The word “monitor” is derived from the Latin monere, meaning “to warn.” CEEG functions much as binoculars do for the lookout on a ship: it provides early warning by extending the viewer’s powers of obrvation.
Although there is an increa in experti in monitoring patients in the ICU, cerebral function still remains hidden in the “black box” of the cranial vault, monitored primarily by bedside obrvations. As treatment options for acute neurological dia have expanded, and as neurologists and neurophysiologists have be-come more involved in neurological intensive care units (NICU), many clinicians have become uncomfortable relying on the traditional neuro-logical examination for detecting potentially re-mediable changes in cerebral function. Bedside asssment becomes progressively uninformative when patients are heavily dated, placed in medical coma, or medically paralyzed. The goal of neurophysiologic monitoring is to extend our powers of obrvation to detect abnormalities at a reversible stage.
Scientific Basis for Continuous EEG:
1. The EEG is tightly linked to cerebral
metabolism.
2. The EEG is nsitive to the most common
caus of cerebral injury: ischemia and
hypoxia.
3. The EEG detects neuronal dysfunction at a
reversible stage.
4. The EEG detects neuronal recovery when the
悲伤留给自己clinical examination cannot.
5. The EEG is the best available method for
detecting epileptic activity.
6. CEEG monitoring provides dynamic
information.7. The EEG provides uful information about
cerebral topography.
CLINICAL APPLICATIONS
The Nicolet™ Monitor allows for better evalua-tion of cerebral function, faster time to treat-ment and better prognostic information which results in quality care for the NICU patient. Can we afford to leave out any vital sign?
CEEG in Status Epilepticus
Seizures are common in the ICU. True incidence of izures in the ICU is under recognized as CEEG monitoring is not done on all patients. Dr. Jordan found 34% of his patients had NCS and 76% of the had NCSE.1Privitera et al. found 27% of his patients at the Emergency unit had NCSE. Treiman et al. found that patients with GCSE who received “adequate” treatment, 20% continued to have NCS and NCSE. In the abnce of CEEG monitoring, the diagnosis of NCS and NCSE is likely to be delayed or misd.2The longer the izure persists, the more difficult it is to treat and the higher the mortality. In one study, the median delay for diagnosis of non-clinical Status Epilepticus in patients with clinical izures was 24 hours. The delay (to diagno without monitoring) was 72 hours in tho with-out clinical izures. Status epilepticus in patients with acute
brain injury and acute ischemic stroke increas the morbidity and mortality rates.3
The deterioration effect of on going izure ac-tivity can be slowed or prevented with clinical intervention. Without CEEG, the patient may be undertreated, or over treated, subjected to the risk of iatrogenic ventilatory failure, cardiovascu-lar instability, and prolonged coma.4CEEG monitoring is necessary to guide the intensity and length of treatment in refractory GCSE.
Continuous EEG Monitoring in the ICU
腐乳肉做法By Dr. Anita Kharbteng, Manager, Clinical Support and Education, Asia CareFusion/Nicolet
CEEG in Acute Focal Cerebral Ischemia
EEG is very nsitive to ischemia and becomes ab-normal when cerebral blood flow falls below 20 to 25 ml/100g/min. Dr. Vespa us the alpha vari-ability trend to help predict vasospasm in SAH pa-tients, 2.9 days before TCD or angiography.5CEEG can also be ud to monitor the effect of HHH therapy.
Dr. Jordan ud CEEG in the emergency depart-ment on suspected acute stroke patients and found they had RAWOD EEG pattern, which is a distinctive EEG pattern found in extensive and ir-reversibl
e focal ischemia, and it signifies a high risk of malignant cerebral edema.1This suggests that urgent EEG in the Emergency Department may be a practical, cost-effective, and objective method for early identification of hemisphere in-farctions. If confirmed, this could be a method that contributes to better lection of patients for therapeutic intervention.
CEEG in Prognosis and Diagnosis of Coma
CEEG monitoring allows the dynamic asssment of the cortex’s reactivity, variability, and sleep pattern integrity. All of the have prognostic im-portance in coma. 30-minutes routine bedside EEG can be misleading. For example, sleep pat-terns may not be detected during the recording, or a ‘snap-shot’ of burst-suppression or epilepti-form activity may have led to a hopeless progno-sis which later resolved. CEEG would help to give a better indication of the state of the brain dur-ing coma for prediction of outcome and manage-ment of patients.6
CEEG in Acute Severe Head Trauma
Much of the neurologic damage does not occur at the moment of impact; rather, over the ensuing hours and days, delayed insults cau condary injury. CEEG monitoring helps to identify impending condary brain injury in time to control or rever it.5CEEG in Detecting New or Increasi
ng
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Intracranial Mass
Although imaging studies are the best way to identify new or enlarging mass lesions, this re-quires the transport of patients out of the ICU. CEEG monitoring can be considered a uful tool for the detection of new or increasing lesions to help in the important decision of whether or not to transport the patient for cerebral imaging.
EEG Systems
Traditionally, the raw EEG generated cumbersome amounts of data and was too complex for interpretation by non-experts. In the 1970s, data compression techniques were introduced in an attempt to simplify EEG interpretation. The techniques entailed the u of quantitative analy-sis of EEG frequency and amplitude in place of the real-time display of EEG like compresd spec-tral array (CSA), the cerebral function monitor (CFM), and topographic brain mapping. Until the 1990s, technological limitations and logistical bar-riers made raw EEG impractical as a real-time physiologic monitor. But with new advances in digital technology, many of the impediments have been overcome, making bedside CEEG a clin-ically relevant tool. New trend analysis packages have been
developed to make EEG easier to analy for non-experts and they sometimes give more information than the raw EEG data.
A SOLUTION TO THE ICU CHALLENGE
The need for a brain monitoring device is clear and devices offering the Intensivists and Neurologists a fully functioning EEG recording with multiple data analyzing tools will deliver a muchneeded solution. The key feature that would differentiate it from a traditional EEG system will be in its ability to provide trending “visuals”, to display information about the data so that it is understandable for ICU staff.
An optimal ICU monitoring system should be:
• More nsitive and specific than clinical obrvations
• Simple to operate and interpret by non-experts • Compatible with medical and nursing care of the patient
• Digitally record continuous EEG for veral days • Recording of at least 8 channels of EEG
• Combining quantitative analysis of EEG with the raw EEG data to speed up the review
process
• Quantification of burst suppression EEGovercame
• Data access from a remote site by computer networking for expert supervision/consultation
The Nicolet Monitor provides brain monitoring capabilities in a format that fits the unique chal-lenges of the ICU striving to offer EFFICIENT and BETTER CARE of the patient:
• Easy-to-u protocols reduce t-up time for different patient groups. Urs can modify pre-configured protocols or create custom ttings.• Innovative touch-screen interface is designed to simplify training and daily operation.
• Wall-mounted or cart-bad designed for the increasing demands of a busy ICU.
• Continuous impedance checks monitor signal quality and indicate which electrodes need
attention.
• Alerts are attached to major events, and automatic notifications can be made by sound, pager, email or SMS.• Network connectivity facilitates export of
data for further analysis and Rearch.
• Raw EEG data is stored for neurological diagnosis
• With more channels, the Nicolet Monitor tests more regions of the brain, identifies focal activity and performs a range of EEG
服装网店functions without the u of additional
社会性动物equipment.
• Monitors other functions such as EKG, respiration and temperature, allowing
obrvation of sleep patterns.
• Remote analysis for experts to review patient data without actually visiting the ICU
NicoletOne Software on the Nicolet Monitor has some of the most sophisticated trends. Trends give a compresd view of long EEG recordings, making it possible to view the entire recording at a glance. This makes it practical to monitor pa-tients as you can quickly identify areas of interest and g
radual changes in patient status. A click at any point in the overview takes you directly to that page on the EEG trace display for a clor look. With the wide variety of available trends on NicoletOne, it is easy to find the trend of your choice and monitor for the relevant behaviour in the EEG. For example, you may be interested in monitoring for levels of anaesthesia while moni-toring for epilepsy at the same time.
Cost Benefit, Cost Effectiveness, and Outcome Studies of CEEG
Cost benefit and cost effectiveness are compli-cated and controversial subjects in health care. It is hard to calculate the cost effectiveness of the number of lives it saves, years of lives saved, and quality of lives saved.
Vespa et al. calculated the ‘cost efficiency’ for CEEG in the ICU in 100 patients with vere head trauma. Its average cost was $560 per patient, which was 1% of the total hospital cost. Over the 4-year period of study, the cost savings was a re-duction of 44%, a reduction in length of stay of 44%, and relative improvement in outcome of patients by 50%. Despite the u of needle elec-trodes, no cas of scalp cellulitis or skin infection were detected.
In Conclusion:
补白
Management decisions for many acute neurologi-cal conditions, such as acute ischemic stroke and status epilepticus, are critically time dependent. With effective treatment now available, it be-comes difficult to justify delays in interpretations
Continuous Brain Monitoring in the ICU can have a significant impact (up to 90% - Vespa et al.) as a guide to clinical decisions:
– Continue or discontinue aggressive care
– Send a patient out of the unit for CT scan
– Adjust dation
– Initiate or modify anticonvulsant drug therapy – Initiate cooling therapy; track changes
– Adjusting cerebral perfusion or mean arterial blood pressure The value of ICU brain monitoring is to:•Improve patient care Improve patient outcome Improve quality of life
• Decrea length of stay
• Protect against litigation
• Decrea Cost
If we concede that brain function is as worthy of monitoring as that of other organs then efforts should be made to provide a new standard of neurological management in the ICU. With the new technology of the new EEG Systems, continu-ous EEG monitoring in the ICU is now feasible. Teamwork between neurologists, intensivists, EEG-technicians and nursing staff using an EEG machine designed specifically for u in the ICU can significantly improve the quality of patient care.
References:
1. Jordan, K.G. Continuous EEG Monitoring in the Neuroscience Intensive Care Unit and Emergency Department. J Clin Neurophysiology, 16(1): 14-39.
2. Vespa, P.M., Nenov, V., Nuwer, M.R. Continuous EEG Monitoring in the Inten-sive Care Unit: Early findings and Clinical Efficacy. J Clin Neurophysiology 1999; 16(1): 1-13
3. Conquering the Next Frontier of ICU Monitoring: The Brain: Lazlo Sandor. July-August 2005
4. Continuous EEG Monitoring in the Intensive Care Unit: An Overview. Lawrence J. Hirsch. J Clin Neurophysiology, Vol 21 (5), October 2004.
物流仓储管理
5. Continuous EEG Monitoring for the Detection of Seizures in Traumatic Brain Injury, Infarction, and Intracerebral Hemorrhage: “To Detect and Protect.” Paul Vespa, J Clin Neurophysiology, Vol 22, Number 2, April 2005.
6. Continuous EEG Monitoring in the Intensive Care Unit. Mark L. Scheuer. Epilepsia, Vol 43, Suppl. 3, 2002.
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