Luchtige Casusbespreking Een beetje Schudderig na Reanimatie

A little shaky after
Cardiac Arrest
Case Discussion
Arthur R.H. van Zanten, MD PhD
Gelderse Vallei Hospital, Ede, The Netherlands
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Disclosures
• None
2
Limitations
• I am not a neurologist, electrophysiologist,
anesthesiologist, cardiologist, …..
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Case
• Male 71 years
• Medical History:
•
•
•
Hypertension
Lumbar Spine Artrosis
Cataract Surgery ODS
• Witnessed Cardiac
Arrest in office GP
• BLS immediately started
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Case
•
Initial rhythm:Ventricular
Fibrillation
•
Ambulance First Responder:
2 Defibrillation
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•
EMD 15 minutes, continued
CPR
•
•
Sinus rhythm
ROSC: 20 minutes
Case
•
•
E1M1V1:
Spontaneous breathing
6
•
ECG: anteroseptal myocardial
infarction
•
intubation for persistent coma
Case
• PTCA: Proximal LAD
stenosis D1 90%
• LAD stent: Orsiro:
3,5x18 mm TIMI III flow
• Balloon dilatation D1:
stenosis: 20% TIMI III flow
• carbasalate calcium,
ticagrelor, nadroparin
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'TIMI Grade Flow' is a scoring system from 0-3 referring to
levels of coronary blood flow assessed during percutaneous
coronary angioplasty:
•
TIMI 0 flow (no perfusion) refers to the absence of
any antegrade flow beyond a coronary occlusion.
•
TIMI 1 flow (penetration without perfusion) is faint
antegrade coronary flow beyond the occlusion, with
incomplete filling of the distal coronary bed.
•
TIMI 2 flow (partial reperfusion) is delayed or
sluggish antegrade flow with complete filling of the
distal territory.
•
TIMI 3 is normal flow which fills the distal coronary
bed completely
First ICU chest X-ray
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Case
• Targeted Temperature Management 32.5 C
• 24 hours
• Controlled rewarming
• Stop remifentanyl, propofol
• Persistent Coma after 48 hours
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Present N20 cortical response (C3’)
patient after cardiac arrest
Absent N20 cortical response (C3’)
patient after cardiac arrest
In comatose survivors after cardiac arrest, somatosensory evoked potentials are elicited by
transcutaneous electrical stimulation applied to the median nerve and then recorded at Erb’s point
(N9), the cervical medulla (N13) and the controlateral cortex (N20).
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Taccone et al. Critical Care 2014 18:202
Case
• Bilateral positive n. medians SSEPs (N20)
• Generalized tonic-clonic seizures
• Start clonazepam and phenytoin
• Status epilepticus
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CT brain
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Case
• CT-scan brain: no abnormalities
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Case
• Persistent status epilepticus
• Levetiracetam
• Propofol
• Midazolam
• Phenytoin
• Therapeutic Drug Levels
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Case
• Status epilepticus for 10 days
• EEG confirmed
• Family, 1 nurse and 1 intensivist believed
that patient was responsive to auditive
stimuli
• What to do?
• Now day 15 days after OHCA
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Case
• Pro: witnessed,VF, direct BLS, ROSC 20
minutes, myocardial infarction, successful
PTCA, bilateral positive SSEPs at 72 h.
• Con: Status epilepticus, refractory to
several anti-epileptica within therapeutic
range, probably severe post-anoxic
encephalopathy.
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31 (22%) of 139 patients were treated with anti-epileptic drugs (phenytoin, levetiracetam,
valproate, clonazepam, propofol, midazolam), of whom 24 had status epilepticus.
Dosages were moderate, barbiturates were not used, medication induced burst-suppression
not achieved, and treatment improved electroencephalographic status epilepticus patterns
temporarily (<6 h). 23 patients treated for status epilepticus (96%) died. In patients
with status epilepticus at 24 h, there was no difference in outcome between those treated
with and without anti-epileptic drugs.
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Multimodal approach to assess
prognosis after cardiac arrest
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Taccone et al. Critical Care 2014 18:202
Electroencephalogram findings from
resuscitated patients after cardiac arrest.
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(A)
Electroencephalogram (EEG) recorded
during therapeutic hypothermia,
showing an example of continuous
EEG: the patient had complete
recovery of consciousness.
(B)
Burst-suppression findings during
normothermia; the patient had
concomitant myoclonus and bilateral
absent N20 cortical responses to
somatosensory evoked potentials, and
eventually died.
(C)
Generalized periodic epileptiform
discharges at 36 hours after hospital
admission; we decided to withdraw
care on day 5 because of persistent
coma with posturing and absent
pupillary reflexes.
Taccone et al. Critical Care 2014 18:202
MRI after Cardiac Arrest
Diffusion-weighted magnetic resonance imaging scan of a 68-year-old man who suffered a ventricular fibrillation cardiac arrest with
prolonged resuscitation. Diffuse cortical hyperintensities are observed, consistent with severe global anoxic injury.
20
Taccone et al. Critical Care 2014 18:202
Cooling- and rewarming-related AEs were not associated with poor
neurological outcome at hospital discharge.
Sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant
use during the advanced critical care period were associated with poor
neurological outcome at hospital discharge in our study.
21
Kim et al. Critical Care (2015) 19:283
22
Kim et al. Critical Care (2015) 19:283
Status epilepticus
• In TH-treated patients, the presence of status epilepticus
(SE), i.e., a prolonged epileptiform activity, during TH or
immediately after rewarming is almost invariably
followed by poor outcome (FPR from 0% to 6%).
• Among those patients, absence of EEG reactivity or a
discontinuous EEG background predicted no chance of
neurological recovery.
• All studies on SE included only a few patients.
• Definitions of SE were inconsistent among those studies.
23
Sandroni C et al. Resuscitation 85 (2014) 1779–1789
Malignant EEG &
outcome
• Generalized periodic epileptiform discharges (GPEDs) are recognized as
"malignant" EEG pattern associated with very poor outcome (no or few
survivors)
• King's College Hospital between 2011-2014 who developed hypoxic
encephalopathy associated with GPEDs, BiPLEDs (bilateral periodic lateralized
epileptiform discharges), and periodic discharges on first EEG.
• 36 postcardiac arrest patients, 24/36 with GPEDs, and 12/36 with BiPLEDs on
first EEG.
• 10 of 36 patients survived, which is slightly higher than previously reported.
• No characteristics different between survivors and nonsurvivors except for trend
to significance for the presence of reactivity on first EEG (p=0.0794).
• On discharge, one survivor had good functional outcome (and subsequently
became independent), but all others were dependent for all ADLs (activities of
daily living)
24
Ribeiro A et al. Epilepsy Behav. 2015 Aug;49:268-72.
Myoclonus
• Myoclonus: clinical phenomenon consisting of sudden, brief, involuntary jerks
caused by muscular contractions or inhibitions.
• A prolonged period of continuous and generalised myoclonic jerks is
commonly described as status myoclonus.
• There is no definitive consensus on the duration or frequency of myoclonic
jerks required to qualify as status myoclonus, however in prognostication
studies in comatose survivors of cardiac arrest the minimum reported
duration is 30 min.
• Myoclonus, myoclonic status, generalised status myoclonicus, and myoclonus
(or myoclonic) status epilepticus have been used interchangeably.
• Although the term myoclonic status epilepticus may suggest an epileptiform
nature for this phenomenon, in post-anoxic comatose patients clinical
myoclonus is only inconsistently associated with epileptiform activity on EEG.
25
Sandroni C et al. Resuscitation 85 (2014) 1779–1789
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Case
• What would you do?
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Case
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Case
• We decided to start
barbiturate coma
induction to burstsuppression
• 72 hours normalization
of plasma levels
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Case
• Opens eyes
• No motor responses
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Case
• Epileptiform activity less
pronounced, some
isolated activity both
frontocentral areas.
• Diffuse slow
hypofunctional EEG
much alpha/beta-activity
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Case
• Opens eyes
• No motor responses
• Why?
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Severe ICU acquired weakness
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Case
• No motor responses
• EMG: axonal
polyneuropathy
• ICU acquired weakness
• PDT
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Chest X-ray after PDT
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Case
• Other complications:
• sinusitis: Serratia marcescens: ciprofloxacin
• paroxysmal atrial fibrillation: sotalol
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Outcome Case
• Discharge to neurology ward after 35 days
• 1 year later good neurological recovery
• Outpatient clinic neurology
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Case follow-up
• Neurologist: good progression neuropathy
recovered
• Cardiologist: stabile condition
• Post ICU clinic 1 year
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Multi Functional
Fatigue Index
MVI-20
Total 62
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CISS-21
Coping Inventory for Stressful Situations (CISS-21)
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Trauma Screening
Questionnaire
PTSS TSQ
No PTSS
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Hospital Anxiety and
Depression Scale (HADS)
HADS
No fear
No depression
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Barthel
Full functional max. score
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SF-36
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A little shaky after
Cardiac Arrest
Case Discussion
Arthur R.H. van Zanten, MD PhD
Gelderse Vallei Hospital, Ede, The Netherlands
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