儿科重症监护病房医护人员应用振幅整合脑电图识别癫痫发作的可行性

Feasibility of using amplitude-integrated electroencephalogram to identify epileptic seizures by pediatric intensive care unit medical staff independently

目的 评估儿科重症监护病房（PICU）医护人员独立应用振幅整合脑电图（aEEG）识别重症患儿癫痫发作的可行性.方法 选取6名受试者（2名PICU医生对照1名脑电图医生、2名PICU护士对照1名脑电图技师）为研究对象,进行短期aEEG判读培训,然后对2013年1月至2015年5月北京大学第一医院PICU内接受aEEG和视频脑电监测（VEEG）同步监测患儿的aEEG图形进行单盲判读,在C3、C4两个通道的aEEG中识别和标记出癫痫发作的时间和类型（短暂发作或持续状态）.以原始VEEG确定的癫痫发作为“金标准”,确定被试者判断的正确率、遗漏率和错误数,并对结果进行秩和检验及kappa检验分析.结果 6名受试者共对56例患儿的82次aEEG同步监测进行判读,经VEEG证实其中32次记录监测到癫痫发作共141次,另外50次记录无发作.6名被试者对119次短暂发作的正确识别率平均为（66±4）％.22次癫痫持续状态的正确识别率3人达到100％,另3人为95％.6人对癫痫发作的遗漏率为24.1％ ～32.6％.被遗漏的癫痫发作除1例为持续状态外,其余均为＜20 s的短暂发作.6人将非癫痫事件识别为癫痫发作的错误数平均（19±9）次（P =0.000）,多数是将各种伪差误判为癫痫发作.各被试者之间对癫痫发作识别的正确率和遗漏率差异无统计学意义（P =0.930、0.996）,而错误数差异有统计学意义（P =0.000）.2名PICU医生与脑电图医生的判读结果具有较好的一致性（k=0.700、k =0.687,P＜0.01）,2名护士与脑电图技师的一致性差异有统计学意义（k=0.705、k=0.396,P ＜0.01）.结论 PICU医生和护士经过短期培训,可根据床旁aEEG识别多数癫痫发作特别是癫痫持续状态.PICU医护人员与脑电图医技人员的判读正确率相似,且有较好的一致性,但有可能遗漏短暂的癫痫发作,并可能将某些非癫痫事件误判为癫痫发作.应保持PICU医生与脑电图医生的沟通交流,并与原始VEEG进行对照分析也很必要.

Objective To evaluate the feasibility of using amplitude-integrated electroencephalogram （aEEG） to identify epileptic seizures by physicians and nurses in pediatric intensive care unit （PICU） independently.Method Six testees （two PICU physicians versus one EEG physician and two PICU nurses versus one EEG technician） accepted a short-term training,then interpreted aEEG in a single blinded way.These aEEG recordings with synchronous VEEG monitoring were done from January 2013 to May 2015 in PICU.The testees should recognize and mark both the seizure type and the seizure duration from the two-channel recorder （C3/C4） of aEEG （short-term seizure or status epilepticus （SE））.Using raw VEEG monitoring as a gold standard to determine a seizure,the accuracy,missing and error rate of each testees were confirmed,and the reasons of the latter two situations were analyzed by rank sum test and intertestee agreement （k）.Result Eighty-two aEEG recordings from 56 patients were interpreted.Thirty-two recordings had 141 epileptic seizures confirmed by VEEG,including 119 short-term seizures and 22 SE.There were 50 recordings without seizure.As for the short-term seizures,the average accuracy of 6 testees by aEEG alone was （66 ±4）%.The accuracy for SE was 100% in three testees and 95% in the other three.Missing rate of the seizures were 24.1%-32.6% in all 6 testees.Those missed seizures were all short-term （duration less than 20 seconds） but one SE.The average error rate was （19 ± 9） times （P =0.000）.These false interpretations were misunderstanding,many kinds of artifacts were regarded as epileptic seizures.The accuracy and missing rate among the testees had no significance（P =0.930,0.996）,but the error rate had（P =0.000）.The inter-testee agreement （k） between two physicians in PICU and the EEG doctor were 0.700 and 0.687 respectively （P 〈 0.01）,which is good.As for two nurses and the EEG technician,the inter-testee agreement （k） was 0.705 and 0.396 respectively （P 〈 0.01）.Conclusion Most of the seizures especially status epilepticus can be detected by PICU staff after short term training.The accuracy of identification of epileptic seizures was similar among observers from PICU and EEG,although some short-term seizures may be missed,and artifacts are mistaken.It＆#39;s necessary to communicate with EEG doctors and compare with the row VEEG when physicians in PICU find suspicious events.