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Continuous EEG in Pediatric Critical Care: Yield and Efficiency of Seizure Detection

Sansevere, Arnold J.*,†; Duncan, Elizabeth D.; Libenson, Mark H.*,†; Loddenkemper, Tobias*,†; Pearl, Phillip L.*,†; Tasker, Robert C.†,‡

Journal of Clinical Neurophysiology: September 2017 - Volume 34 - Issue 5 - p 421–426
doi: 10.1097/WNP.0000000000000379
Original Research

Purpose: Our goal was to define the duration of continuous EEG (cEEG) monitoring needed to adequately capture electrographic seizures and EEG status epilepticus in the pediatric intensive care unit using clinical and background EEG features.

Methods: Retrospective study of patients aged 1 month to 21 years admitted to a tertiary pediatric intensive care unit and undergoing cEEG (>3 hours). Clinical data collected included admission diagnosis, EEG background features, and time variables including time to first seizure after initiation of cEEG.

Results: Four hundred fourteen patients aged 4.2 (0.75–11.3) years (median, interquartile range) were included. With a median duration of 21 (16–42.2) hours of cEEG monitoring, we identified electrographic seizure or EEG status epilepticus in 25% of subjects. We identified three features that could improve the efficiency of cEEG resources and provide a decision-making framework: (1) clinical history of acute encephalopathy is not predictive of detecting electrographic seizure or EEG status epilepticus, whereas a history of status epilepticus or seizures is; (2) normal EEG background or absence of epileptiform discharges in the initial 24 hours of recording informs the decision to discontinue cEEG; (3) failure to record electrographic ictal events within the first 4 to 6 hours of monitoring may be sufficient to predict the absence of subsequent ictal events.

Conclusions: Individualized monitoring plans are necessary to increase seizure detection yield while improving resource utilization. A strategy using information from the clinical history, initial EEG background, and the first 4 to 6 hours of recording may be effective in determining the necessary duration of cEEG monitoring in the pediatric intensive care unit.

*Division of Epilepsy and Neurophysiology, Boston Children's Hospital, Boston, Massachusetts, U.S.A.;

Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, U.S.A.; and

Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, U.S.A.

Address correspondence and reprint requests to Arnold J. Sansevere, MD, Division of Epilepsy and Clinical Neurophysiology, Fegan 9 Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, U.S.A.; e-mail: arnold.sansevere@childrens.harvard.edu.

T. Loddenkemper serves on the Laboratory Accreditation Board for Long Term (Epilepsy and Intensive Care Unit) Monitoring, on the Council (and as Treasurer) of the American Clinical Neurophysiology Society, on the American Board of Clinical Neurophysiology, as an associate editor for Seizure, as Contributing editor for Epilepsy Currents, and as an associate editor for the 6th edition of Wyllie's Treatment of Epilepsy. He is part of pending patent applications to detect and predict seizures and to diagnose epilepsy. He receives research support from the Epilepsy Research Fund, the American Epilepsy Society, the Epilepsy Foundation of America, the Epilepsy Therapy Project, PCORI, the Pediatric Epilepsy Research Foundation, CURE, HHV-6 Foundation, and has received research grants from Lundbeck, Eisai, Upsher-Smith, Acorda, and Pfizer. He serves as a consultant for Zogenix, Upsher-Smith, and Lundbeck. He performs video electroencephalogram long-term and ICU monitoring, electroencephalograms, and other electrophysiological studies, and bills for these procedures, at Boston Children's Hospital and affiliated hospitals, and he evaluates pediatric neurology patients and bills for clinical care. He has received speaker honorariums from national societies including the AAN, AES, and ACNS and for grand rounds at various academic centers. His wife, Dr. Karen Stannard, is a pediatric neurologist who performs video electroencephalogram long-term and ICU monitoring, electroencephalograms, and other electrophysiological studies and bills for these procedures, and she evaluates pediatric neurology patients and bills for clinical care. The remaining authors have no funding or conflicts of interest to disclose.

P. L. Pearl is supported in part by the NIH/NINDS (R01 82286) and the SSADH Association.

© 2017 by the American Clinical Neurophysiology Society