Electrographic Seizures in Children and Neonates Undergoing Extracorporeal Membrane Oxygenation

Abstract

Objective We aimed to determine the incidence and risk factors for electrographic seizures (ES) in neonates and children requiring extracorporeal membrane oxygenation (ECMO) support. Design Prospective quality improvement project. Setting Quaternary care pediatric institution. Patients Consistent with American Clinical Neurophysiology Society EEG monitoring recommendations, neonates and children requiring ECMO support underwent clinically indicated EEG monitoring. Interventions We performed a two-year quality improvement study from July 2013 – June 2015 evaluating ES incidence and risk factors. Main Results 99 of 112 patients (88%) requiring ECMO support underwent EEG monitoring. ES occurred in 18 patients (18%), of which 11 patients (61%) had electrographic status epilepticus and 15 patients (83%) had exclusively EEG-only seizures. ES were more common in patients with low cardiac output syndrome (p=0.03). Patients with ES were more likely to die prior to discharge (72% vs 30%, p=0.01) and have unfavorable outcomes (54% vs 17%, p=0.004) than those without ES. Conclusions ES occurred in 18% of neonates and children requiring ECMO support, often constituted electrographic status epilepticus, and were often EEG-only thereby requiring EEG monitoring for identification. Low cardiac output syndrome was associated with an increased risk for ES. ES were associated with higher mortality and unfavorable outcomes. Further investigation is needed to determine whether ES identification and management improves outcomes.

EEG is A Predictor of Neuroimaging Abnormalities in Pediatric Extracorporeal Membrane Oxygenation

“…Electroencephalogram (EEG) is a non-invasive, well-tolerated study that can give dynamic information on cerebral functioning and provide insight into the risk of neurologic sequelae. A 2017 study by Lin et al looked at a series of 112 patients who received ECMO in which 88% underwent EEG [10]. They found favorable neurologic outcomes in those without seizures versus those with seizures and noted an increased risk of death associated with electrographic seizures [10].…”

“…A 2017 study by Lin et al looked at a series of 112 patients who received ECMO in which 88% underwent EEG [10]. They found favorable neurologic outcomes in those without seizures versus those with seizures and noted an increased risk of death associated with electrographic seizures [10]. Seizures during ECMO are associated with neurologic complications such as developmental delay, motor deficits, behavioral problems, and decreased quality of life scores [11,12].…”

A retrospective comparison of phenobarbital and levetiracetam for the treatment of seizures following cardiac surgery in neonates

“…Efficacy was not associated with the choice of first‐line ASM (PHB or LEV), but it was associated with seizure burden and underlying disease severity. Factors associated with less favorable response to first‐line ASM therapy included ECMO exposure and single‐ventricle defects, which are both independently associated with an increased risk of seizures 2,29,30 …”

Neurologic Complications and Neuromonitoring on ECMO

“…Although less common than intracranial hemorrhage and stroke, seizures can be difficult to recognize if they are nonconvulsive or subclinical. A study of children and neonates undergoing ECMO revealed that 18% of patients had electrographic seizures, with 61% of those patients having electrographic status epilepticus and 83% having exclusively electrographic seizures [39]. Another recent study of neonatal and pediatric patients found electrographic seizures in 23% of their patients, especially within the first 24 hours of ECMO [40].…”