EEG monitoring duration to identify electroencephalographic seizures in critically ill children

Abstract

ObjectivesDetermine the optimal duration of continuous EEG monitoring (CEEG) for electrographic seizure (ES) identification in critically ill children.MethodsWe performed a prospective observational cohort study of 719 consecutive critically ill children with encephalopathy. We evaluated baseline clinical risk factors (age and prior clinically evident seizures) and emergent CEEG risk factors (epileptiform discharges and ictal-interictal continuum patterns) using a multi-state survival model. For each subgroup, we determined the CEEG duration for which the risk of ES was <5% and <2%.ResultsES occurred in 184 children (26%). Patients achieved <5% risk of ES after: (1) ∼6 hours if ≥1 year without prior seizures or EEG risk factors; (2) ∼1 day if <1 year without prior seizures or EEG risks; (3) ∼1 day if ≥1 year with either prior seizures or EEG risks; (4) ∼2 days if ≥1 year with prior seizures and EEG risks; (5) ∼2 days if <1 year without prior seizures but with EEG risks; and (6) ∼2.5 days if <1 year with prior seizures irrespective of the presence of EEG risks. Patients achieved <2% risk of ES at the same durations except patients without prior seizures or EEG risk factors would require longer CEEG (∼1.5 days if <1 year; ∼1 day if ≥1 year).ConclusionsA model derived from 2 baseline clinical risk factors and emergent EEG risk factors would allow clinicians to implement personalized strategies that optimally target limited CEEG resources. This would enable more widespread use of CEEG-guided management as a potential neuroprotective strategy.

Periodic and rhythmic patterns in critically ill children: Incidence, interrater agreement, and seizures

“…32 The methods and data unrelated to PRP have been reported previously. [14][15][16]21,22,33 We enrolled consecutive critically ill children with acute encephalopathy with and without epilepsy diagnoses treated in the Pediatric Intensive Care Unit of a quaternary care hospital who underwent clinically indicated CEEG to screen for ES based on a guideline-adherent [2][3][4] institutional pathway 34 between April 2017 and November 2020. We excluded (1) neonates (<30 days old), (2) patients who received brief epilepsy surgery care in the Pediatric Intensive Care Unit, and (3) patients admitted after >2 days of care for refractory status epilepticus at a different institution.…”

“…Definitions of key variables have been published previously. [14][15][16]21,22,33 ES were defined as abnormal paroxysmal events that were different from the background, lasted longer than 10 s, had a plausible electrographic field, and had a temporal-spatial evolution in morphology, frequency, and amplitude. 37 The primary electroencephalographer (F.W.F.)…”

“…Continuous electroencephalographic monitoring (CEEG) is used with increasing frequency among critically ill children to identify electroencephalographic seizures (ES). [1][2][3][4] Studies have shown that ES are common in critically ill children, [5][6][7][8][9][10][11][12][13][14][15][16][17][18] high ES exposure is associated with unfavorable outcomes, 5,6,13,[19][20][21] and ES can often be managed with standard antiseizure medications. 22,23 Periodic and rhythmic patterns (PRP) may occur during CEEG, and standardized terminology for these patterns has been developed.…”

Validation of a model to predict electroencephalographic seizures in critically ill children

“…A model in critically ill children has provided initial evidence-based guidance regarding the duration of CEEG for specific patient cohorts. 50 Overall, an ES prediction model employing five readily available clinical and EEG variables performed well when validated in a new cohort. The three clinical variables (age, acute encephalopathy category, and clinically evident seizure[s] prior to CEEG initiation) are readily accessible on admission.…”

“…Finally, this model might be useful in selecting which patients should have CEEG initiated, but it does not inform CEEG duration. A model in critically ill children has provided initial evidence‐based guidance regarding the duration of CEEG for specific patient cohorts 50 …”