To know or not to know: does EEG monitoring in the paediatric intensive care unit add anything besides cost?
To know or not to know: does EEG monitoring in the paediatric intensive care unit add anything besides cost?
复制标题
是否知道：儿科重症监护病房的脑电图监测除了成本之外还会增加什么吗？
DOI：
10.1093/brain/awu080
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发表时间：
2014
期刊：
影响因子：
--
通讯作者：
Holmes,GregoryL
中科院分区：
文献类型：
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作者：
Holmes,GregoryL
你被叫到重症监护室，去看一个患有脑炎的6岁女孩。患儿出现2天发热、意识模糊和嗜睡，在全身强直阵挛性癫痫发作持续8分钟后入院，接受静脉注射劳拉西泮，随后接受左乙拉西坦治疗。当你看到这个孩子时，她是昏迷的，对口头命令没有反应，但没有持续癫痫发作的临床症状。重症监护室的工作人员想知道他们是否应该请技术人员来获取EEG。对于一个已经有过惊厥发作的孩子，正在接受抗癫痫治疗，并且没有表现出持续癫痫发作活动的迹象，脑电图监测是否会增加她的管理？在本期的《大脑》杂志上，佩恩等人。（2014）提供证据表明它可能。关于癫痫发作，无论是临床的还是亚临床的，对危重患儿是否有害，一直存在争议。许多临床医生认为癫痫发作的病因是结果的决定因素，癫痫发作本身只是潜在疾病严重程度的反映。有人认为，在脑炎等疾病中，病情较严重的儿童比病情较轻的儿童更容易癫痫发作。换句话说，癫痫发作是严重脑病的标志，但不会造成额外的脑损伤。由于癫痫发作的存在或不存在对结果没有影响，为什么要进行不改变临床过程的昂贵测试？根据这种观点，重点应该是治疗癫痫发作的原因，而不是癫痫发作本身。相反的论点是，癫痫发作，即使是心电图和没有临床表现，是有害的，需要迅速识别和积极治疗。因此，了解癫痫发作在严重疾病中是否有害至关重要。佩恩和他的同事（2014）现在已经为这个有争议的问题提供了答案。研究人员前瞻性地评估了259名在多伦多儿童医院儿科和心脏重症监护室接受连续视频脑电图监测的儿童。引人注目的是，36%的儿童发生癫痫发作，9%的儿童经历癫痫持续状态。为了确定癫痫发作是否对神经功能有影响，研究人员使用儿科脑功能分类（PCPC）评分来估计住院前后的神经系统状态。在这组危重儿童中，67%的儿童出现神经功能下降。此外，神经功能下降与癫痫发作明显相关;在PCPC恶化的儿童中，平均癫痫发作负荷（计算为电描记癫痫发作占用的任何给定小时的最大百分比）为15.7%，而在无PCPC恶化的儿童中为1.8%。使用多变量分析，调整诊断和疾病严重程度，佩恩等。（2014）表明，癫痫发作，独立于疾病的严重程度，导致发病率增加，但不是死亡率。基础科学研究人员几十年前就在动物身上证明，电图癫痫发作可导致严重的脑损伤，即使没有癫痫引起的氧合、温度或血压的全身变化，或癫痫引起的电解质异常或低血糖，癫痫发作（无论临床上是否明显）与不良结局相关的发现也不会令人惊讶。Meldrum and colleagues（1973）and Brierley et al.（1972）比较了青少年狒狒惊厥性和非惊厥性癫痫发作造成的脑损伤。长期的...
You are called to the intensive care unit to see a 6-year-old girl admitted with encephalitis. The child presented with 2 days of fever, confusion and lethargy and was admitted following a generalized tonic-clonic seizure lasting 8min, which was treated with intravenous lorazepam followed by levetiracetam. When you see the child she is stuporous and does not respond to verbal commands but shows no clinical signs of ongoing seizures. The staff in the intensive care unit wish to know whether they should call in a technician to obtain an EEG. In a child who has already had a convulsive seizure, is on antiepileptic therapy and is showing no signs of ongoing seizure activity, will EEG monitoring add anything to her management? In the current issue of Brain, Payne et al.(2014) provide evidence to suggest that it might. There is a long-standing controversy as to whether seizures, either clinical or subclinical, are harmful in critically ill children. Many clinicians are of the mindset that the aetiology of seizures is the determinant of outcome and that seizures themselves are simply a reflection of the severity of the underlying condition. In a condition such as encephalitis, it is argued, children with more severe disease are more likely to have seizures than children with milder forms. In other words, seizures are a marker of a severe encephalopathy but do not cause additional brain damage. As the presence or absence of seizures has no bearing on outcome, why perform expensive testing that does not alter the clinical course? According to this viewpoint, the emphasis should be on treating the cause of the seizures, not the seizures themselves. The counter-argument is that seizures, even if electrographic and without clinical manifestations, are harmful and need to be identified quickly and treated aggressively. Knowing whether seizures are harmful in the context of a severe illness is therefore of critical importance. Payne and colleagues (2014) have now provided an answer to this contentious question. The investigators prospectively evaluated 259 children who underwent continuous video-EEG monitoring upon admission to the paediatric and cardiac intensive care units at the Hospital for Sick Children in Toronto. Strikingly, seizures occurred in 36% of the children with 9% experiencing status epilepticus. To determine whether seizures had an impact on neurological function, the investigators used a Paediatric Cerebral Performance Category (PCPC) score to estimate neurological status before and after hospitalization. Neurological decline was seen in 67% of this group of critically ill children. Moreover, neurological decline was clearly related to seizures; in the children with PCPC worsening the mean seizure burden (calculated as the maximum percentage of any given hour occupied by electrographic seizures) was 15.7% compared to 1.8% for those without PCPC worsening. Using multivariable analysis, which adjusted for diagnosis and illness severity, Payne et al.(2014) show that seizures, independent of illness severity, result in increased morbidity, but not mortality. The finding that seizures, whether clinically evident or not, are associated with poor outcomes would not be surprising to basic science investigators who demonstrated decades ago in animals that electrographic seizures can result in substantial brain damage, even in the absence of seizure-induced systemic changes in oxygenation, temperature or blood pressure, or seizure-induced electrolyte abnormalities or hypoglycaemia. Meldrum and colleagues (1973) and Brierley et al.(1972) compared the brain damage caused by convulsive and non-convulsive seizures in adolescent baboons. Prolonged …