title: Reliability in interpretation of median somatosensory evoked potentials in the setting of coma: factors and implications.
abstract: BACKGROUND
  Median nerve short-latency somatosensory evoked potentials (SSEPs) are useful in determining prognosis for awakening after coma following hypoxic ischemic encephalopathy, but reliability of interpretation is unclear.
  
  
  OBJECTIVE
  To measure inter- and intra-observer reliability of determining presence or absence of SSEPs in comatose patients following hypoxic ischemic encephalopathy and to identify factors that enhance reliability.
  
  
  METHODS
  Retrospective review by four readers (experience ranging from 2-27 years) of SSEP recordings in 95 comatose patients. Twenty waveforms were presented twice and five waveforms were presented pre- and post-neuromuscular junction (NMJ) blockade.
  
  
  METHODS
  Academic teaching hospital and level 1 trauma center.
  
  
  METHODS
  Inpatients in coma due to hypoxic ischemic encephalopathy.
  
  
  RESULTS
  Kappa values among the four readers, reflecting inter-observer reliability, ranged from 0.39 to 0.79 (mean 0.60, SD 0.16), a level of agreement interpreted as "moderate." Better inter-observer reliability was seen when: cortical amplitudes were ≥ 0.7 μV, baseline noise was smaller, and when experience level between reviewers was most similar. In cases examined both pre- and post-NMJ blockade, average kappa values of inter-observer reliability increased significantly from 0.03 pre-NMJ blockade to 0.41 post-NMJ blockade. Intra-observer reliability was higher than that for inter-observer, with a "substantial" average kappa of 0.84 (range 0.79-0.89, SD .06).
  
  
  CONCLUSIONS
  Inter- and intra-observer reliability of SSEP interpretation in comatose patients varies from moderate to substantial, respectively. In order to reliably interpret the presence of small cortical responses, NMJ blockade should be used when baseline noise is excessive.
authors: Department of Rehabilitation Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98195, USA. khakimi@u.washington.edu
authors: Kevin
authors: K
authors: Hakimi
authors: Greg
authors: G
authors: Kinney
authors: George
authors: G
authors: Kraft
authors: Paula
authors: P
authors: Micklesen
authors: Lawrence
authors: L
authors: Robinson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016477:Artifacts; D003128:Coma / Q000175:diagnosis*; D003943:Diagnostic Techniques, Neurological / Q000592:standards*; D005073:Evoked Potentials, Somatosensory; D005260:Female; D006801:Humans; D020925:Hypoxia-Ischemia, Brain / Q000175:diagnosis*; D008297:Male; D008475:Median Nerve; D008875:Middle Aged; D015588:Observer Variation; D011930:Reaction Time; D015203:Reproducibility of Results; D012189:Retrospective Studies; D055815:Young Adult