monitorização neuro
TRANSCRIPT
INTENSIVE CARE UNIT / CONTINOUS EEG MONITORING
STAFFING AND IMPLEMENTATION
Maria Lucia Furtado de Mendonça Iodete Carneiro do PradoElizabeth Maria D’Almeida RibeiroElizabeth Maria D’Almeida RibeiroAna Cláucida T. Mattos
WHY MONITOR THE BRAIN
IN I.C.U. ???
?
� Physiophatological changes are dynamic
� Information must be dynamic
� Neurophysiological abnormalities are detectedbefore clinical deterioration
CRITICAL CARE PATIENT:
� Intervention before clinical deterioration
� Therapeutic control
� Early prognostic information
� Differential diagnosis of conscience disturbances
DOPPLER DOPPLER TRANSCRANIANOTRANSCRANIANO
SUPORTE NEUROLÓGICO EM U.T.I.SUPORTE NEUROLÓGICO EM U.T.I.
PRESSÃOPRESSÃOINTRACRANIANAINTRACRANIANA
EEG CONTINUO EEG CONTINUO
SjVO2SjVO2
MICRODIÁLISEMICRODIÁLISEPOTENCIAISPOTENCIAISEVOCADOSEVOCADOS
JULGAMENTO MÉDICOJULGAMENTO MÉDICO
� Cobertura cortical ampla
� Relação direta e dinâmica com anormalidades de perfusão
ELETRENCEFALOGRAMA:
sensível a anestesia, temperatura e sensível a anestesia, temperatura e distúrbios metabólicosdistúrbios metabólicos
� Resistente a anestésicos e hipotermia
� Correlação estabelecida com isquemia cerebral
POTENCIAL EVOCADO SÔMATO SENSITIVO:
Limitado a uma via neuralLimitado a uma via neural
� Detecta e quantifica sinais de microembolização (MES)
� Detecta anormalidades hemodinâmicas intracranianas em tempo real
DOPPLER TRANSCRANIANO:
Não avalia função cerebral diretamenteNão avalia função cerebral diretamente
INDICATIONS FOR ICU - CEEG :
� Unexplained decrease in LOC
�Detection of subclinical seizures
�Unstable cerebral ischaemia�Unstable cerebral ischaemia
�Early detection of vasospasm in SAH
�Increased ICP with decrease in LOC
�Prognosis
Uninformative bedside assessment:
INDICATIONS FOR ICU - CEEG :cont.
�Medication - induced coma with/without NMB use
1. SENSITIVE TO CARDIAC ISCHEMIA
SENSITIVE TO CEREBRAL ISCHEMIA
2. DETECTS CARDIAC ISCHEMIA DETECTS CEREBRAL ISCHEMIA
EKG EEG
CEEG = “EKG MONITORING” OF THE BRAIN
Courtesy KG Jordan ,MD. 2006KG Jordan ,MD. 2006
2. DETECTS CARDIAC ISCHEMIA AT A REVERSIBLE STAGE
DETECTS CEREBRAL ISCHEMIA AT A REVERSIBLE STAGE
3. CORRELATES WITH CARDIAC BLOOD FLOW
CORRELATES WITH CEREBRAL BLOOD FLOW
4. RAPIDLY AND ACCURATELY DETECTS CARDIAC ARRHYTHMIAS
RAPIDLY AND ACCURATELY DETECTS EPILEPTIC ACTIVITY
Are nonconvulsive seizures a significant problem in the ICU ??
�� 35%35% of NeuroICU patients found to have seizures (Jordan 1992)
�� 22%22% of TBI patients have seizures, ½ of which are nonconvulsive (Vespa 1999)
YES!!!
22%22%nonconvulsive (Vespa 1999)
�� 28%28% of ICH patients have seizures, ½ of which are nonconvulsive (Vespa 2003)
�� 15%15% of SAH patients have seizures (Claassen 2004)
�� 44%44% of pediatric ICU patients have seizures on cEEG (Jette, Hirsch 2006)
CEEG findings – 570 patients Claassen, 2004 :
MORTALIDADE - EMENC•• Retardo no diagnóstico:Retardo no diagnóstico:
– <0.5 h: 36% (5/14)– >1 <24 h: 39% (7/18) – ≥24 h: 75% (6/8)
•• Duração da criseDuração da crise::
– <10 h: 10% (3/30)
* Young GB, Jordan KG., Doig G. Neurology, 1996
•• Duração da criseDuração da crise– <10 h: 10% (3/30) – 10-20 h: 33% (2/6) – >20 h: 85% (11/13)
•• Etiologia:Etiologia:– Lesão crônica : 16% (4/25)– Lesão aguda : 46% (11/24)
MOST CRITICAL CARE PATIENTS HAD EXCLUSIVELY
NONCONVULSIVE SEIZURES
WITHOUT CEEG, THE RECOGNITION OF NCSE
IS DELAYED OR MISSED
INCREASE RATES OF MORBIDITY AND MORTALITY
74a74aPassado de AVE Passado de AVE Sepse urináriaSepse urináriaInsuficiência renal agudaInsuficiência renal agudaUso de quinolonaUso de quinolonaDeterioração do nível de consciênciaDeterioração do nível de consciência
TORPOROSA ACORDOU APÓS 1 mg MIDAZOLAM
Quanto tempo um paciente agudo
necessita ficar monitorizado paranecessita ficar monitorizado para
detecção de crises epilépticas ?
Tempo para gravar a primeira crise, comparando os pacientes comatososTempo para gravar a primeira crise, comparando os pacientes comatosose não comatosos e não comatosos
Neurology 2004;62:1743-1748
48 horas ou mais podem ser necessários para detecção de crises epilépticasnão convulsivas em pacientes comatosos
DETECTING AND MONITORING
CEREBRAL ISCHAEMIA
“The singular focus inneurocritical care is
to prevent or rapidly identifyneurocritical care is
to prevent or rapidly identifyand then reversebrain ischemiaif it occurs”
CBF CBF LEVELLEVEL
(ml/100gm/min)(ml/100gm/min)
EEG CHANGEEEG CHANGE DEGREE OF DEGREE OF NEURONAL INJURYNEURONAL INJURY
35-70 NORMAL NO INJURY
25-35 LOSS OF FAST BETA FREQUENCIES
USUALLY REVERSIBLEEEG reveals a “window of reversibility”
18-25 SLOWING OF BACKGROUND T0 5-7HZ THETA
POTENTIALLY REVERSIBLE
12-18 SLOWING TO 1-4HZ DELTA POTENTIALLY REVERSIBLE
< 8-10 SUPRESSION OF ALL FREQUENCIES
NEURONAL DEATH
Jordan K. JCN 2004
“window of reversibility”of
ischaemic cerebral injury
38a38aPO DISSECÇÃO AÓRTICAPO DISSECÇÃO AÓRTICA2h PARADA CIRCULATÓRIA2h PARADA CIRCULATÓRIAAVE HCDAVE HCD
PAM: 63 mmHg PAM: 95 mmHg
AVALIAÇÃO PROGNÓSTICA DOS COMASAVALIAÇÃO PROGNÓSTICA DOS COMAS
ELEMENTOS FISIOLÓGICOS DO SONO
REATIVIDADE
VARIABILIDADE
PADRÕES DE BOM PROGNÓSTICOPADRÕES DE BOM PROGNÓSTICO
PADRÕES DE MAU PROGNÓSTICO PADRÕES DE MAU PROGNÓSTICO
M O N Ó T O N O
LENTO E NÃO REATIVOLENTO E NÃO REATIVOCRISES EPILÉPTICASCRISES EPILÉPTICAS
PADRÕES DE MAU PROGNÓSTICO PADRÕES DE MAU PROGNÓSTICO
INATIVIDADE ELÉTRICA CEREBRALINATIVIDADE ELÉTRICA CEREBRALSURTO SUPRESSÃO SURTO SUPRESSÃO
ESPEC. = 100%
LANCET 1998 , 352 : 1808-12
POTENCIAL EVODACO SÔMATO SENSITIVO CURTA LATÊNCIA POTENCIAL EVODACO SÔMATO SENSITIVO CURTA LATÊNCIA –– N. MEDIANON. MEDIANO
APÓS 72 HORASAPÓS 72 HORAS
NORMALNORMAL ANORMALANORMAL
COMPONENTE CORTICAL SEM COMPONENTE CORTICAL
ML1
Slide 27
ML1 Pacientes comatosos com CC bilat. tem o prognóstico incertoDra. Malu; 20/10/2003
POTENCIAL EVODACO SÔMATO SENSITIVO POTENCIAL EVODACO SÔMATO SENSITIVO –– N. MEDIANO N. MEDIANO -- RCPRCP
2 50
3 0 0
N= 572N= 572
ÓBITO OU EVPÓBITO OU EVP
251229
J Clin Neurophysiol 2000 17 (5) 486-97
Ted L. Rothstein
D 3 EM DIANTE
0
50
10 0
150
2 0 0
PESS PESS C/ CCC/ CC
PESS PESS S/ CCS/ CC
RECUPERAÇÃORECUPERAÇÃO
ÓBITO OU EVPÓBITO OU EVP
144
0
PESS S/ CC BILATERAL APÓS PCR - SENS 68% VPP: 100% VPP: 100%
ML2
Slide 28
ML2 META ANÁLISE DE COMA ANÓXICO ISQUÊMICOE COMPONENTE COETICAL DA VIA SOMATO SENSITIVA EM 572 PACIENTESDra. Malu; 2/8/2003
DURING THE PAST 10 YEARS :
ICU/cEEG is becoming a
STANDART OF CARE
BUT...
SO...
�Very few neurointensivists read EEG
�There is a very shortage of EEGers to serve this unmet patient need 24/7
BUT...
Interdependence become increasingly important among all who are involved in the patient care
TEAMWORK
CONTINUOUS EEG MONITORING IN ICUCONTINUOUS EEG MONITORING IN ICU
��NEUROPHYSIOLOGY TEAMNEUROPHYSIOLOGY TEAM
��REAL TIME OBSERVATION “24/7”REAL TIME OBSERVATION “24/7”
��ICU TEAM BASIC AND CONTINUOUS TRAININGICU TEAM BASIC AND CONTINUOUS TRAINING
ICU/cEEG program most successful with
collaboration of all who areinvolved in the patient care
•Neurointensivist•Neurointensivist•Intensivist•Neurosurgeons•Fellows/Residents•ICU nurse•Neurophysiologist•Technologists
ICUICU--CEEG WORKSHOPCEEG WORKSHOP
Basic and advanced training of ICU team includes:
�Neuroanatomy
�Neurophysiology
ICUICU--CEEG WORKSHOPCEEG WORKSHOP
�Neurophysiology
�Technical application
�Computer application
�Waveform recognition
�Clinical correlation
FUNDAMENTAL POINTS - BASIC TRAINING
- Computer application :
�Bedside acquisition unit trainning
�Long distance real time conection
FUNDAMENTAL POINTS - BASIC TRAINING�Technical application
FP1
F4Fz
FP2
F8F7
F3
Left=odd Right=even
Electrode Placement/nomenclature
P4P3 Pz
Cz C4 T4
T6
O2O1
C3
T5
T3
“Z”=midline
Electrode application method
FUNDAMENTAL POINTS - BASIC TRAINING
FUNDAMENTAL POINTS - BASIC TRAINING
Electrode application method
Needle electrodes
FUNDAMENTAL POINTS - BASIC TRAINING
Electrode application method
FUNDAMENTAL POINTS - BASIC TRAINING
Waveform recognition
-Artefact recognition
-Simetry ( frequency and amplitude )
-Reactivity
-Epileptiform activity
-Sedation level
WAVEFORM RECOGNITION TRAINING
Courtesy KG Jordan ,MD.KG Jordan ,MD.
CHARTING CODES FOR CEEG WAVEFORMS
Courtesy KG Jordan ,MD.KG Jordan ,MD.
11 14
13
111
1213
2
3
4
1
Left Right
6
5
Left Right
1
11
10
9
12
11
9
105
6
1
12
14
15
16
111
1213
6
7
9
111
1213
18
17
1
EKG 19
LP, LA, UELP, LA, UE
LT, LA, UELT, LA, UELT, LA, UELT, LA, UE
RP, MA, ERP, MA, E
RT, MA, ERT, MA, E
NURSE ICUNURSE ICU--CEEG FLOWCHARTCEEG FLOWCHART
Each hour nurses would look
at the CEEG waveforms and
note them on the flow sheet.
Courtesy KG Jordan ,MD.KG Jordan ,MD.
24/7 !!!!
�� ICU team comfortable with waveform ICU team comfortable with waveform recognition from their experience with recognition from their experience with other monitors in the ICU.other monitors in the ICU.
��They accept CEEG monitoring as natural They accept CEEG monitoring as natural extension of physiologic monitoring to the extension of physiologic monitoring to the extension of physiologic monitoring to the extension of physiologic monitoring to the brain. brain.
��They embrace CEEG benefit to patient They embrace CEEG benefit to patient care. care.
CONCLUSIONS:� EEG detects real time ischaemia and in reversible stages ;
� Nonconvulsive seizures are common in critical carepatients, 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 observationin real time by a specialist is possible;
�Institutional support and comitment are funtamental pointsto CEEG monitoring program success.
“ SOME PEOPLE DREAM OF SUCCESS...
WHILE OTHERS WAKE UP AND WORK HARD AT IT “