WASHINGTON – After a life-threatening event prompted a trial of continuous monitoring of patients during intracranial stereotactic electroencephalogram (EEG), the rate of adverse events and missed seizures went to zero, according to a single-center analysis presented at the annual meeting of the American Epilepsy Society.
“After initiating a full-time, bedside sitter, none of the major events we saw in the presitter period, which included unrecognized tonic-clonic seizures or patient removal of electrodes, was observed,” reported Brad Kamitaki, MD, who is completing an epilepsy fellowship at Columbia University, New York.
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Dr. Brad Kamitaki
Continuous observation of patients undergoing intracranial EEG has been described as mandatory in guidelines from the National Association of Epilepsy Centers (Epilepsia. 2010 Nov;51[11]:2322-33), but the type of monitoring, such as bedside sitter versus closed circuit video, has not been specified, according to Dr. Kamitaki. Although continuous bedside monitoring might offer the best opportunity to capture seizures and reduce the risk of adverse events, there are few comparative data.
In this study, the rate of adverse events was evaluated after a full-time, bedside sitter was initiated and compared with the rate observed prior to this step. There were 13 adult patients each in the presitter and sitter groups. All patients were admitted to an epilepsy unit for intracranial stereotactic EEG evaluation. Video monitoring by nursing staff was in place in the presitter period and continued to be active during the sitter periods.
There were 63 seizures captured in the presitter group and 53 in the sitter group. Of these, 21 were unrecognized in the presitter group versus 8 in the sitter group (P = .03). While most of the missed seizures were focal unaware in both groups (19 and 8, respectively), two focal-to-bilateral tonic-clonic seizures were missed in the presitter group versus zero in the sitter group.
In addition, there were two seizure-related adverse events in the presitter group versus none in the sitter group. Both of the adverse events, occurring in separate patients, were inappropriate electrode removals attributed to peri-ictal confusion during a focal unaware seizure. One required surgical reimplantation.
The greater mean time to nursing response after EEG onset of a seizure in the presitter group, compared with that of the sitter group, fell just short of statistical significance (77.1 vs. 56.7 seconds; P = .06), but the mean response time after clinical onset was significantly shorter in the sitter group (58.8 vs. 37.7 seconds; P = .02), according to Dr. Kamitaki.
Overall, the study “supports the likelihood that continuous bedside monitoring reduces the risk of adverse events,” Dr. Kamitaki said. “We did not look at what this costs, but concern about cost at our center was the reason that this program was not continued.”
A nursing assistant trained to recognize seizure activity performed the continuous bedside monitoring. The sitter remained beside the patient’s bed over a 24-hour period, leaving only if patient visitors obviated the need for a sitter. The monitoring was typically maintained over several days.
“Not all patients liked having a bedside sitter there at all times,” conceded Dr. Kamitaki, who acknowledged that other, less labor-intensive strategies might provide similar protection against adverse events. For example, a dedicated observer of multiple patients through video monitoring also might be effective, although formal studies are needed to evaluate how this compares with the current system of video monitors in a nursing station that do not have a dedicated observer.
“These data associate continuous bedside monitoring with fewer unrecognized seizures, quicker nursing response, and a reduced risk of seizure-related adverse events, but each center needs to decide whether it is practical,” Dr. Kamitaki said.
Dr. Kamitaki reported having no potential conflicts of interest related to this topic.