Effects of epileptiform activity on discharge outcome in critically ill patients in the USA: a retrospective cross-sectional study.
Effects of epileptiform activity on discharge outcome in critically ill patients in the USA: a retrospective cross-sectional study.
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DOI：
10.1016/s2589-7500(23)00088-2
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发表时间：
2023-08
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影响因子：
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通讯作者：
Westover MB
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作者：
Parikh H;Hoffman K;Sun H;Zafar SF;Ge W;Jing J;Liu L;Sun J;Struck A;Volfovsky A;Rudin C;Westover MB
癫痫样活动与更差的患者结局相关，包括残疾和死亡风险增加。然而，抗癫痫药物治疗和癫痫样活动负荷之间的反馈混淆了癫痫样活动对神经系统结局的影响。我们的目的是量化癫痫样活动的异质性影响与解释为中心的方法。我们对马萨诸塞州综合医院（美国马萨诸塞州波士顿）重症监护室的患者进行了回顾性横断面研究。参与者年龄在18岁或以上，并且有临床神经生理学家或癫痫学家鉴定的电描记癫痫样活动。结局为出院时的二分改良兰金量表（mRS），暴露量为癫痫样活动负荷，定义为脑电图检查前24小时内6小时窗口内癫痫样活动的平均或最大时间比例。如果数据集中的每个人都经历了特定的癫痫样活动负担并且未接受治疗，我们估计了出院时mRS的变化。我们将药理学建模与可解释的匹配方法相结合，以解释混淆和癫痫样活动-抗癫痫药物反馈。匹配组的质量由神经科医生验证。2011年12月1日至2017年10月14日期间，1514名患者入住马萨诸塞州综合医院重症监护室，其中995名（66%）患者纳入分析。与最大癫痫样活动为0至小于25%的患者相比，最大癫痫样活动负荷为75%或以上的患者在未经治疗时，不良结局（严重残疾或死亡）的机会平均增加22.27%（SD 0.92）。中度但持续时间长的癫痫样活动（平均癫痫样活动负荷2%至<10%）使不良结局的风险平均增加13.52%（SD 1.93）。影响大小是异质性的，取决于入院前的配置文件，例如，缺氧缺血性脑病或获得性脑损伤的患者比没有这些条件的患者受到更不利的影响。我们的研究结果表明，干预措施应该把一个更高的优先级，平均癫痫样活动负担10%或更高的患者，治疗应该更保守，当最大癫痫样活动负担低。治疗也应该根据个人入院前的情况进行调整，因为癫痫样活动造成伤害的可能性取决于年龄、病史和入院原因。国立卫生研究院和国家科学基金会。
Epileptiform activity is associated with worse patient outcomes, including increased risk of disability and death. However, the effect of epileptiform activity on neurological outcome is confounded by the feedback between treatment with antiseizure medications and epileptiform activity burden. We aimed to quantify the heterogeneous effects of epileptiform activity with an interpretability-centred approach. We did a retrospective, cross-sectional study of patients in the intensive care unit who were admitted to Massachusetts General Hospital (Boston, MA, USA). Participants were aged 18 years or older and had electrographic epileptiform activity identified by a clinical neurophysiologist or epileptologist. The outcome was the dichotomised modified Rankin Scale (mRS) at discharge and the exposure was epileptiform activity burden defined as mean or maximum proportion of time spent with epileptiform activity in 6 h windows in the first 24 h of electroencephalography. We estimated the change in discharge mRS if everyone in the dataset had experienced a specific epileptiform activity burden and were untreated. We combined pharmacological modelling with an interpretable matching method to account for confounding and epileptiform activity–antiseizure medication feedback. The quality of the matched groups was validated by the neurologists. Between Dec 1, 2011, and Oct 14, 2017, 1514 patients were admitted to Massachusetts General Hospital intensive care unit, 995 (66%) of whom were included in the analysis. Compared with patients with a maximum epileptiform activity of 0 to less than 25%, patients with a maximum epileptiform activity burden of 75% or more when untreated had a mean 22·27% (SD 0·92) increased chance of a poor outcome (severe disability or death). Moderate but long-lasting epileptiform activity (mean epileptiform activity burden 2% to <10%) increased the risk of a poor outcome by mean 13·52% (SD 1·93). The effect sizes were heterogeneous depending on preadmission profile—eg, patients with hypoxic-ischaemic encephalopathy or acquired brain injury were more adversely affected compared with patients without these conditions. Our results suggest that interventions should put a higher priority on patients with an average epileptiform activity burden 10% or greater, and treatment should be more conservative when maximum epileptiform activity burden is low. Treatment should also be tailored to individual preadmission profiles because the potential for epileptiform activity to cause harm depends on age, medical history, and reason for admission. National Institutes of Health and National Science Foundation.