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Short-Acting Neuromuscular Blockade Improves Inter-rater Reliability of Median Somatosensory Evoked Potentials in Post-cardiac arrest Prognostication

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Abstract

Background

Although median nerve somatosensory evoked potentials are routinely used for prognostication in comatose cardiac arrest survivors, myogenic artifact can reduce inter-rater reliability, leading to unreliable or inaccurate results. To minimize this risk, we determined the benefit of neuromuscular blockade agents in improving the inter-rater reliability and signal-to-noise ratio of SSEPs in the context of prognostication.

Methods

Thirty comatose survivors of cardiac arrest were enrolled in the study, following the request from an intensivist to complete an SSEP for prognostication. Right and left median nerve SSEPs were obtained from each patient, before and after administration of an NMB agent. Clinical histories and outcomes were retrospectively reviewed. The SSEP recordings before and after NMB were randomized and reviewed by five blinded raters, who assessed the latency and amplitude of cortical and noncortical potentials (vs. absence of response) as well as the diagnostic quality of cortical recordings. The inter-rater reliability of SSEP interpretation before and after NMB was compared via Fleiss’ κ score.

Results

Following NMB administration, Fleiss’ κ score for cortical SSEP interpretation significantly improved from 0.37 to 0.60, corresponding to greater agreement among raters. The raters were also less likely to report the cortical recordings as nondiagnostic following NMB (40.7% nondiagnostic SSEPs pre-NMB; 17% post-NMB). The SNR significantly improved following NMB, especially when the pre-NMB SNR was low (< 10 dB). Across the raters, there were three patients whose SSEP interpretation changed from bilaterally absent to bilaterally present after NMB was administered (potential false positives without NMB).

Conclusions

NMB significantly improves the inter-rater reliability and SNR of median SSEPs for prognostication among comatose cardiac arrest survivors. To ensure the most reliable prognostic information in comatose post-cardiac arrest survivors, pharmacologic paralysis should be consistently used before recording SSEPs.

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Abbreviations

CPC:

Cerebral performance category score

ICC:

Intraclass correlation coefficient

NMB:

Neuromuscular blockade

RMS:

Root mean square

SNR:

Signal-to-noise ratio

SSEP:

Somatosensory evoked potential

TH:

Therapeutic hypothermia

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Acknowledgements

We would like to thank Jay Mandrekar, PhD, and Ross Dierkhising, MS, for their expertise and assistance with statistics.

Funding

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Authors and Affiliations

  1. Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA

    Tatsuya Oishi, James D. Triplett, Ruple S. Laughlin, Sara E. Hocker, Sarah E. Berini & Ernest M. Hoffman

  2. Department of Neurology, Concord Repatriation General Hospital, Concord, NSW, Australia

    James D. Triplett

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  1. Tatsuya Oishi
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  2. James D. Triplett
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Contributions

Conceptualization: all authors. Methodology: T.O., J.D.T., E.M.H. Formal analysis and investigation: T.O., J.D.T., E.M.H. Programming and data analysis: T.O. Statistical analysis: T.O., E.M.H. Original draft preparation: T.O., J.D.T., E.M.H. Review and editing: T.O., J.D.T., R.S.L., S.E.H., S.E.B., E.M.H.

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Correspondence to Tatsuya Oishi.

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12028_2022_1601_MOESM2_ESM.tif

Rate of agreement between the five raters and the formal interpretation by the neurophysiologist, when the official interpretation was (A) present and (B) absent N20 cortical response. Because all formal interpretations by the neurophysiologist were deemed diagnostic, the raters’ response on the presence or absence of cortical potential was used for comparison (irrespective of their rating on diagnostic quality). Abbreviations: NMB = neuromuscular blockade. SSEP = somatosensory evoked potential. (TIF 361 kb)

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Oishi, T., Triplett, J.D., Laughlin, R.S. et al. Short-Acting Neuromuscular Blockade Improves Inter-rater Reliability of Median Somatosensory Evoked Potentials in Post-cardiac arrest Prognostication. Neurocrit Care 38, 600–611 (2023). https://doi.org/10.1007/s12028-022-01601-4

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