conection

FUNDAMENTAL POINTS - BASIC TRAINING�Technical application

FP1

F4Fz

FP2

F8F7

F3

Left=odd Right=even

Electrode Placement/nomenclature

P4P3 Pz

Cz C4 T4

T6

O2O1

C3

T5

T3

“Z”=midline

Electrode application method

FUNDAMENTAL POINTS - BASIC TRAINING

FUNDAMENTAL POINTS - BASIC TRAINING

Electrode application method

Needle electrodes

FUNDAMENTAL POINTS - BASIC TRAINING

Electrode application method

FUNDAMENTAL POINTS - BASIC TRAINING

Waveform recognition

-Artefact recognition

-Simetry ( frequency and amplitude )

-Reactivity

-Epileptiform activity

-Sedation level

WAVEFORM RECOGNITION TRAINING

Courtesy KG Jordan ,MD.KG Jordan ,MD.

CHARTING CODES FOR CEEG WAVEFORMS

Courtesy KG Jordan ,MD.KG Jordan ,MD.

11 14

13

111

1213

2

3

4

1

Left Right

6

5

Left Right

1

11

10

9

12

11

9

105

6

1

12

14

15

16

111

1213

6

7

9

111

1213

18

17

1

EKG 19

LP, LA, UELP, LA, UE

LT, LA, UELT, LA, UELT, LA, UELT, LA, UE

RP, MA, ERP, MA, E

RT, MA, ERT, MA, E

NURSE ICUNURSE ICU--CEEG FLOWCHARTCEEG FLOWCHART

Each hour nurses would look

at the CEEG waveforms and

note them on the flow sheet.

Courtesy KG Jordan ,MD.KG Jordan ,MD.

24/7 !!!!

�� ICU team comfortable with waveform ICU team comfortable with waveform recognition from their experience with recognition from their experience with other monitors in the ICU.other monitors in the ICU.

��They accept CEEG monitoring as natural They accept CEEG monitoring as natural extension of physiologic monitoring to the extension of physiologic monitoring to the extension of physiologic monitoring to the extension of physiologic monitoring to the brain. brain.

��They embrace CEEG benefit to patient They embrace CEEG benefit to patient care. care.

CONCLUSIONS:� EEG detects real time ischaemia and in reversible stages ;

� Nonconvulsive seizures are common in critical carepatients, and is related to marked adverse effects;

� ICU/cEEG is becoming a standart of care;

�ICU patients need CEEG avaiable 24/7;

� As well as basic and continuous training , remote observationin real time by a specialist is possible;

�Institutional support and comitment are funtamental pointsto CEEG monitoring program success.

“ SOME PEOPLE DREAM OF SUCCESS...

WHILE OTHERS WAKE UP AND WORK HARD AT IT “