Authors :
Presenting Author: Margaret Logan, MD – University of Kansas Medical Center
Vishal Shah, MD – University of Kansas Medical Center
Patrick Landazuri, MD – Department of Neurology, University of Kansas Medical Center
Carol Ulloa, MD – The University of Kansas Medical Center
Utku Uysal, MD – The University of Kansas Medical Center
Ryan Lay, MD – University of Kansas Medical Center
Murtaza Khan, MD – University of Kansas Medical Center
Nancy Hammond, MD – University of Kansas Medical Center
Rationale:
Stereotactic intracranial electroencephalogram monitoring (SEEG) is important to localize the seizure onset zone (SOZ) for drug-resistant epilepsy (DRE) patients. SEEG implantations are invasive diagnostic procedures, where even minor complications can have large ramifications. The overall risk of serious complications with SEEG is ~1%, including intracranial hemorrhage, ischemic stroke or neurologic deficit. This risk may increase substantially if explantation of electrodes occurs without a neurosurgeon guiding this procedure. SEEG volume at the University of Kansas Health System (TUKHS) has increased over the past 10 years and so have incidents of patient self-explantation. We aim to review practices to identify at risk patients, identify prevention methods and suggest mitigating factors and treatment processes if these issues occur.
Methods:
Root Cause Analysis (RCA) is an analytical method that was used to identify underlying systemic problems. Six adult patients that suffered electrode self-explantation during SEEG monitoring were identified using a surgical database from 2014-2023. Patient factors, staffing factors, communication factors, interventions, policy factors, equipment factors and outcomes were reviewed.
Results:
100% of the six patients identified who suffered self-explantation had history of known psychiatric co-morbidities. 67% had history of post-ictal agitation (PIA) with previous seizures. Only 33% had a psychological risk stratification done prior to the SEEG. Patient 1 did not have 24-hour tech monitoring and the response time was > 1 hour. This self-explantation served as an index event thereby facilitating 24-hour monitoring as standard of care at TUKHS. This has resulted in reduced response time in identification and management of ictal or post-ictal state. Significantly, 0% of our patients had a history of delirium on any previous hospital admissions, but delirium was the cause for explantation in 33% of them. None of these patients needed any pharmacological intervention after this event. For the remainder 67%, PIA was the main cause for explantation. 100% of these patients needed pharmacological intervention. It is significant to note that despite the presence of 1-3 staff members in the room at the time of the event, 67% of our pateints explanted their apparatus. This suggests that epilepsy monitoring unit (EMU) focused staff training and simulations may be important in reducing these events.
Conclusions:
There is a current need to improve the safety of SEEG evaluation in the inpatient setting. RCA creates a framework for multidisciplinary and systemic assessment and improvement. It is imperative to identify patient risk factors and prevent these complications as able. A multidisciplinary approach to selecting appropriate patients for SEEG is necessary. A psychologist and neuropsychologist should be involved and there should be a pre-surgical psychology evaluation. Patients at risk for post-ictal agitation or post-surgical delirium should be identified. A system should be in place to intervene swiftly in these instances to prevent self-explantation or other electrode issues.
Funding: None