Seizure burden is independently associated with short term outcome in critically ill children
Seizure burden is independently associated with short term outcome in critically ill children
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DOI：
10.1093/brain/awu042
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发表时间：
2014-05-01
期刊：
影响因子：
14.5
通讯作者：
Hahn, Cecil D.
中科院分区：
文献类型：
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作者：
Payne, Eric T.;Zhao, Xiu Yan;Hahn, Cecil D.
癫痫发作在危重患者中很常见，但其与结果的关系仍不清楚。在一群危重儿童中，佩恩等人。证明即使在调整癫痫病因和疾病严重程度后，电图癫痫发作负担的增加与短期神经功能衰退独立相关。癫痫发作在危重儿童中很常见，但其与结果的关系仍不清楚。我们试图量化电图癫痫发作负担与短期神经系统结果之间的关系，同时控制诊断和疾病严重程度。此外，我们试图确定是否存在癫痫发作负担阈值，超过该阈值神经功能衰退的可能性就会增加。我们前瞻性地评估了儿科和心脏重症监护室收治的所有婴儿和儿童，这些婴儿和儿童在 3 年的时间内接受了临床要求的连续视频脑电图监测。通过计算电图癫痫发作所占的任何小时的最大百分比来量化癫痫发作负担。结果指标包括神经功能衰退（定义为入院和出院期间小儿脑功能类别评分恶化）以及院内死亡率。接受评估的 259 名受试者（51% 为男性），中位年龄为 2.2 岁（四分位距：0.3 天至 9.7 岁）。连续视频脑电图监测的中位持续时间为 37 小时（四分位距：21-56 小时）。 93 名受试者（36%，95% 置信区间 = 30-42%）发生癫痫发作，其中 23 名受试者（9%，95% 置信区间 = 5-12%）经历癫痫持续状态。 174 名受试者 (67%) 观察到神经功能衰退，平均最大癫痫发作率为每小时 15.7%，而没有神经功能衰退的受试者为每小时 1.8% (P < 0.0001)。当超过每小时（12 分钟）20% 的最大癫痫负担阈值时，所有诊断类别中神经功能衰退的概率和程度均急剧上升 (P < 0.0001)。在调整诊断和疾病严重程度的多变量分析中，每小时最大癫痫发作负担每增加 1%，神经功能衰退的几率就会增加 1.13（95% 置信区间 = 1.05-1.21，P = 0.0016）。癫痫发作负担与死亡率无关（比值比：1.003，95% 置信区间：0.99-1.02，P = 0.613）。我们的结论是，在这组危重儿童中，癫痫发作负担的增加与神经功能衰退的可能性和程度更大独立相关。我们观察到，在给定时间内癫痫发作超过 12 分钟与神经功能衰退密切相关，这表明该人群有必要进行早期抗癫痫药物管理，并将癫痫发作负担阈值确定为潜在的治疗目标。这些发现支持这样的假设：电图癫痫发作独立地导致脑损伤并恶化结果。我们的结果激励并为未来研究的设计提供信息，以确定更积极的癫痫治疗是否可以改善结果。
Seizures are common among critically ill patients, but their relationship to outcome remains unclear. In a cohort of critically ill children, Payne et al. demonstrate that increasing electrographic seizure burden is independently associated with short-term neurological decline, even after adjusting for seizure aetiology and illness severity.Seizures are common among critically ill children, but their relationship to outcome remains unclear. We sought to quantify the relationship between electrographic seizure burden and short-term neurological outcome, while controlling for diagnosis and illness severity. Furthermore, we sought to determine whether there is a seizure burden threshold above which there is an increased probability of neurological decline. We prospectively evaluated all infants and children admitted to our paediatric and cardiac intensive care units who underwent clinically ordered continuous video-electroencephalography monitoring over a 3-year period. Seizure burden was quantified by calculating the maximum percentage of any hour that was occupied by electrographic seizures. Outcome measures included neurological decline, defined as a worsening Paediatric Cerebral Performance Category score between hospital admission and discharge, and in-hospital mortality. Two hundred and fifty-nine subjects were evaluated (51% male) with a median age of 2.2 years (interquartile range: 0.3 days-9.7 years). The median duration of continuous video-electroencephalography monitoring was 37 h (interquartile range: 21-56 h). Seizures occurred in 93 subjects (36%, 95% confidence interval = 30-42%), with 23 (9%, 95% confidence interval = 5-12%) experiencing status epilepticus. Neurological decline was observed in 174 subjects (67%), who had a mean maximum seizure burden of 15.7% per hour, compared to 1.8% per hour for those without neurological decline (P < 0.0001). Above a maximum seizure burden threshold of 20% per hour (12 min), both the probability and magnitude of neurological decline rose sharply (P < 0.0001) across all diagnostic categories. On multivariable analysis adjusting for diagnosis and illness severity, the odds of neurological decline increased by 1.13 (95% confidence interval = 1.05-1.21, P = 0.0016) for every 1% increase in maximum hourly seizure burden. Seizure burden was not associated with mortality (odds ratio: 1.003, 95% confidence interval: 0.99-1.02, P = 0.613). We conclude that in this cohort of critically ill children, increasing seizure burden was independently associated with a greater probability and magnitude of neurological decline. Our observation that a seizure burden of more than 12 min in a given hour was strongly associated with neurological decline suggests that early antiepileptic drug management is warranted in this population, and identifies this seizure burden threshold as a potential therapeutic target. These findings support the hypothesis that electrographic seizures independently contribute to brain injury and worsen outcome. Our results motivate and inform the design of future studies to determine whether more aggressive seizure treatment can improve outcome.