1. INTENSIVE CARE UNIT / CONTINOUS EEG MONITORING
STAFFING AND IMPLEMENTATION
Maria Lucia Furtado de Mendonça
Iodete Carneiro do Prado
Elizabeth Maria D’Almeida Ribeiro
Ana Cláucida T. Mattos

2. WHY MONITOR THE BRAIN
IN I.C.U. ???
?

3. CRITICAL CARE PATIENT:
Physiophatological changes are dynamic
Information must be dynamic
Neurophysiological abnormalities are detected
before clinical deterioration
Intervention before clinical deterioration
Therapeutic control
Early prognostic information
Differential diagnosis of conscience disturbances

4. SUPORTE NEUROLÓGICO EM U.T.I.
DOPPLER PRESSÃO
TRANSCRANIANO INTRACRANIANA
EEG CONTINUO
SjVO2
POTENCIAIS
MICRODIÁLISE EVOCADOS
JULGAMENTO MÉDICO

5. ELETRENCEFALOGRAMA:
Cobertura cortical ampla
Relação direta e dinâmica com anormalidades de perfusão
sensível a anestesia, temperatura e
distúrbios metabólicos

6. POTENCIAL EVOCADO SÔMATO SENSITIVO:
Resistente a anestésicos e hipotermia
Correlação estabelecida com isquemia cerebral
Limitado a uma via neural

7. DOPPLER TRANSCRANIANO:
Detecta e quantifica sinais de microembolização (MES)
Detecta anormalidades hemodinâmicas intracranianas em tempo real
Não avalia função cerebral diretamente

8. INDICATIONS FOR ICU - CEEG :
Unexplained decrease in LOC
Detection of subclinical seizures
Unstable cerebral ischaemia
Early detection of vasospasm in SAH
Increased ICP with decrease in LOC
Prognosis

9. INDICATIONS FOR ICU - CEEG :
cont.
Uninformative bedside assessment:
Medication - induced coma with/
without NMB use

10. CEEG = “EKG MONITORING”
OF THE BRAIN
EKG EEG
1. SENSITIVE TO CARDIAC SENSITIVE TO CEREBRAL
ISCHEMIA ISCHEMIA
2. DETECTS CARDIAC ISCHEMIA DETECTS CEREBRAL ISCHEMIA
AT A REVERSIBLE STAGE AT A REVERSIBLE STAGE
3. CORRELATES WITH CARDIAC CORRELATES WITH CEREBRAL
BLOOD FLOW BLOOD FLOW
4. RAPIDLY AND ACCURATELY RAPIDLY AND ACCURATELY
DETECTS CARDIAC DETECTS EPILEPTIC ACTIVITY
ARRHYTHMIAS
Courtesy KG Jordan ,MD. 2006

11. Are nonconvulsive seizures a
significant problem in the ICU ??
YES!!!
35% of NeuroICU patients found to have seizures
(Jordan 1992)
22% of TBI patients have seizures, ½ of which are
nonconvulsive (Vespa 1999)
28% of ICH patients have seizures, ½ of which are
nonconvulsive (Vespa 2003)
15% of SAH patients have seizures (Claassen 2004)
44% of pediatric ICU patients have seizures on cEEG
(Jette, Hirsch 2006)

13. CEEG findings – 570 patients Claassen, 2004 :

14. MORTALIDADE - EMENC
* Young GB, Jordan KG., Doig G. Neurology, 1996
• Retardo no diagnóstico:
– <0.5 h: 36% (5/14)
– >1 <24 h: 39% (7/18)
– ≥24 h: 75% (6/8)
• Duração da crise:
– <10 h: 10% (3/30)
– 10-20 h: 33% (2/6)
– >20 h: 85% (11/13)
• Etiologia:
– Lesão crônica : 16% (4/25)
– Lesão aguda : 46% (11/24)

15. MOST CRITICAL CARE PATIENTS HAD EXCLUSIVELY
NONCONVULSIVE SEIZURES
WITHOUT CEEG, THE RECOGNITION OF NCSE
IS DELAYED OR MISSED
INCREASE RATES OF MORBIDITY AND MORTALITY

16. 74a
Passado de AVE
Sepse urinária
Insuficiência renal aguda
Uso de quinolona
Deterioração do nível de consciência
TORPOROSA ACORDOU APÓS 1 mg MIDAZOLAM

17. Quanto tempo um paciente agudo
necessita ficar monitorizado para
detecção de crises epilépticas ?

18. Tempo para gravar a primeira crise, comparando os pacientes comatosos
e não comatosos
48 horas ou mais podem ser necessários para detecção de crises epilépticas
não convulsivas em pacientes comatosos
Neurology 2004;62:1743-1748

19. DETECTING AND MONITORING
CEREBRAL ISCHAEMIA

20. “The singular focus in
neurocritical care is
to prevent or rapidly identify
and then reverse
brain ischemia
if it occurs”

21. CBF EEG CHANGE DEGREE OF
LEVEL NEURONAL INJURY
(ml/100gm/min)
35-70 NORMAL NO INJURY
25-35 EEG reveals a
LOSS OF FAST BETA
FREQUENCIES
USUALLY REVERSIBLE
“window of reversibility”
18-25 SLOWING OF BACKGROUND POTENTIALLY
T0 5-7HZ THETA REVERSIBLE
of
12-18 SLOWING TO 1-4HZ DELTA POTENTIALLY
ischaemic cerebral REVERSIBLE
< 8-10 injury
SUPRESSION OF ALL
FREQUENCIES
NEURONAL DEATH
Jordan K. JCN 2004

22. 38a
PO DISSECÇÃO AÓRTICA
2h PARADA CIRCULATÓRIA
AVE HCD
PAM: 63 mmHg PAM: 95 mmHg

23. AVALIAÇÃO PROGNÓSTICA DOS COMAS

24. PADRÕES DE BOM PROGNÓSTICO
ELEMENTOS FISIOLÓGICOS DO SONO
REATIVIDADE
VARIABILIDADE

25. PADRÕES DE MAU PROGNÓSTICO
CRISES EPILÉPTICAS LENTO E NÃO REATIVO
MONÓTON O

26. PADRÕES DE MAU PROGNÓSTICO
SURTO SUPRESSÃO INATIVIDADE ELÉTRICA CEREBRAL
ESPEC. = 100%
LANCET 1998 , 352 : 1808-12

27. ML1
POTENCIAL EVODACO SÔMATO SENSITIVO CURTA LATÊNCIA – N. MEDIANO
APÓS 72 HORAS
NORMAL ANORMAL
COMPONENTE CORTICAL SEM COMPONENTE CORTICAL

28. Slide 27
ML1 Pacientes comatosos com CC bilat. tem o prognóstico incerto
Dra. Malu; 20/10/2003

29. ML2
POTENCIAL EVODACO SÔMATO SENSITIVO – N. MEDIANO - RCP
D 3 EM DIANTE
J Clin Neurophysiol 2000 17 (5) 486-97
Ted L. Rothstein
300
N= 572 251
2 50 229
200 ÓBITO OU EVP
15 0
144 RECUPERAÇÃO
10 0
50
0
0
PESS PESS
C/ CC S/ CC
PESS S/ CC BILATERAL APÓS PCR - SENS 68% VPP: 100%

30. Slide 28
ML2 META ANÁLISE DE COMA ANÓXICO ISQUÊMICO
E COMPONENTE COETICAL DA VIA SOMATO SENSITIVA EM 572 PACIENTES
Dra. Malu; 2/8/2003

31. SO...
DURING THE PAST 10 YEARS :
ICU/cEEG is becoming a
STANDART OF CARE
BUT...
Very few neurointensivists read EEG
There is a very shortage of EEGers to serve
this unmet patient need 24/7

32. Interdependence become increasingly important
among all who are involved in the patient care
TEAMWORK

33. CONTINUOUS EEG MONITORING IN ICU
NEUROPHYSIOLOGY TEAM
REAL TIME OBSERVATION “24/7”
ICU TEAM BASIC AND CONTINUOUS TRAINING

34. ICU/cEEG program
most successful with
collaboration of all who are
involved in the patient care
•Neurointensivist
•Intensivist
•Neurosurgeons
•Fellows/Residents
•ICU nurse
•Neurophysiologist
•Technologists

35. ICU-
ICU-CEEG WORKSHOP

36. ICU-
ICU-CEEG WORKSHOP
Basic and advanced training of ICU team includes:
Neuroanatomy
Neurophysiology
Technical application
Computer application
Waveform recognition
Clinical correlation

37. FUNDAMENTAL POINTS - BASIC TRAINING
- Computer application :
Bedside acquisition unit trainning
Long distance real time conection

38. FUNDAMENTAL POINTS - BASIC TRAINING
Technical application
Electrode Placement/nomenclature
Left=odd FP1 FP2 Right=even
F7
F3 Fz F4 F8
T3 C3 Cz C4 T4
P3 Pz P4
T5 T6
“Z”=midline
O1 O2

39. FUNDAMENTAL POINTS - BASIC TRAINING
Electrode application method

40. FUNDAMENTAL POINTS - BASIC TRAINING
Electrode application method
Needle electrodes

41. FUNDAMENTAL POINTS - BASIC TRAINING
Electrode application method

42. FUNDAMENTAL POINTS - BASIC TRAINING
Waveform recognition
-Artefact recognition
-Simetry ( frequency and amplitude )
-Reactivity
-Epileptiform activity
-Sedation level

43. WAVEFORM RECOGNITION TRAINING
Courtesy KG Jordan ,MD.

44. CHARTING CODES FOR CEEG
WAVEFORMS
Courtesy KG Jordan ,MD.

45. Left Right
Left Right
9
1 10
2 11
11
1 3 12
4 12
13
5 13
1 14
6 11
11 1
17 15
9 12 12
13 16
9
17
11
10
1 18 5 EKG 19
12
6
13

46. LP, LA, UE
LT, LA, UE
RP, MA, E
RT, MA, E

47. NURSE ICU-CEEG FLOWCHART
ICU-
Each hour nurses would look
at the CEEG waveforms and
note them on the flow sheet.
Courtesy KG Jordan ,MD.

48. 24/7 !!!!

49. ICU team comfortable with waveform
recognition from their experience with
other monitors in the ICU.
They accept CEEG monitoring as natural
extension of physiologic monitoring to the
brain.
They embrace CEEG benefit to patient
care.

50. CONCLUSIONS:
EEG detects real time ischaemia and in reversible stages ;
Nonconvulsive seizures are common in critical care
patients, and is related to marked adverse effects;
ICU/cEEG is becoming a standart of care;
ICU patients need CEEG avaiable 24/7;
As well as basic and continuous training , remote observation
in real time by a specialist is possible;
Institutional support and comitment are funtamental points
to CEEG monitoring program success.

51. “ SOME PEOPLE DREAM OF SUCCESS...
WHILE OTHERS WAKE UP AND WORK HARD AT IT “