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Continuous EEG in a Pediatric Intensive Care Unit: Adherence to Monitoring Criteria and Barriers to Adequate Implementation

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Abstract

Background

Subclinical seizures are common in critically ill children and are best detected by continuous EEG (cEEG) monitoring. Timely detection of seizures requires pediatric intensive care unit (PICU) physicians to identify patients at risk of seizures and request cEEG monitoring. A recent consensus statement from the American Clinical Neurophysiology Society (ACNS) outlines the indications for cEEG monitoring in critically ill patients. However, adherence to these cEEG monitoring criteria among PICU physicians is unknown. Our project had two goals: 1. To assess adherence to cEEG monitoring indications and barriers toward their implementation; 2. To improve compliance with the ACNS cEEG monitoring criteria in our PICU.

Methods

This is a single-institution study. A total of 234 PICU admissions (183 unique patients) were studied. A 6-month retrospective chart review identified PICU patients meeting ACNS criteria for cEEG monitoring, and patients for whom monitoring was requested. This was followed by an 8-week quality improvement project. During this mentorship period, a didactic 15-min lecture and summary handouts regarding the ACNS indications for cEEG monitoring were provided to all PICU physicians. Requests for cEEG monitoring during the mentorship period were compared to baseline adherence to cEEG monitoring recommendations, and barriers toward timely cEEG monitoring were assessed.

Results

Nearly every fifth PICU patient met cEEG monitoring indications, and prevalences of patients meeting those indications were similar in the retrospective and the prospective mentorship period (18% vs. 19%). Almost all patients (98%) requiring cEEG as per ACNS criteria met the indication for monitoring already at the time of their PICU admission. During the retrospective period, 23% of patients meeting ACNS criteria had a request for cEEG monitoring, which increased to 83% during the mentorship period. The median delay to cEEG initiation was 16.7 h during the mentorship period, largely due to limited hours of EEG technician availability. Electrographic seizures were identified in 36% of patients monitored, all within the first 120 min of cEEG recording. The majority (79%) of cEEGs informed clinical management.

Conclusions

A brief teaching intervention supplemented by pictographic handouts significantly increased adherence to cEEG monitoring recommendations, and cEEGs guided clinical management. However, there were long delays to cEEG initiation. In order to promptly recognize subclinical seizures in critically ill children, we strongly advocate for a routine screening for cEEG monitoring indications as part of the PICU admission process, and a care model allowing for cEEG initiation around-the-clock.

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References

  1. Abend NS, Arndt DH, Carpenter JL, Chapman KE, Cornett KM, Gallentine WB, et al. Electrographic seizures in pediatric ICU patients: cohort study of risk factors and mortality. Neurology. 2013;81:383–91.

    Article  Google Scholar 

  2. Fink EL, Kochanek PM, Tasker RC, Beca J, Bell MJ, Clark RSB, et al. International survey of critically ill children with acute neurologic insults: the prevalence of acute critical neurological disease in children: a global epidemiological assessment study. Pediatr Crit Care Med. 2017;18:330–42.

    Article  Google Scholar 

  3. Williams K, Jarrar R, Buchhalter J. Continuous video-EEG monitoring in pediatric intensive care units. Epilepsia. 2011;52:1130–6.

    Article  Google Scholar 

  4. Jette N, Claassen J, Emerson RG, Hirsch LJ. Frequency and predictors of nonconvulsive seizures during continuous electroencephalographic monitoring in critically ill children. Arch Neurol. 2006;63:1750–5.

    Article  Google Scholar 

  5. Hosain SA, Solomon GE, Kobylarz EJ. Electroencephalographic patterns in unresponsive pediatric patients. Pediatr Neurol. 2005;32:162–5.

    Article  Google Scholar 

  6. Shahwan A, Bailey C, Shekerdemian L, Harvey AS. The prevalence of seizures in comatose children in the pediatric intensive care unit: a prospective video-EEG study. Epilepsia. 2010;51:1198–204.

    Article  Google Scholar 

  7. McCoy B, Sharma R, Ochi A, Go C, Otsubo H, Hutchison JS, et al. Predictors of nonconvulsive seizures among critically ill children. Epilepsia. 2011;52:1973–8.

    Article  Google Scholar 

  8. Kirkham FJ, Wade AM, McElduff F, Boyd SG, Tasker RC, Edwards M, et al. Seizures in 204 comatose children: incidence and outcome. Intensive Care Med. 2012;38:853–62.

    Article  Google Scholar 

  9. Abend NS, Gutierrez-Colina AM, Topjian AA, Zhao H, Guo R, Donnelly M, et al. Nonconvulsive seizures are common in critically ill children. Neurology. 2011;76:1071–7.

    Article  CAS  Google Scholar 

  10. Schreiber JM, Zelleke T, Gaillard WD, Kaulas H, Dean N, Carpenter JL. Continuous video EEG for patients with acute encephalopathy in a pediatric intensive care unit. Neurocrit Care. 2012;17:31–8.

    Article  Google Scholar 

  11. Lalgudi Ganesan S, Hahn CD. Electrographic seizure burden and outcomes following pediatric status epilepticus. Epilepsy Behav. 2019;101:106409. https://doi.org/10.1016/j.yebeh.2019.07.010.

    Article  PubMed  Google Scholar 

  12. Gwer S, Idro R, Fegan G, Chengo E, Garrashi H, White S, et al. Continuous EEG monitoring in Kenyan children with non-traumatic coma. Arch Dis Child. 2012;97:343–9.

    Article  Google Scholar 

  13. Topjian AA, Gutierrez-Colina AM, Sanchez SM, Berg RA, Friess SH, Dlugos DJ, et al. Electrographic status epilepticus is associated with mortality and worse short-term outcome in critically III children. Crit Care Med. 2013;41:215–23.

    Article  Google Scholar 

  14. Payne ET, Zhao XY, Frndova H, McBain K, Sharma R, Hutchison JS, et al. Seizure burden is independently associated with short term outcome in critically ill children. Brain. 2014;137:1429–38.

    Article  Google Scholar 

  15. Abend NS, Wagenman KL, Blake TP, Schultheis MT, Radcliffe J, Berg RA, et al. Electrographic status epilepticus and neurobehavioral outcomes in critically ill children. Epilepsy Behav. 2015;49:238–44. https://doi.org/10.1016/j.yebeh.2015.03.013.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Gaínza-Lein M, Fernández IS, Jackson M, Abend NS, Arya R, Nicholas Brenton J, et al. Association of time to treatment with short-term outcomes for pediatric patients with refractory convulsive status epilepticus. JAMA Neurol. 2018;75:410–8.

    Article  Google Scholar 

  17. Sánchez Fernández I, Sansevere AJ, Guerriero RM, Buraniqi E, Pearl PL, Tasker RC, et al. Time to electroencephalography is independently associated with outcome in critically ill neonates and children. Epilepsia. 2017;58:420–8.

    Article  Google Scholar 

  18. Wilson CA. Continuous electroencephalogram detection of non-convulsive seizures in the pediatric intensive care unit: review of the utility and impact on management and outcomes. Transl Pediatr. 2015;4:283–9.

    PubMed  PubMed Central  Google Scholar 

  19. Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology. 2004;62:1743–8.

    Article  CAS  Google Scholar 

  20. Fogang Y, Legros B, Depondt C, Mavroudakis N, Gaspard N. Yield of repeated intermittent EEG for seizure detection in critically ill adults. Neurophysiol Clin. 2017;47:5–12. https://doi.org/10.1016/j.neucli.2016.09.001.

    Article  PubMed  Google Scholar 

  21. Sanchez SM, Carpenter J, Chapman KE, Dlugos DJ, Gallentine WB, Giza CC, et al. Pediatric ICU EEG monitoring: current resources and practice in the United States and Canada. J Clin Neurophysiol. 2013;30:156–60.

    Article  Google Scholar 

  22. Herman ST, Abend NS, Bleck TP, Chapman KE, Drislane FW, Emerson RG, et al. Consensus statement on continuous EEG in critically Ill adults and children, part I: indications. J Clin Neurophysiol. 2015;32:87–95.

    Article  Google Scholar 

  23. Park A, Chapman M, McCredie VA, Debicki D, Gofton T, Norton L, et al. EEG utilization in Canadian intensive care units: a multicentre prospective observational study. Seizure. 2016;43:42–7. https://doi.org/10.1016/j.seizure.2016.10.021.

    Article  PubMed  Google Scholar 

  24. Yuliati A, Weber ARB. Use of continuous EEG monitoring in children presenting with encephalopathy following convulsive status epilepticus. J Clin Neurophysiol. 2019;36:181–5.

    Article  Google Scholar 

  25. Shafi MM, Westover MB, Cole AJ, Kilbride RD, Hoch DB, Cash SS. Absence of early epileptiform abnormalities predicts lack of seizures on continuous EEG. Neurology. 2012;79:1796–801.

    Article  Google Scholar 

  26. Abend NS, Topjian AA, Gutierrez-Colina AM, Donnelly M, Clancy RR, Dlugos DJ. Impact of continuous EEG monitoring on clinical management in critically ill children. Neurocrit Care. 2011;15:70–5.

    Article  Google Scholar 

  27. Kolls BJ, Lai AH, Srinivas AA, Reid RR. Integration of EEG lead placement templates into traditional technologist-based staffing models reduces costs in continuous video-EEG monitoring service. J Clin Neurophysiol. 2014;31:187–93.

    Article  Google Scholar 

  28. Swisher CB, White CR, Mace BE, Dombrowski KE, Husain AM, Kolls BJ, et al. Diagnostic accuracy of electrographic seizure detection by neurophysiologists and non-neurophysiologists in the adult ICU using a panel of quantitative EEG trends. J Clin Neurophysiol. 2015;32:324–30.

    Article  Google Scholar 

  29. Pensirikul AD, Beslow LA, Kessler SK, Sanchez SM, Topjian AA, Dlugos DJ, et al. Density spectral array for seizure identification in critically ill children. J Clin Neurophysiol. 2013;30:371–5.

    Article  Google Scholar 

  30. Stewart CP, Otsubo H, Ochi A, Sharma R, Hutchison JS, Hahn CD. Seizure identification in the ICU using quantitative EEG displays. Neurology. 2010;75:1501–8.

    Article  CAS  Google Scholar 

  31. Topjian AA, Fry M, Jawad AF, Herman ST, Nadkarni VM, Ichord R, et al. Detection of electrographic seizures by critical care providers using color density spectral array after cardiac arrest is feasible. Pediatr Crit Care Med. 2015;16:461–7.

    Article  Google Scholar 

  32. Du Pont-Thibodeau G, Sanchez SM, Jawad AF, Nadkarni VM, Berg RA, Abend NS, et al. Seizure detection by critical care providers using amplitude-integrated electroencephalography and color density spectral array in pediatric cardiac arrest patients. Pediatr Crit Care Med. 2017;18:363–9.

    Article  Google Scholar 

  33. Lalgudi Ganesan S, Stewart CP, Atenafu EG, Sharma R, Guerguerian AM, Hutchison JS, et al. Seizure identification by critical care providers using quantitative electroencephalography. Crit Care Med. 2018;46:e1105–11.

    Article  Google Scholar 

  34. Lambrechtsen FACP, Buchhalter JR. Aborted and refractory status epilepticus in children: a comparative analysis. Epilepsia. 2008;49:615–25.

    Article  Google Scholar 

  35. Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17:3–23.

    Article  Google Scholar 

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Acknowledgments

We thank Sara Victoria Ieradi for providing research administrative support for our study.

Funding

This study is not sponsored or funded.

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Authors and Affiliations

  1. Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

    Jamie Ghossein, Fuad Alnaji & Daniela Pohl

  2. Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada

    Fuad Alnaji, Srinivas Bulusu & Daniela Pohl

  3. CHEO Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada

    Fuad Alnaji, Richard J. Webster & Daniela Pohl

Authors
  1. Jamie Ghossein
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  2. Fuad Alnaji
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  3. Richard J. Webster
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  4. Srinivas Bulusu
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  5. Daniela Pohl
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Contributions

JG contributed to data acquisition, analysis, and interpretation. RJW and DP contributed to data interpretation. All authors contributed to the conception, drafting, critical revision and final approval of the manuscript.

Corresponding author

Correspondence to Daniela Pohl.

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Conflict of interest

None of the authors have any conflict of interest to disclose.

Ethical Approval

The study complies with all applicable ethical guidelines. The retrospective chart review was approved by our institution’s research ethics review board, and an ethics waiver was obtained for the prospective study as it was categorized as a quality improvement project. The study complies with the SQUIRE checklist for quality improvement studies.

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Ghossein, J., Alnaji, F., Webster, R.J. et al. Continuous EEG in a Pediatric Intensive Care Unit: Adherence to Monitoring Criteria and Barriers to Adequate Implementation. Neurocrit Care 34, 519–528 (2021). https://doi.org/10.1007/s12028-020-01053-8

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  • DOI: https://doi.org/10.1007/s12028-020-01053-8

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