CONTINUOUS EEG IS SUPERIOR - MKON ... continuous eeg is superior eeg monitoring during coma after cardiac

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  • CONTINUOUS EEG IS SUPERIOR EEG MONITORING DURING COMA AFTER CARDIAC ARREST

    JEANNETTE HOFMEIJER, MD PHD

  •  Epilepsy detection

     Outcome prediction

    Requirements

    EEG features

    EEG AFTER CARDIAC ARREST

    100% specificity for poor outcome prediction

    High specificity for good outcome prediction

    Background pattern

    Reactivity

  • REACTIVITYBACKGROUND PATTERN

    POOR OUTCOME PREDICTION

  • REACTIVITYBACKGROUND PATTERN

    N = 1175

    False positives = 0

    Clear definitions

    POOR OUTCOME PREDICTION

    SUPPRESSION IDENTICAL BURSTS-

    SUPPRESSION GPD-SUPPRESSION

  • REACTIVITY

    N = 1131

    False positives = 45

    Moderate definitions

    BACKGROUND PATTERN

    N = 1175

    False positives = 0

    Clear definitions

    POOR OUTCOME PREDICTION

    SUPPRESSION IDENTICAL BURSTS-

    SUPPRESSION GPD-SUPPRESSION

  • TP FN FP TN total

    48h 12 5 1 5 23

    All time points 51 19 14 65 149

    ABSENT EEG REACTIVITY HIGH FALSE POSITIVE RATE FOR POOR OUTCOME PREDICTION

    Admiraal et al. Annals of Neurology (accepted)

  • EVOLUTION OF THE EEG FAVORABLE OR UNFAVORABLE

    5h 12h 24h

    Sondag et al. Crit Care 2017

    Hofmeijer et al. Neurology 2015

    Sivaraju et al. Int Care Med 2015

  • THE EVIDENCE

    Ruijter et al. Annals of Neurology (accepted)

  •  Identify more patients with poor or good outcome

     Greater reliability of EEG conclusions

     Detection of epilepsy

     Future of brain monitoring

    WHY CONTINUOUS EEG?

  •  Identify more patients with poor or good outcome

     Greater reliability of EEG conclusions

     Detection of epilepsy

     Future of brain monitoring

    WHY CONTINUOUS EEG?

  • RESULTS PREDICTIVE VALUES FOR POOR OUTCOME

    Ruijter et al. Ann Neurol (accepted)

  • RESULTS PREDICTIVE VALUES FOR POOR OUTCOME

    >50% outside

    office hours

    Ruijter et al. Ann Neurol (accepted)

  • YIELD OF REPEATED MEASUREMENTS RELIABLE PROGNOSIS IN MORE PATIENTS

  • YIELD OF REPEATED MEASUREMENTS RELIABLE PROGNOSIS IN MORE PATIENTS

  •  Identify more patients with poor or good outcome

     Greater reliability of EEG conclusions

     Detection of epilepsy

     Future of brain monitoring

    WHY CONTINUOUS EEG?

  • YIELD OF REPEATED MEASUREMENTS DECREASED UNCERTAINTY

    12h 18h 24h

    24h 30h 36h

  •  Identify more patients with poor or good outcome

     Greater reliability of EEG conclusions

     Detection of epilepsy

     Future of brain monitoring

    WHY CONTINUOUS EEG?

  •  Electrographic seizures / status epilepticus: 10-20%

     Non-convulsive ‘seizures’: 10-15%

    YIELD OF CONTINUOUS MONITORING DETECTION OF ELECTROGRAPHIC SEIZURES

    Ruijter et al. Trials 2014

    Knight et al. Epoilpesy Res 2013

    Rittenberger et al. Neurocrit care 2012

    Rossetti & Lowenstein. Lancet Neurol 2011

  •  Identify more patients with poor or good outcome

     Greater reliability of EEG conclusions

     Detection of epilepsy

     Future of brain monitoring

    WHY CONTINUOUS EEG?

  • FUTURE OF BRAIN MONITORING BEDSIDE COMPUTER ASSISTED INTERPRETATION

    Tjepkema-Cloostermans et al. Crit Care Med 2017

    Nagaraj et al. Clin Neurophysiol 2018

  • FUTURE OF BRAIN MONITORING BEDSIDE COMPUTER ASSISTED INTERPRETATION

    Tjepkema-Cloostermans et al. Crit Care Med 2017

    Nagaraj et al. Clin Neurophysiol 2018

  • 25%

    50% uncertainty

    25%

    Hofmeijer et al. Neurology 2015

    Ruijter et al. Ann Neurol (accepted)

  • Nagaraj et al. Clin Neurophysiol 2018

    25%

    50% uncertainty

    25%

    +

    27.5%

    45%

    27.5%

  • 25%

    50% uncertainty

    25%

    27.5%

    45%

    27.5%

    Tjepkema et al. Crit Care Med (accepted)

    +

    30%

    40%

    30%

  • WHY NOT CONTINUOUS EEG? UNJUSTIFIED CONSERVATISM

  • cEEG  Móre reliable predictions in móre patients.

    For epilepsy detection cEEG is obligate

    Predictive values improve by bedside, computer assisted analysis

    Arguments to withhold cEEG are based on conservatism

    CONCLUSION COMA AFTER CARDIAC ARREST