Abstract
Purpose
To evaluate the predictive value of EEG reactivity assessment and confounders for
neurological outcome after cardiac arrest.
Methods
All consecutive patients admitted in a tertiary cardiac arrest center between 2007
and 2016 still alive 48 h after admission with at least one EEG recorded during coma.
EEG reactivity was defined as a reproducible waveform change in amplitude or frequency
following standardized stimulation. Each EEG was classified based on American Clinical
Neurophysiology Society nomenclatures and classified in highly malignant (including
status epilepticus), malignant, or benign EEG. We assessed the predictive values of
EEG reactivity and sedation effect for neurologic outcome at ICU discharge using the
Cerebral Performance Category scale (with CPC 1–2 assumed as favorable outcome and
CPC 3-4-5 considered as poor outcome).
Results
Among 428 patients, a poor outcome was observed in 80% patients. The median time to
EEG recording was 3 (1–4) days and 51% patients had a non-reactive EEG. The positive
predictive value (PPV) of a non-reactive EEG to predict an unfavorable outcome was
97.1% (IC95% 93.6–98.9), increasing to 98.3% (IC95 94.1–99.8) when the EEG had been
performed without sedation. In multivariate analysis, a non-reactive EEG was associated
with poor outcome (OR 12.6 IC95% 4.7–33.6; p < 0.001). In multivariate analysis, concomitant
sedation was not statistically associated with EEG non-reactivity. The PPV of a benign
EEG to predict favorable outcome was 49.7% (IC95% 41.5–57.9), increasing to 66.2%
(IC95% 54.3–76.8) when EEG was recorded earlier, with ongoing sedation.
Conclusions
After cardiac arrest, absence of EEG reactivity was predictive of unfavorable outcome.
By contrast, a benign EEG was slightly predictive of a favorable outcome. Reactivity
assessment may have important implications in the neuroprognostication process after
cardiac arrest and could be influenced by sedation.
Abbreviations:
CA (cardiac arrest), CPC (cerebral performance category), EEG (electroencephalogram), ESM (electronic supplementary material), FPR (false positive rate), GCS (glasgow coma scale), ICU (intensive-care-unit), IQR (interquartile-range), NPV (negative predictive value), PPV (positive predictive value), RASS (Richmond-Agitation-Sedation-Scale), ROSC (return of spontaneous circulation), SD (standard deviation), SSEP (short-latency somatosensory evoked potentials), TTM (targeted temperature management), WLST (withdrawal-of-life-sustaining-treatments)Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to ResuscitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort.Intensive Care Med. 2013; 39 (1972:1013:1972 Intensive care unit mo)
- Characteristics and prognosis of sudden cardiac death in Greater Paris: population-based approach from the Paris Sudden Death Expertise Center (Paris-SDEC).Intensive Care Med. 2014; 40 (846–814;846 Characteristics and prog)
- European Resuscitation Council and European Society of Intensive Care Medicine 2015 guidelines for post-resuscitation care.Intensive Care Med. 2015; 41 (2039–015;2039 CD, et al. European Re)
- Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine.Intensive Care Med. 2014; 40 (1816–014;1816rognostication in comat)
- Delayed awakening after cardiac arrest: prevalence and risk factors in the Parisian registry.Intensive Care Med. 2016; 42 (1128–016;42:1128elayed awakening after)
- Awakening and withdrawal of life-sustaining treatment in cardiac arrest survivors treated with therapeutic hypothermia.Crit Care Med. 2014; 42 (2493–014;249314;42:24932493withdrawal)
- Survey on current practices for neurological prognostication after cardiac arrest.Resuscitation. 2015; 90 (1580–158)https://doi.org/10.1016/j.resuscitation.2015.01.018
- EEG patterns in hypoxic encephalopathies (post-cardiac arrest syndrome): fluctuations, transitions, and reactions.J Clin Neurophysiol Off Publ Am Electroencephalogr Soc. 2013; 30 (477–477)
- Prognostication of post-cardiac arrest coma: early clinical and electroencephalographic predictors of outcome.Intensive Care Med. 2015; 41 (1264–015:1264JJ, et al. Prognosticat)
- Value analysis of continuous EEG in patients during therapeutic hypothermia after cardiac arrest.Resuscitation. 2014; 85 (785–014)https://doi.org/10.1016/j.resuscitation.2014.01.019
- Predictors of neurologic outcome in hypothermia after cardiac arrest.Ann Neurol. 2010; 68 (907768:907ologic ou): 907-910
- Clinical evolution after a non-reactive hypothermic EEG following cardiac arrest.Neurocrit Care. 2015; 22 (40322:40315;22:403evolutio): 403-415
- Post cardiac arrest service. Malignant EEG patterns in cardiac arrest patients treated with targeted temperature management who survive to hospital discharge.Resuscitation. 2015; 90 (127–015)https://doi.org/10.1016/j.resuscitation.2015.03.005
- Multimodal outcome prognostication after cardiac arrest and targeted temperature management: analysis at 36 °C.Neurocrit Care. 2018; 28: 104-109https://doi.org/10.1007/s12028-017-0393-8
- Electroencephalography predicts poor and good outcomes after cardiac arrest: a two-center study.Crit Care Med. 2017; 45 (e674e674ography Predict)
- Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry.Circ Cardiovasc Interv. 2010; 3 (2000;3:20002010;3:2000:200v 2010;3:200): 200-210
- Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein resuscitation registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.Resuscitation. 2015; 96: 328https://doi.org/10.1016/j.resuscitation.2014.11.002
- Comparison of two sedation regimens during targeted temperature management after cardiac arrest.Resuscitation. 2018; 128: 204-210https://doi.org/10.1016/j.resuscitation.2018.03.025
- Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).JAMA. 2003; 289 (2983–003;2983JWW, Wheeler AP, Gord)
- European resuscitation council. European Resuscitation Council guidelines for resuscitation 2005. Section 1. Introduction.Resuscitation. 2005; 67: S3-S33https://doi.org/10.1016/j.resuscitation.2005.10.002
- Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.Neurology. 2006; 67: 2037-2203https://doi.org/10.1212/01.wnl.0000227183.21314.cd
- Part 1: executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.Resuscitation. 2010; 81: e1-e11https://doi.org/10.1016/j.resuscitation.2010.08.002
- EEG reactivity to pain in comatose patients: Importance of the stimulus type.Resuscitation. 2015; 97: 015https://doi.org/10.1016/j.resuscitation.2015.09.380
- American Clinical Neurophysiology Society Societyal Neurophysiology SocietySocietylogy: 2012 version.J Clin Neurophysiol Off Publ Am Electroencephalogr Soc. 2013; 30 (110:11logr Soc 2013;30:130:130): 1-013
- Assessment of outcome after severe brain damage.Lancet Lond Engl. 1975; 1: 480-497
- Sedation confounds outcome prediction in cardiac arrest survivors treated with hypothermia.Neurocrit Care. 2011; 15 (113–011;11315:11311;15:113utcome p)
- Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia.Resuscitation. 2013; 84: 013https://doi.org/10.1016/j.resuscitation.2013.06.020
- Factors associated with post-arrest withdrawal of life-sustaining therapy.Resuscitation. 2016; 110: 114-119https://doi.org/10.1016/j.resuscitation.2016.10.021
- Prognostic value of electroencephalography (EEG) after out-of-hospital cardiac arrest in successfully resuscitated patients used in daily clinical practice.Resuscitation. 2014; 85https://doi.org/10.1016/j.resuscitation.2014.08.031
- Standardized EEG interpretation accurately predicts prognosis after cardiac arrest.Neurology. 2016; 86: 016https://doi.org/10.1212/WNL.0000000000002462
- Continuous electroencephalography monitoring for early prediction of neurological outcome in postanoxic patients after cardiac arrest: a prospective cohort study.Crit Care Med. 2012; 40 (2867–012;286712;40:28672867rest: a pros)
- Guidelines for the evaluation and management of status epilepticus.Neurocrit Care. 2012; 17: 3-012https://doi.org/10.1007/s12028-012-9695-z
- Highly malignant routine EEG predicts poor prognosis after cardiac arrest in the target temperature management trial.Resuscitation. 2018; 131: 018https://doi.org/10.1016/j.resuscitation.2018.07.024
- Effect of sedation on quantitative electroencephalography after cardiac arrest.Resuscitation. 2017; 124: 132-137https://doi.org/10.1016/j.resuscitation.2017.11.068
- Prognostic value of electrographic postanoxic status epilepticus in comatose cardiac-arrest survivors in the therapeutic hypothermia era.Resuscitation. 2013; 84: 013https://doi.org/10.1016/j.resuscitation.2012.11.001
- Interrater variability of EEG interpretation in comatose cardiac arrest patients.Clin Neurophysiol Off J Int Fed Clin Neurophysiol. 2015; 126 (2397–015)https://doi.org/10.1016/j.clinph.2015.03.017
- International consensus on EEG reactivity testing after cardiac arrest: towards standardization.Resuscitation. 2018; 131 (36–01)https://doi.org/10.1016/j.resuscitation.2018.07.025
- Value and mechanisms of EEG reactivity in the prognosis of patients with impaired consciousness: a systematic review.Crit Care Lond Engl. 2018; 22: 184https://doi.org/10.1186/s13054-018-2104-z
- Automated analysis of background EEG and reactivity during therapeutic hypothermia in comatose patients after cardiac arrest.Clin EEG Neurosci. 2014; 45https://doi.org/10.1177/1550059413509616
- Electroencephalography reactivity for prognostication of post-anoxic coma after cardiopulmonary resuscitation: a comparison of quantitative analysis and visual analysis.Neurosci Lett. 2016; 626https://doi.org/10.1016/j.neulet.2016.04.055
- Yield of intermittent versus continuous EEG in comatose survivors of cardiac arrest treated with hypothermia.Crit Care Lond Engl. 2013; 17: R190https://doi.org/10.1186/cc12879
Article info
Publication history
Published online: June 15, 2019
Accepted:
June 7,
2019
Received in revised form:
June 7,
2019
Received:
March 5,
2019
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.
