4
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Continuous vs Routine Electroencephalogram in Critically Ill Adults With Altered Consciousness and No Recent Seizure : A Multicenter Randomized Clinical Trial

      research-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Key Points

          Question

          In patients with acute consciousness impairment and no recent seizures, does continuous electroencephalogram (cEEG) correlate with reduced mortality compared with repeated routine EEG (rEEG)?

          Findings

          In this pragmatic, multicenter randomized clinical trial analyzing 364 adults, cEEG translated into a higher rate of seizures/status epilepticus detection and antiseizure treatment modifications but did not improve mortality compared with rEEG.

          Meaning

          Pending larger studies, rEEG may represent a valid alternative to cEEG in centers with limited resources.

          Abstract

          Importance

          In critically ill patients with altered consciousness, continuous electroencephalogram (cEEG) improves seizure detection, but is resource-consuming compared with routine EEG (rEEG). It is also uncertain whether cEEG has an effect on outcome.

          Objective

          To assess whether cEEG is associated with reduced mortality compared with rEEG.

          Design, Setting, and Participants

          The pragmatic multicenter Continuous EEG Randomized Trial in Adults (CERTA) was conducted between 2017 and 2018, with follow-up of 6 months. Outcomes were assessed by interviewers blinded to interventions.The study took place at 4 tertiary hospitals in Switzerland (intensive and intermediate care units). Depending on investigators’ availability, we pragmatically recruited critically ill adults having Glasgow Coma Scale scores of 11 or less or Full Outline of Responsiveness score of 12 or less, without recent seizures or status epilepticus. They had cerebral (eg, brain trauma, cardiac arrest, hemorrhage, or stroke) or noncerebral conditions (eg, toxic-metabolic or unknown etiology), and EEG was requested as part of standard care. An independent physician provided emergency informed consent.

          Interventions

          Participants were randomized 1:1 to cEEG for 30 to 48 hours vs 2 rEEGs (20 minutes each), interpreted according to standardized American Clinical Neurophysiology Society guidelines.

          Main Outcomes and Measures

          Mortality at 6 months represented the primary outcome. Secondary outcomes included interictal and ictal features detection and change in therapy.

          Results

          We analyzed 364 patients (33% women; mean [SD] age, 63 [15] years). At 6 months, mortality was 89 of 182 in those with cEEG and 88 of 182 in those with rEEG (adjusted relative risk [RR], 1.02; 95% CI, 0.83-1.26; P = .85). Exploratory comparisons within subgroups stratifying patients according to age, premorbid disability, comorbidities on admission, deeper consciousness reduction, and underlying diagnoses revealed no significant effect modification. Continuous EEG was associated with increased detection of interictal features and seizures (adjusted RR, 1.26; 95% CI, 1.08-1.15; P = .004 and 3.37; 95% CI, 1.63-7.00; P = .001, respectively) and more frequent adaptations in antiseizure therapy (RR, 1.84; 95% CI, 1.12-3.00; P = .01).

          Conclusions and Relevance

          This pragmatic trial shows that in critically ill adults with impaired consciousness and no recent seizure, cEEG leads to increased seizure detection and modification of antiseizure treatment but is not related to improved outcome compared with repeated rEEG. Pending larger studies, rEEG may represent a valid alternative to cEEG in centers with limited resources.

          Trial Registration

          ClinicalTrials.gov Identifier: NCT03129438

          Abstract

          This randomized clinical trial investigates whether continuous electroencephalogram is associated with reduced mortality compared with routine electroencephalogram.

          Related collections

          Most cited references41

          • Record: found
          • Abstract: found
          • Article: not found

          Validation of a new coma scale: The FOUR score.

          The Glasgow Coma Scale (GCS) has been widely adopted. Failure to assess the verbal score in intubated patients and the inability to test brainstem reflexes are shortcomings. We devised a new coma score, the FOUR (Full Outline of UnResponsiveness) score. It consists of four components (eye, motor, brainstem, and respiration), and each component has a maximal score of 4. We prospectively studied the FOUR score in 120 intensive care unit patients and compared it with the GCS score using neuroscience nurses, neurology residents, and neurointensivists. We found that the interrater reliability was excellent with the FOUR score (kappa(w) = 0.82) and good to excellent for physician rater pairs. The agreement among raters was similar with the GCS (kappa(w) = 0.82). Patients with the lowest GCS score could be further distinguished using the FOUR score. We conclude that the agreement among raters was good to excellent. The FOUR score provides greater neurological detail than the GCS, recognizes a locked-in syndrome, and is superior to the GCS due to the availability of brainstem reflexes, breathing patterns, and the ability to recognize different stages of herniation. The probability of in-hospital mortality was higher for the lowest total FOUR score when compared with the lowest total GCS score.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Detection of electrographic seizures with continuous EEG monitoring in critically ill patients.

            To identify patients most likely to have seizures documented on continuous EEG (cEEG) monitoring and patients who require more prolonged cEEG to record the first seizure. Five hundred seventy consecutive patients who underwent cEEG monitoring over a 6.5-year period were reviewed for the detection of subclinical seizures or evaluation of unexplained decrease in level of consciousness. Baseline demographic, clinical, and EEG findings were recorded and a multivariate logistic regression analysis performed to identify factors associated with 1) any EEG seizure activity and 2) first seizure detected after >24 hours of monitoring. Seizures were detected in 19% (n = 110) of patients who underwent cEEG monitoring; the seizures were exclusively nonconvulsive in 92% (n = 101) of these patients. Among patients with seizures, 89% (n = 98) were in intensive care units at the time of monitoring. Electrographic seizures were associated with coma (odds ratio [OR] 7.7, 95% CI 4.2 to 14.2), age 24 hours of monitoring (20% vs 5% of noncomatose patients; OR 4.5, p = 0.018). CEEG monitoring detected seizure activity in 19% of patients, and the seizures were almost always nonconvulsive. Coma, age 24 hours of monitoring to detect the first electrographic seizure.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              Consensus statement on continuous EEG in critically ill adults and children, part I: indications.

              Critical Care Continuous EEG (CCEEG) is a common procedure to monitor brain function in patients with altered mental status in intensive care units. There is significant variability in patient populations undergoing CCEEG and in technical specifications for CCEEG performance.
                Bookmark

                Author and article information

                Journal
                JAMA Neurol
                JAMA Neurol
                JAMA Neurol
                JAMA Neurology
                American Medical Association
                2168-6149
                2168-6157
                October 2020
                27 July 2020
                27 July 2020
                : 77
                : 10
                : 1-8
                Affiliations
                [1 ]Department of Neurology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
                [2 ]Sleep-Wake-Epilepsy-Center, Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
                [3 ]Clinic for Intensive Care Medicine, University Hospital Basel and University of Basel, Basel, Switzerland
                [4 ]Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland
                [5 ]Department of Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
                [6 ]Clinical Trial Unit, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
                [7 ]Department of Neurology, Hôpital du Valais, Sion, Switzerland
                Author notes
                Article Information
                Corresponding Author: Andrea O. Rossetti, MD, Service de Neurologie, CHUV-BH07, CH-1011 Lausanne, Switzerland ( andrea.rossetti@ 123456chuv.ch ).
                Accepted for Publication: April 9, 2020.
                Published Online: July 27, 2020. doi:10.1001/jamaneurol.2020.2264
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Rossetti AO et al. JAMA Neurology.
                Author Contributions: Dr Rossetti had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Rossetti, Schindler, Rüegg, Alvarez.
                Acquisition, analysis, or interpretation of data: All authors.
                Drafting of the manuscript: Rossetti, Schindler.
                Critical revision of the manuscript for important intellectual content: All authors.
                Statistical analysis: Rossetti, Sutter, Novy.
                Obtained funding: Rossetti, Schindler, Sutter, Rüegg, Oddo.
                Administrative, technical, or material support: Schindler, Sutter, Rüegg, Zubler, Warpelin-Decrausaz.
                Supervision: Rossetti, Schindler, Rüegg.
                Other - patient recruitment: Zubler.
                Conflict of Interest Disclosures: Dr Rossetti reported grants from Swiss National Scientific Found during the conduct of the study. Dr Sutter reported grants from the Swiss National Foundation (320030_169379) during the conduct of the study; grants from the Research Fund of the University of Basel, Scientific Society Basel, the Bangerter-Rhyner Foundation, and UCB Pharma; and holds stocks from Alcon, Johnson & Johnson, Novartis, and Roche outside the submitted work. Dr Rüegg reported grants from Swiss National Science Foundation during the conduct of the study. Dr Zubler reported grants from Swiss National Science Foundation during the conduct of the study. Dr Novy reported personal fees from UCB, Eiai, Arvelle Tx, Desitin, and Sandoz outside the submitted work. No other disclosures were reported.
                Funding/Support: The Swiss National Science Foundation (grant 320030_169379) supported this study.
                Role of the Funder/Sponsor: The Swiss National Science Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Data Sharing Statment: See Supplement 3.
                Additional Contributions: We thank the following persons for their help on this study: Sarah Tschudin-Sutter, MD, for statistical advice; Laura Pezzi, RN, Loredana Sene, RN, Christiane Pellet, RN, Andreja Vujicic Zagar, MD, Aude Erdmann-Voisin, Vassili Soumas, and Fady Fares (CTU Lausanne); Joyce Santos de Jesus, Patricia Arnaiz, Klaus Ehrlich (CTU Basel); Matteo Caporro, MD, Sandy Grabner, MD, Matthias Hänggi, MD, Rebekka Zimmermann, MD (Inselspital Berne); and Francine Favre, RN (Neurology Sion), contributed to data assessment. Marc Froissart, MD (CRC Lausanne), provided inputs on a previous version of the manuscript. All except for Dr Froissart were supported through their institution by Swiss National Science Foundation grant 320030_169379.
                Article
                noi200046
                10.1001/jamaneurol.2020.2264
                7385681
                32716479
                345df216-26a1-4bbf-a31c-9b9553d9892a
                Copyright 2020 Rossetti AO et al. JAMA Neurology.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 4 December 2019
                : 9 April 2020
                Categories
                Research
                Research
                Original Investigation
                Online First
                Comments

                Comments

                Comment on this article