Early Electroencephalographic Background Features Predict Outcomes in Children Resuscitated From Cardiac Arrest*

Abstract

Objective To determine a) whether early electroencephalographic (EEG) background features were associated with survival and neurologic outcomes among children resuscitated from cardiac arrest and not treated with therapeutic hypothermia and b) if addition of EEG background to commonly used clinical criteria is more predictive of outcome than clinical criteria alone. Design Retrospective study. Setting Pediatric intensive care unit and Cardiac Intensive Care Units of a tertiary children’s hospital. Patients Patients resuscitated from in-hospital or out-of-hospital cardiac arrest who underwent clinically indicated EEG monitoring and were not treated with therapeutic hypothermia. Interventions None Measurements and Main Results One-hundred twenty-eight patients underwent EEG monitoring within one day of return of spontaneous circulation (ROSC). Background category was normal in 4 subjects (3%), slow-disorganized in 58 subjects (45%), discontinuous - burst-suppression in 24 subjects (19%) and attenuated-flat in 42 subjects (33%). Forty-six subjects (36%) had a reactive EEG. Twenty subjects (15%) had a seizure during EEG monitoring. Absence of reactivity (p<0.001) and seizures (p=0.04) were associated with worse EEG background category. After controlling for covariates, for each incrementally worse background score, the odds of death was 3.63 (95% CI: 2.18, 6.0, p<0.001) and the odds of unfavorable neurologic outcome was 4.38 (95% CI: 2.51, 7.17, p=0.001). Conclusions Worse EEG background early after resuscitation from both in-hospital and out-of-hospital cardiac arrest is associated with increased odds of death and unfavorable neurologic outcomes at hospital discharge. These EEG background patterns may be used in addition to clinical criteria to support prognostic decision making.

Interrater Agreement of EEG Interpretation After Pediatric Cardiac Arrest Using Standardized Critical Care EEG Terminology

“…Most electroencephalographic seizures have no clinical correlate and thus are not identified by clinical observation. (15, 20) Our study of 128 children post cardiac arrest undergoing EEG monitoring identified electrographic seizures in 15% of subjects. Electrographic status epilepticus occurred in 80% of subjects with seizures and was associated with unfavorable short-term neurologic outcomes.…”

“…(28) This may be similar to the Overall Background Category which had substantial interrater agreement in this study and has been used in prior pediatric investigations. (20–22, 33)…”

“…Prior publications of EEG monitoring in critically ill children have used this categorical system. (20–22, 33)…”

An Update on Cardiopulmonary Resuscitation in Children

“…Furthermore, absence of reactivity and worse EEG background scores are associated with increased odds of death and unfavorable neurologic outcomes after pediatric cardiac arrest [97,98].…”

“…These include pupillary responses [98,118] serum biomarkers such as neuronspecific enolase and S100B [119,120] serum lactate levels [121], EEG findings [97,98], somatosensory evoked potentials [122], neuroimaging studies [123], non-invasive cerebral tissue oxygenation [105,124], and presence or absence of hypotension [94]. Importantly, the data supporting the application of these tools as prognosticators are not as robust in children as they are in adults, and each patient's overall clinical status after cardiac arrest must be considered over any one finding.…”