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Sedation of Children for EEG

Sedation of Children for EEG

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HahnDonald M. Olson, Maureen G. Sheehan, William Thompson, Phyllis T. Hall and Jin 
Sedation of Children for Electroencephalograms
 http://www.pediatrics.org/cgi/content/full/108/1/163located on the World Wide Web at:The online version of this article, along with updated information and services, is
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright © 2001 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
at Indonesia:AAP Sponsored on December 18, 2008www.pediatrics.orgDownloaded from
Sedation of Children for Electroencephalograms
Donald M. Olson, MD*‡; Maureen G. Sheehan, RN, PNP*‡; William Thompson, RN, BSN‡;Phyllis T. Hall, REEGT‡; and Jin Hahn, MD*‡
Sedation sometimes is neces-sary to perform an electroencephalogram (EEG) on achild. A dramatic decline in the need to use conscioussedation in our EEG laboratory prompted this review ofour sedation experience. The purpose of this review wasto determine the incidence of adverse sedation effectsand to determine why the need for sedation had de-clined.
All 513 attempts to administer sedation tochildren who were undergoing EEG studies during a4-year period were reviewed retrospectively. Parametersstudied included type and amount of the sedative agents,need for repeated dosing, successful completion of theEEG, and complications attributed to the sedative.
Sedation was attempted in 513 (18%) of 2855EEGs performed during the 4-year period. Ninety-onepercent of the EEGs performed with sedation were com-pleted successfully. Chloral hydrate was the most fre-quently administered sedative. Complications (transientoxygen desaturation) occurred in 3 children, all of whomhad recognized risk factors for airway compromise. Theproportion of children who required sedation decreasedfrom 32% to just 2% during that time period.
Sedation of children who are undergoingEEG examinations is effective and safe. Complicationsare infrequent. The need for sedation can be decreasedgreatly by adequate preparation and by creating a less-threatening, child-friendly environment in which to per-form the study.
electroen-cephalography, child, conscious sedation.
ABBREVIATION. EEG, electroencephalogram.
n the EEG laboratory, sedation has several pur-poses: it allows application of recording elec-trodes to the scalp without causing excessive anx-iety and without the need for restraints, it permitsrecordings with less muscle and movement artifact,and it allows the recording of the drowsy and asleepstates. EEG recordings of these states often are nec-essary to provide the most complete data possible.
For most children, conscious sedation is completedeasily and without complications.
However, somechildren are at increased risk for complications fromsedation, particularly those who have an underlyingproblem with control of secretions or their airway.
During a 4-year period, we noticed a dramaticdecline in the need to use conscious sedation in ourEEG laboratory. We reviewed our experience withsedation to determine whether this was attributableto a perceived improvement in the preparation ofchildren for EEG or to some other variable such as anunacceptably high complication rate or an excessivesedation failure rate. In addition, a number of differ-ent sedation paradigms were used in our laboratoryand prompted additional scrutiny of our sedationpractice.
Between January 1995 and December 1998, 2855 EEGs wereperformed. Conscious sedation was attempted during 513 (18%)of these tests. A database has been maintained by the sedationteam and was used to review types of sedation administered,dosage, time until sedated, duration of sedation, successful com-pletion of the test, and any complications that arose. All childrenwere sedated under supervision of a sedation nurse and closelymonitored in accordance with the guidelines suggested by theAmerican Academy of Pediatrics.
A total of 210 children who received sedative med-ication were girls (age: 2 months to 20 years; averageage: 3 years), and 303 were boys (ages: 2 months to 19years; average age: 4 years). The vast majority of theEEGs performed with the use of sedation were com-pleted successfully (469 [91%] of 513). A total of 44studies (9%) were incomplete (including 4 childrenwho underwent 2 unsuccessful sedation attempts)(Table 1). An additional EEG with sedation was notattempted for the remainder.Diagnoses before the attempt at sedation wereavailable for 31 of the 40 patients whose studiescould not be completed. Only 2 of the 31 children didnot have complicating medical conditions or devel-opmental delay. Twenty-nine of the children whocould not be sedated adequately had a history ofdevelopmental delay or autism.Chloral hydrate alone was the most commonlyadministered sedative, followed by a combination ofchloral hydrate and hydroxyzine. Other sedativesoccasionally were used alone or in combination.When medications other than chloral hydrate wereused, the reason usually was that a previous sedationattempt with chloral hydrate had failed (Table 2).There was no significant difference between the av-erage dose of chloral hydrate (55 mg/kg) used forsuccessful and unsuccessful sedation.
From the Departments of *Neurology and ‡Pediatrics, Stanford UniversityMedical Center, Stanford, California.Received for publication Oct 24, 2000; accepted Jan 16, 2001.Reprint requests to (D.M.O.) Department of Neurology, Stanford UniversityMedical Center, 300 Pasteur Dr, MC5235, Stanford, CA 94305-5235. E-mail:dmolson@stanford.eduPEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad-emy of Pediatrics.
PEDIATRICS Vol. 108 No. 1 July 2001
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Success Rate After Second Dose of Sedation
Medication often was repeated if the first dose didnot sedate the child successfully. A total of 147 chil-dren (29% of all patients sedated for EEGs) receiveda second dose of sedative medication. EEGs werecompleted successfully in 114 cases (78%). A repeatdose of chloral hydrate usually was the second med-ication given (most often 25 mg/kg). Sometimes hy-droxyzine was the second medication.
Complications were rare. Only 3 children requiredsupplemental oxygen or airway manipulation be-cause of desaturation as measured by transcutaneousoxygen saturation. One child, a 5-year-old withSmith-Magenis syndrome, had a history of sleep ap-nea and just 2 weeks earlier had undergone adenoid-ectomy. He had received a second dose of chloralhydrate (25 mg/kg) after the first dose (50 mg/kg)failed to provide adequate sedation. He had transcu-taneous oxygen saturation that dropped from 98% to88%. After repositioning of his head on several occa-sions, he was awakened. He was observed in thepostanesthesia recovery unit and then sent home.The second child, a 3-year-old, had Duchenne mus-cular dystrophy, was sedated with 50 mg/kg of chlo-ral hydrate, and had oxygen desaturation that fellfrom 98% to 82% when he was asleep during hisEEG. Airway obstruction with oxygen saturation aslow as 77% had prompted tonsillectomy and ade-noidectomy 6 months earlier. He needed to be stim-ulated and awakened. The third was a 2-year-oldchild with Down syndrome and a large tongue. Ox-ygen saturation dropped transiently to 85% (from94%), but the child responded to repositioning of hishead. He had received a single 50 mg/kg dose ofchloral hydrate.For 468 children, there was information about thetime it took to become sedated. The average time tosedation was 38 minutes. Recorded times rangedfrom 5 minutes to 180 minutes. Sedation usuallylasted
30 minutes.
Our findings demonstrate that sedation of childrenin an EEG laboratory is safe and effective. Sedation(most often with chloral hydrate) took effect rapidlyand lasted long enough to permit electrode applica-tion or recording of sleep or both. The sedation teammember easily treated the 3 children who experi-enced complications. All of those who had compli-cations were at risk of airway compromise because oftheir underlying medical condition.Most studies of the use of conscious sedation inchildren concern painful and frightening procedures,such as suturing, or procedures during which chil-dren must be kept very still to obtain an artifact-freestudy, such as radiologic imaging.
Little has been written about the effectiveness and safety ofsedation in the EEG laboratory in general and inchildren in particular.For EEG recording, issues other than the depth ofsedation must be considered when choosing a seda-tive medication. It is not sufficient merely to be ableto apply recording electrodes to the scalp and sample brain activity during the drowsy and asleep states.The ideal sedative agent will not suppress abnormalEEG activity (ie, provoke a false-negative recording)or induce changes in the background activity thatmight obscure subtle abnormalities.
Sedative drugssuch as benzodiazepines and barbiturates may in-crease the amount of faster background EEG activityand make interpretation more difficult.
Deep seda-tion and anesthesia may not only affect the back-ground EEG activity but also suppress interictalspike discharges.
Chloral hydrate has been themost frequently used sedation for our EEG record-ings. This medication generally is considered safewhen used at sedative doses.
It has little effect onthe background EEG activity.
Airway compromise is the most likely acute com-plication of conscious sedation.
When complicationsoccurred in our laboratory, they were in childrenwho were readily recognized as being at risk. Con-scious sedation is recognized as conferring increasedrisk of complications for children with airway abnor-malities, including those that are the result of neuro-logic disorders such as trisomy 21.
The 3 children inour series who became hypoxic (as indicated bytranscutaneous oxygen saturation monitoring) wereidentified quickly, and complications were pre-vented. All had identifiable risk factors for airwaycompromise. The necessity of close monitoring ofnormal children (without identified risk factors forairway compromise) remains unresolved by this re-view. At most, we can conclude that complications ofconscious sedation in the EEG laboratory are rarewhen established guidelines are followed
and sed-ative dosage is not extreme. A cost–benefit analysis
Total Number of EEGs for Each Year and Numberof EEGs Performed With the Use of SedationYear TotalEEGsSedation(% of Total EEGs)Incomplete EEGs(% of Total EEGs,% of Sedations)1995 740 236 (32) 21 (3,9)1996 705 179 (25) 16 (2,9)1997 708 81 (11) 7 (1,9)1998 702 17 (2) 0 (0,0)Total 2855 513 (18) 44 (2,9)
Number of EEGs Attempted With a Given SedativeMedication and Number of Unsuccessful EEGs (Failed)Sedative EEGs Failed(%)ComplicationsChloral hydrate 459 30 (7) 3Chloral hydrate
hydroxyzine 26 8 (31) 0Hydroxyzine 12 2 (17) 0Other sedation* 16 4 (25) 0Total sedations 513 44 (9) 3Total number of EEGs 2856 44 (2)* Amitriptyline (3 patients, 0 failed); meperidine
chlorpromazine (3,0); hydroxyzine
pentobarbital (3,0); hy-droxyzine
pentobarbital (2,1); amitriptyline
hydroxyzine(1,0); diphenhydramine (1,1); hydroxyzine
diphenhydramine(1,1); hydroxyzine
chlorpromazine(1,1); hydroxyzine
pentobarbital (1,0); lorazepam (1,0); pento- barbital (1,0); pentobarbital
diphenhydramine (1,0).
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