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Continuous Electroencephalography Markers of Prognostication in Comatose Patients on Extracorporeal Membrane Oxygenation

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An Invited Commentary to this article was published on 30 September 2022

Abstract

Background

We aimed to identify continuous electroencephalogram (cEEG) markers associated with survival and death in patients with extracorporeal membrane oxygenation (ECMO) support under standardized sedation cessation protocol.

Methods

Prospectively collected records of adult patients (age ≥ 18 years) who were started on ECMO support in July 2016 to December 2020 at a single tertiary center were analyzed. cEEGs were performed on patients on the basis of inclusion and exclusion criteria. Patients receiving sedation that affect cEEG reactivity at the start of cEEG recording, including propofol, ketamine, or benzodiazepines, were excluded. We allowed fentanyl and dexmedetomidine during cEEG monitoring. cEEGs were evaluated for frequency, amplitude, variability, reactivity, and state changes.

Results

Of 290 patients, 40 underwent cEEG in the absence of confounding sedation (median age 60 years, 85% venoarterial-ECMO, 15% venovenous-ECMO). The median length of ECMO support and analyzable cEEG were 143 h and 24 h, respectively. A total of 27 patients underwent withdrawal of life-sustaining therapies (WOLST) during ECMO support. Of the 13 who weaned off ECMO, 9 underwent WOLST later in the hospitalization and 4 survived at hospital discharge. Decisions of WOLST were not influenced by cEEG features’ results. Proportions of present EEG reactivity, present state changes, and fair/good variability were significantly higher in patients who survived compared with those who died (odds ratios infinity, infinity, and 13.57, respectively; p values < 0.001, < 0.001, and 0.0299, respectively). Sensitivity and specificity for survival at discharge were 100% and 91.67% for intact reactivity, 100% and 97.20% for present state changes, and 75% and 83.3% for fair/good variability.

Conclusions

Although future multicenter studies with larger patient cohorts are certainly warranted, we were able to validate the feasibility of protocolized sedation cessation and cEEG analyses in the absence of a confounding effect from sedating medications. Moreover, we demonstrate some evidence that cEEG features of intact reactivity, present state changes, and fair/good variability in comatose patients on ECMO may be associated with survival at hospital discharge.

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Funding

No external funding was used for this study.

Author information

Author notes

  1. Eva K. Ritzl and Sung-Min Cho have contributed equally as co-senior authors.

Authors and Affiliations

  1. Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA

    Jaeho Hwang, Jay Bronder, Romergryko Geocadin, Eva K. Ritzl & Sung-Min Cho

  2. Division of Epilepsy, Department of Neurology, Johns Hopkins Hospital, Baltimore, MD, USA

    Jay Bronder, Nirma Carballido Martinez & Eva K. Ritzl

  3. Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, 21287, USA

    Romergryko Geocadin, Eva K. Ritzl & Sung-Min Cho

  4. Department of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA

    Bo Soo Kim

  5. Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA

    Errol Bush

  6. Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA

    Glenn Whitman & Chun Woo Choi

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  1. Jaeho Hwang
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Contributions

The authorship requirements have been met, and the final manuscript was approved by all authors. JH is a physician in neurology; he contributed to data collection from reviewing medical records, reviewed EEGs of patients, performed all statistical analyses, drafted and revised the manuscript. JB is a physician in epilepsy; he contributed to data collection from reviewing medical records, reviewed EEGs of patients, and revised the manuscript. NCM is an EEG technician; she set up and troubleshooted EEG monitoring for patients, allowing data collection of EEGs, and revised the manuscript. RG is a physician in neurocritical care, and Chairman of the multi-disciplinary critical care practice committee; he attended to the medical needs of ECMO patients in the critical care unit, and revised the manuscript. BSK is a physician in pulmonary and critical care medicine; he attended to the medical needs of ECMO patients in the critical care unit, and revised the manuscript. EB is a surgeon in general thoracic surgery, and the Surgical Director of the advanced lung disease and lung transplant program; he performed cannulation and decannulation surgeries related to ECMO, and revised the manuscript. GW is a surgeon in cardiac surgery, and the Director of cardiovascular surgical intensive care unit; he performed cannulation and decannulation surgeries related to ECMO, and revised the manuscript. CWC is a surgeon in cardiac surgery, and the Surgical Director of the ECMO program; he performed cannulation and decannulation surgeries related to ECMO, and revised the manuscript. EKR is a physician in epilepsy, Director of continuous EEG monitoring service, and co-senior author of this manuscript; she formed the hypothesis, designed the study protocols, reviewed EEGs of patients, and revised the manuscript. S-MC is a physician in neurocritical care, Research Director of adult ECMO, and co-senior director of this manuscript. Formed the hypothesis. Designed study protocols. Attended to the medical needs of ECMO patients in the critical care unit. Revised the manuscript.

Corresponding author

Correspondence to Sung-Min Cho.

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Conflicts of interest

Glenn Whitman is on the Data Safety Monitoring Board of Cytosorbent Corporation. Eva K Ritzl is a medical legal expert witness and council member of American Clinical Neurophysiology Society. Sung-Min Cho is funded by NHLBI 1K23HL157610. The remaining authors have disclosed that they do not have any conflicts of interest.

Ethical approval/Informed consent

This study was adherent to the use of ethical guidelines and informed consent and was approved by the Johns Hopkins Medicine Institutional Review Board.

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This article is related to the Commentary available at https://doi.org/10.1007/s12028-022-01487-2

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Hwang, J., Bronder, J., Martinez, N.C. et al. Continuous Electroencephalography Markers of Prognostication in Comatose Patients on Extracorporeal Membrane Oxygenation. Neurocrit Care 37, 236–245 (2022). https://doi.org/10.1007/s12028-022-01482-7

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