Frank A Rasulo1,2, Philip Hopkins3, Francisco A Lobo4, Pierre Pandin5, Basil Matta6, Carla Carozzi7, Stefano Romagnoli8, Anthony Absalom9, Rafael Badenes10, Thomas Bleck11, Anselmo Caricato12, Jan Claassen13, André Denault14, Cristina Honorato15, Saba Motta16, Geert Meyfroidt17, Finn Michael Radtke18, Zaccaria Ricci19, Chiara Robba20, Fabio S Taccone5, Paul Vespa21, Ida Nardiello22, Massimo Lamperti4. 1. Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy. francesco.rasulo@unibs.it. 2. Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy. francesco.rasulo@unibs.it. 3. Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK. 4. Institute of Anesthesiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates. 5. Department of Anesthesia and Intensive Care, Erasme Hospital, Universitè Libre de Bruxelles, Brussels, Belgium. 6. Department of Anaesthesia and Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK. 7. Department of Anesthesia and Intensive Care, Istituto Neurologico C. Besta, Milan, Italy. 8. Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy. 9. Department of Anesthesiology, University Medical Center Groningen, Groningen, Netherlands. 10. Department of Anesthesia and Intensive Care, University of Valencia, Valencia, Spain. 11. Division of Stroke and Neurocritical Care, Department of Neurology, Northwestern University, Evanston, IL, USA. 12. Department of Anesthesia and Intensive Care, Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy. 13. Department of Neurocritical Care, Columbia University Irving Medical Center, New York, NY, USA. 14. Critical Care Division, Montreal Heart Institute, Université de Montréal, Montreal, Canada. 15. Department of Anesthesiology and Critical Care, Universidad de Navarra, Pamplona, Spain. 16. Scientific Library, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy. 17. Department of Intensive Care, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Katholieke Universiteit Leuven, Leuven, Belgium. 18. Department of Anesthesiology IRS, Nykøbing F. Hospital, Nykøbing Falster, Denmark. 19. Department of Pediatric Anesthesia, Meyer University Hospital of Florence, University of Florence, Florence, Italy. 20. Department of Anesthesia and Intensive Care, Policlinico San Martino and University of Genoa, Genoa, Italy. 21. Department of Neurosurgery and Neurocritical Care, Los Angeles Medical Center, Ronald Reagan University of California, Los Angeles, CA, USA. 22. Department of Anesthesiology and Intensive Care, Spedali Civili Hospital, Brescia, Italy.
Abstract
BACKGROUND: The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. METHODS: A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology. Panelists were assigned four domains (techniques for electroencephalography [EEG] monitoring, patient selection, use of the EEG monitors, competency, and training the principles of pEEG monitoring) from which a list of questions and statements was created to be addressed. A Delphi method based on iterative approach was used to produce the final statements. Statements were classified as highly appropriate or highly inappropriate (median rating ≥ 8), appropriate (median rating ≥ 7 but < 8), or uncertain (median rating < 7) and with a strong disagreement index (DI) (DI < 0.5) or weak DI (DI ≥ 0.5 but < 1) consensus. RESULTS: According to the statements evaluated by the panel, frontal pEEG (which includes a continuous colored density spectrogram) has been considered adequate to monitor the level of sedation (strong consensus), and it is recommended by the panel that all sedated patients (paralyzed or nonparalyzed) unfit for clinical evaluation would benefit from DOS monitoring (strong consensus) after a specific training program has been performed by the ICU staff. To cover the gap between knowledge/rational and routine application, some barriers must be broken, including lack of knowledge, validation for prolonged sedation, standardization between monitors based on different EEG analysis algorithms, and economic issues. CONCLUSIONS: Evidence on using DOS monitors in ICU is still scarce, and further research is required to better define the benefits of using pEEG. This consensus highlights that some critically ill patients may benefit from this type of neuromonitoring.
BACKGROUND: The use of processed electroencephalography (pEEG) for depth of sedation (DOS) monitoring is increasing in anesthesia; however, how to use of this type of monitoring for critical care adult patients within the intensive care unit (ICU) remains unclear. METHODS: A multidisciplinary panel of international experts consisting of 21 clinicians involved in monitoring DOS in ICU patients was carefully selected on the basis of their expertise in neurocritical care and neuroanesthesiology. Panelists were assigned four domains (techniques for electroencephalography [EEG] monitoring, patient selection, use of the EEG monitors, competency, and training the principles of pEEG monitoring) from which a list of questions and statements was created to be addressed. A Delphi method based on iterative approach was used to produce the final statements. Statements were classified as highly appropriate or highly inappropriate (median rating ≥ 8), appropriate (median rating ≥ 7 but < 8), or uncertain (median rating < 7) and with a strong disagreement index (DI) (DI < 0.5) or weak DI (DI ≥ 0.5 but < 1) consensus. RESULTS: According to the statements evaluated by the panel, frontal pEEG (which includes a continuous colored density spectrogram) has been considered adequate to monitor the level of sedation (strong consensus), and it is recommended by the panel that all sedated patients (paralyzed or nonparalyzed) unfit for clinical evaluation would benefit from DOS monitoring (strong consensus) after a specific training program has been performed by the ICU staff. To cover the gap between knowledge/rational and routine application, some barriers must be broken, including lack of knowledge, validation for prolonged sedation, standardization between monitors based on different EEG analysis algorithms, and economic issues. CONCLUSIONS: Evidence on using DOS monitors in ICU is still scarce, and further research is required to better define the benefits of using pEEG. This consensus highlights that some critically ill patients may benefit from this type of neuromonitoring.
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Authors: Gerald Chanques; Jean-Michel Constantin; John W Devlin; E Wesley Ely; Gilles L Fraser; Céline Gélinas; Timothy D Girard; Claude Guérin; Matthieu Jabaudon; Samir Jaber; Sangeeta Mehta; Thomas Langer; Michael J Murray; Pratik Pandharipande; Bhakti Patel; Jean-François Payen; Kathleen Puntillo; Bram Rochwerg; Yahya Shehabi; Thomas Strøm; Hanne Tanghus Olsen; John P Kress Journal: Intensive Care Med Date: 2020-11-10 Impact factor: 17.440