Remote Teamwork Management of NORSE During the COVID-19 Lockdown

Discussion

NORSE is often associated with unfavorable outcome.² Patients fail to respond to first- and second-line therapies, requiring continuous intravenous anesthetic drugs to control ongoing seizures.³ They need to be admitted in ICU, where the length of stay can last several weeks or months. Over this period, the management of patients with NORSE is multifaceted.

In NCSE, seizure burden correlates with increased risk of poor outcome in children.⁶ Continuous EEG monitoring is indispensable to recognize nonconvulsive seizures, rapidly detect seizures worsening, and avoid delay in adequate therapeutic modifications.⁷

The COVID-19 pandemic affected the workflow of many healthcare workers; in our case, nonurgent care was postponed and the presence of physicians in hospitals was encouraged to be limited.

Remote VEEG/aEEG monitoring allowed real-time analysis from different locations within the hospital, making the presence of clinical neurophysiologist on patient bedside unnecessary. Furthermore, remote VEEG/aEEG monitoring was available on domestic electronic devices of authorized physicians and residents, with a possibility to live comment through text chat and microphone. This brought several additional benefits.

EEG features can vary radically during NCSE, and electroclinical targets need to be remodulated accordingly.⁷ Furthermore, “individual members of the medical teams may have differing knowledge of the disorder and differing views on treatment goals, including when to stop or withhold treatment.”¹ In our case, despite the child neurologist's presence limited to the on-call specialist, electroclinical course could be followed daily by all team members using remote EEG. Medical decisions, goals, and potential future treatment options were discussed and shared during scheduled online meetings. Besides minimizing handover errors during shift changes,⁸ this allowed to pursue a coherent long-term therapeutic strategy, avoiding decisions to be taken by the on-call child neurologist solely on the basis of latest hours of EEG recordings.

Moreover, NORSE is an uncommon condition, and each specialist has usually treated a limited number of patients, so “sharing knowledge by participating in meetings, inviting outside specialists, and fostering multidisciplinary communication and collaboration is vital.”³ A senior expert was invited at online meetings, being able to see EEG traces remotely and participate to decision-making.

In addition, child neuropsychiatry residents were admitted joining online meetings. Pediatric NORSE is an extremely rare condition,² and our case constituted a unique occasion of case-based learning joined with a hands-on approach that could have been lost without this “telemedicine” management.

In NORSE cases, the care is usually performed by 2 different teams: the ICU team and the neurology team, and a constant cooperation is crucial.¹ Besides multiple meetings on weekdays, coupling VEEG, aEEG, and remote monitoring allowed a strict collaboration with the PICU team during night shifts and weekends. Because seizures were identifiable on aEEG (figure), PICU physicians were instructed to suspect seizures and notify the neurologist on-call, who could remotely confirm changes in seizure frequency, adjust treatment quickly, and monitor the effect.

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Figure Shared Screen During Continuous VEEG and aEEG Monitoring in PICU

The image shows a cropped version of the streamed monitoring interface, with the live raw EEG data on the left-hand side, showing 20 seconds of recording, and a multichannel aEEG interface on the right-hand side displaying roughly 3 hours of monitoring. In the streaming interface, a smaller video feed of the patient was available to evaluate clinical manifestation of seizure or recognize artifact. (A) Third day of admission in the PICU: the aEEG documents the periodic recurrence of diffuse seizures, roughly 7 in the first hour. The seizures on aEEG are characterized by the concomitant increase of the maximum and minimum amplitude in the corresponding bipolar channels. After 1 hour and 30 minutes (blue vertical line), a bolus of phenobarbital (PB) (100 mg) is administered, followed by a decrease of the seizure frequency, with 4 seizures with a progressively longer interval. (B) Fourth day of admission in the PICU: the aEEG initially shows a continuous high amplitude activity (high max. and min. amplitude). After a first bolus and an increase of the ketamine infusion (50 mg followed by 20 μg/kg/min), indicated by the first blue line (KET), the activity is characterized by an initial response, followed by the recurrence of seizures. After a second 50 mg bolus (second blue line) and an increase of the ketamine infusion rate (25 μg/kg/min), the activity is characterized by a fluctuating and discontinuous pattern. (C) Sixth day of admission in the PICU: in the first hour, the activity has a burst-suppression pattern, with a continuously low maximum amplitude, interloped with short, and high amplitude bursts. In the following 90 minutes, the activity becomes continuous with a progressively higher maximum amplitude and the recurrence of diffused seizures. On the right central electrode (and therefore on aEEG Fp2-C4 and C3-C4 channels), the trace is disturbed by a continuous artifact. The blue line (TPS) indicates a 60 mg bolus thiopental, followed by increase in the infusion velocity (10 mg/kg/h), after which the activity returns to a burst-suppression pattern. aEEG = amplitude-integrated EEG; PICU = paediatric intensive care unit; VEEG = video EEG.

The clinical uncertainty associated with NORSE can lead to specific communication issues between physicians and families who have to be constantly updated to be included in the decision-making process.^1,–,3 Information given to families need to be coherent and coordinated among all members of the team.^1,3 In our hospital, during the COVID-19 pandemic, the presence of 1 child neurologist per day for urgent cases was planned on 12-hour shifts. Consequently, all team members had to interface with the patient's family. To guarantee nonambiguous communication, a shared strategy was outlined during online daily meetings. The constant monitoring of our team, even if not physically present, was known to the patient's family and was a source of reassurance of the continuous care of the patient's conditions.

The possibility to share clinical material and information remotely allowed our team to guarantee the best possible care, exploiting new media and virtual environments to share decision-making in a multidisciplinary manner. The streaming and sharing of EEG traces/trends and clinical decisions had also great educational value for residents and young fellows who were able to witness clinical practice in real-time.

In many ways, the COVID-19 pandemic will represent a turning point for modern medicine. This new status quo has brought to mass attention available instruments that could lead to long-lasting changes healthcare practice.⁹

Regarding epilepsy, efforts have been made to implement telemedicine for the long-term care of epileptic patients, with particular attention to rural or low resources areas, where specialist to patient ratio is low.¹⁰ Our report shows how telemedicine can be implemented to treat urgent and severe condition such as NORSE and NCSE, playing a vital role in guaranteeing a high level of care.