Clinical Development and Implementation of an Institutional Guideline for Prospective EEG Monitoring and Reporting of Delayed Cerebral Ischemia.
Clinical Development and Implementation of an Institutional Guideline for Prospective EEG Monitoring and Reporting of Delayed Cerebral Ischemia.
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DOI：
10.1097/wnp.0000000000000281
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发表时间：
2016-06
期刊：
影响因子：
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通讯作者：
Rosenthal ES
中科院分区：
文献类型：
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作者：
Muniz CF;Shenoy AV;OʼConnor KL;Bechek SC;Boyle EJ;Guanci MM;Tehan TM;Zafar SF;Cole AJ;Patel AB;Westover MB;Rosenthal ES
延迟性脑缺血（DCI）是蛛网膜下腔出血（SAH）住院患者中最常见和致残的并发症。临床和影像学方法往往不能及早发现DCI以避免不可逆转的损伤。我们评估了将连续脑电图（cEEG）缺血监测服务用于早期DCI检测的临床可行性，并将其作为机构指南的一部分。一个由神经危重症护理、临床神经生理学和神经外科医生、护理人员和脑电图技术人员组成的跨学科团队设计了一个机构神经监测指南。跨学科团队专注于1)高危患者的选择标准，2)最小化与长期监测相关的安全问题，3)基于专家共识和文献回顾的定量和定性神经生理学参数的技术选择，4)结构化的解释和报告方法，促进直接的患者评估和反复的神经危重症护理。5)两层质量保证流程，包括结构化的临床医生访谈，评估神经系统恶化事件，以及对神经影像学和医疗记录的裁决共识审查。然后对指南的临床可行性进行前瞻性评估。机构SAH监测指南采用经颅多普勒超声（TCD）和脑电图（cEEG）监测Fisher 3或Hunt Hess 4-5 SAH患者的血管痉挛和缺血监测。安全标准侧重于防止皮肤破裂和躁动。技术成分包括监测TCD速度和脑电图特征，包括定量α: δ比值和α变异性百分比，新病灶减慢的定性证据，迟发性癫痫样活动，或背景整体恶化。介绍了结构化的脑电图报告，包括有关神经功能衰退的发现的口头交流。该指南成功实施了27个月，在此期间，神经危重症护理医生推荐了71例SAH患者进行TCD和cEEG联合监测。质量保证过程确定监测人群中的DCI率为48%，其中90%以上发生在症状出现后2.7天开始的cEEG监测期间（平均6.9天）。实施脑电图监测和报告SAH缺血的制度性指南是可行的，可以有效地识别监测期间DCI基线高风险患者。
Delayed cerebral ischemia (DCI) is the most common and disabling complication among patients hospitalized for subarachnoid hemorrhage (SAH). Clinical and radiographic methods often fail to detect DCI early enough to avert irreversible injury. We assessed the clinical feasibility of implementing a continuous electroencephalography (cEEG) ischemia monitoring service for early DCI detection as part of an institutional guideline. An institutional neuromonitoring guideline was designed by an interdisciplinary team of neurocritical care, clinical neurophysiology and neurosurgery physicians as well as nursing staff and cEEG technologists. The interdisciplinary team focused on 1) selection criteria of high-risk patients, 2) minimization of safety concerns related to prolonged monitoring, 3) technical selection of quantitative and qualitative neurophysiologic parameters based on expert consensus and review of the literature, 4) a structured interpretation and reporting methodology, prompting direct patient evaluation and iterative neurocritical care, and 5) a two-layered quality assurance process including structured clinician interviews assessing for events of neurological worsening and an adjudicated consensus review of neuroimaging and medical records. The resulting guideline’s clinical feasibility was then prospectively evaluated. The institutional SAH monitoring guideline employed transcranial Doppler ultrasonography (TCD) and cEEG monitoring for vasospasm and ischemia monitoring in patients with either Fisher 3 or Hunt Hess 4–5 SAH. Safety criteria focused on prevention of skin breakdown and agitation. Technical components included monitoring of TCD velocities and cEEG features including quantitative alpha:delta ratio and percent alpha variability, qualitative evidence of new focal slowing, late-onset epileptiform activity, or overall worsening of background. Structured cEEG reports were introduced including verbal communication for findings concerning for neurological decline. The guideline was successfully implemented over 27 months, during which neurocritical care physicians referring 71 SAH patients for combined TCD and cEEG monitoring. The quality assurance process determined a DCI rate of 48% among the monitored population, over 90% of which occurred during the duration of cEEG monitoring (mean 6.9 days) beginning 2.7 days after symptom onset. An institutional guideline implementing cEEG for SAH ischemia monitoring and reporting is feasible to implement and efficiently identify patients at high baseline risk of DCI during the period of monitoring.