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The use of amplitude-integrated electroencephalography combined with continuous conventional electroencephalography during therapeutic hypothermia for an infant with postnatal cardiac arrest.

Ito A, Mishima Y, Koga Y, Saho M, Hiraki T, Ushijima K - Springerplus (2014)

Bottom Line: Intermittent and discrete seizures were detected on aEEG and confirmed with raw cEEG during the TH and rewarming periods.Seizures were controlled by the treatments, and she showed no clinical seizures after TH and AED discontinuation.This case indicated the possibility that the use of aEEG with continuous cEEG for a postnatal infant after cardiac arrest was feasible to detect and assess seizures and the effects of antiepileptic therapy while undergoing TH.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011 Japan.

ABSTRACT

Introduction: Amplitude-integrated electroencephalography (aEEG) has been employed in therapeutic hypothermia (TH) trials of neonates after perinatal hypoxic-ischemic encephalopathy (HIE). We present a case report involving the use of aEEG during TH with continuous conventional electroencephalography (cEEG) for an infant who experienced postnatal intraoperative cardiac arrest.

Case description: A five-month-old infant developed cardiac arrest during operation. Return of spontaneous circulation was achieved after one hour of cardiopulmonary resuscitation. Therapeutic hypothermia was applied with neuromuscular blockades. During the TH, the brain function and seizures were monitored with aEEG, which can also display continuous cEEG. Intermittent and discrete seizures were detected on aEEG and confirmed with raw cEEG during the TH and rewarming periods. Several kinds of antiepileptic drugs (AEDs) were administered to manage seizures according to the findings of aEEG with cEEG. Seizures were controlled by the treatments, and she showed no clinical seizures after TH and AED discontinuation.

Discussion and evaluation conclusions: This case indicated the possibility that the use of aEEG with continuous cEEG for a postnatal infant after cardiac arrest was feasible to detect and assess seizures and the effects of antiepileptic therapy while undergoing TH.

No MeSH data available.


Related in: MedlinePlus

The waveforms of aEEG and cEEG for 70 hours after the induction of TH. The upper panel represent amplitude-integrated EEG (aEEG), showing a repetitive narrowing bandwidth with a sharp rise in the lower margin accompanied by a smaller rise in the upper margin (arrows), which was suspected as intermittent and discrete seizrues. Raw cEEG tracing corresponding to light blue band in aEEG confirms the waveform of aEEG as seisures.
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Fig1: The waveforms of aEEG and cEEG for 70 hours after the induction of TH. The upper panel represent amplitude-integrated EEG (aEEG), showing a repetitive narrowing bandwidth with a sharp rise in the lower margin accompanied by a smaller rise in the upper margin (arrows), which was suspected as intermittent and discrete seizrues. Raw cEEG tracing corresponding to light blue band in aEEG confirms the waveform of aEEG as seisures.

Mentions: A 2,540-g female infant was delivered spontaneously at 37 weeks of gestation with esophageal atresia and a distal thoracoesophageal fistula (TEF). A primary anastomosis of the esophagus and ligation of the fistula was performed under general anesthesia at the age of 1 day. However, recurrent TEF was found with her. She underwent gastrostomy at the age of 42 days and was decided to perform re-operation and closure of TEF at the age of 5 months. During the operation, cardiac arrest occurred and cardiopulmonary resuscitation was initiated. Return of spontaneous circulation was achieved after one hour, and she was admitted to a pediatric intensive care unit (ICU). Immediately, continuous assessments of the brain function and seizure detection were performed using aEEG (Nicolet One® System, CareFusion, San Diego, CA, USA), which can also monitor continuous cEEG. The infant underwent cEEG with 11 electrodes applied by using the 10 - 20 international system, at the following locations: Fp1, Fp2, T3, T4, C3, Cz, C4, O2 and O1 to record EEG activity from frontal, temporal, central and occipital areas. The 1-channel aEEG traces those were obtained as the voltage potential difference between the O1 - O2, O1 - Cz, and O2 - Cz were continuously monitored. A severely supressed background was found on aEEG and TH was induced with whole-body cooling using a cooling mattress for neuroprotection. Her core body temperature was monitored continuously at the rectum. The target core temperature of 33.5°C was achieved in one hour. While cooling, she was mechanically ventilated and administered muscle relaxant and fentanyl. By five hours after the induction of TH, disorganized, low amplitude delta activities appeared on cEEG and amplitude of 5 to 50μV with weak cycling appeared on aEEG. Seventy hours after the induction of TH, an abrupt, sharp rise in the lower margin accompanied by a smaller rise in the upper margin with narrowing of the band width were repetitively detected on aEEG (arrows in Figure 1) with an amplitude of 5 to 50μV, and the corresponding raw cEEG confirmed to be seizures (Figure 1). Phenobarbital was administered, and the subsequent aEEG revealed an apparent decrease in seizures. Eighty-four hours after the induction of hypothermia, the patient was rewarmed and the rectal temperature was allowed to rise by no more than 0.5°C per hour to a maximum of 37°C. During the rewarming period, four episodes of seizures on both aEEG and cEEG were detected. They were effectively treated with midazolam followed by phenytoin, but the interval between seizures shortened, suggesting highly refractory epileptic activity. No electrographical seizures were detected on aEEG for several days after starting the continuous administration of thiamylal sodium with its dose of 3 mg per kg per hour. The aEEG monitoring was discontinued after thiamylal sodium was tapered. She was then extubated without respiratory distress, and showed no clinical seizures thereafter. Auditory brainstem responses identified no apparent abnormality based on wave amplitudes on postoperative day (POD) 34. Cerebral magnetic resonance imaging on POD 36 showed diffuse high intensity areas on T2-weighed image in her bilateral frontal and occipital lobes and putamen, which suspected hypoxic brain damage. She was alive with a cerebral outcome of Cerebral Performance Category of 3, which means severe cerebral disability, dependent on others for daily support because of impaired brain function at 6-month follow up.Figure 1


The use of amplitude-integrated electroencephalography combined with continuous conventional electroencephalography during therapeutic hypothermia for an infant with postnatal cardiac arrest.

Ito A, Mishima Y, Koga Y, Saho M, Hiraki T, Ushijima K - Springerplus (2014)

The waveforms of aEEG and cEEG for 70 hours after the induction of TH. The upper panel represent amplitude-integrated EEG (aEEG), showing a repetitive narrowing bandwidth with a sharp rise in the lower margin accompanied by a smaller rise in the upper margin (arrows), which was suspected as intermittent and discrete seizrues. Raw cEEG tracing corresponding to light blue band in aEEG confirms the waveform of aEEG as seisures.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4117861&req=5

Fig1: The waveforms of aEEG and cEEG for 70 hours after the induction of TH. The upper panel represent amplitude-integrated EEG (aEEG), showing a repetitive narrowing bandwidth with a sharp rise in the lower margin accompanied by a smaller rise in the upper margin (arrows), which was suspected as intermittent and discrete seizrues. Raw cEEG tracing corresponding to light blue band in aEEG confirms the waveform of aEEG as seisures.
Mentions: A 2,540-g female infant was delivered spontaneously at 37 weeks of gestation with esophageal atresia and a distal thoracoesophageal fistula (TEF). A primary anastomosis of the esophagus and ligation of the fistula was performed under general anesthesia at the age of 1 day. However, recurrent TEF was found with her. She underwent gastrostomy at the age of 42 days and was decided to perform re-operation and closure of TEF at the age of 5 months. During the operation, cardiac arrest occurred and cardiopulmonary resuscitation was initiated. Return of spontaneous circulation was achieved after one hour, and she was admitted to a pediatric intensive care unit (ICU). Immediately, continuous assessments of the brain function and seizure detection were performed using aEEG (Nicolet One® System, CareFusion, San Diego, CA, USA), which can also monitor continuous cEEG. The infant underwent cEEG with 11 electrodes applied by using the 10 - 20 international system, at the following locations: Fp1, Fp2, T3, T4, C3, Cz, C4, O2 and O1 to record EEG activity from frontal, temporal, central and occipital areas. The 1-channel aEEG traces those were obtained as the voltage potential difference between the O1 - O2, O1 - Cz, and O2 - Cz were continuously monitored. A severely supressed background was found on aEEG and TH was induced with whole-body cooling using a cooling mattress for neuroprotection. Her core body temperature was monitored continuously at the rectum. The target core temperature of 33.5°C was achieved in one hour. While cooling, she was mechanically ventilated and administered muscle relaxant and fentanyl. By five hours after the induction of TH, disorganized, low amplitude delta activities appeared on cEEG and amplitude of 5 to 50μV with weak cycling appeared on aEEG. Seventy hours after the induction of TH, an abrupt, sharp rise in the lower margin accompanied by a smaller rise in the upper margin with narrowing of the band width were repetitively detected on aEEG (arrows in Figure 1) with an amplitude of 5 to 50μV, and the corresponding raw cEEG confirmed to be seizures (Figure 1). Phenobarbital was administered, and the subsequent aEEG revealed an apparent decrease in seizures. Eighty-four hours after the induction of hypothermia, the patient was rewarmed and the rectal temperature was allowed to rise by no more than 0.5°C per hour to a maximum of 37°C. During the rewarming period, four episodes of seizures on both aEEG and cEEG were detected. They were effectively treated with midazolam followed by phenytoin, but the interval between seizures shortened, suggesting highly refractory epileptic activity. No electrographical seizures were detected on aEEG for several days after starting the continuous administration of thiamylal sodium with its dose of 3 mg per kg per hour. The aEEG monitoring was discontinued after thiamylal sodium was tapered. She was then extubated without respiratory distress, and showed no clinical seizures thereafter. Auditory brainstem responses identified no apparent abnormality based on wave amplitudes on postoperative day (POD) 34. Cerebral magnetic resonance imaging on POD 36 showed diffuse high intensity areas on T2-weighed image in her bilateral frontal and occipital lobes and putamen, which suspected hypoxic brain damage. She was alive with a cerebral outcome of Cerebral Performance Category of 3, which means severe cerebral disability, dependent on others for daily support because of impaired brain function at 6-month follow up.Figure 1

Bottom Line: Intermittent and discrete seizures were detected on aEEG and confirmed with raw cEEG during the TH and rewarming periods.Seizures were controlled by the treatments, and she showed no clinical seizures after TH and AED discontinuation.This case indicated the possibility that the use of aEEG with continuous cEEG for a postnatal infant after cardiac arrest was feasible to detect and assess seizures and the effects of antiepileptic therapy while undergoing TH.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011 Japan.

ABSTRACT

Introduction: Amplitude-integrated electroencephalography (aEEG) has been employed in therapeutic hypothermia (TH) trials of neonates after perinatal hypoxic-ischemic encephalopathy (HIE). We present a case report involving the use of aEEG during TH with continuous conventional electroencephalography (cEEG) for an infant who experienced postnatal intraoperative cardiac arrest.

Case description: A five-month-old infant developed cardiac arrest during operation. Return of spontaneous circulation was achieved after one hour of cardiopulmonary resuscitation. Therapeutic hypothermia was applied with neuromuscular blockades. During the TH, the brain function and seizures were monitored with aEEG, which can also display continuous cEEG. Intermittent and discrete seizures were detected on aEEG and confirmed with raw cEEG during the TH and rewarming periods. Several kinds of antiepileptic drugs (AEDs) were administered to manage seizures according to the findings of aEEG with cEEG. Seizures were controlled by the treatments, and she showed no clinical seizures after TH and AED discontinuation.

Discussion and evaluation conclusions: This case indicated the possibility that the use of aEEG with continuous cEEG for a postnatal infant after cardiac arrest was feasible to detect and assess seizures and the effects of antiepileptic therapy while undergoing TH.

No MeSH data available.


Related in: MedlinePlus