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
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
pentobarbital (1,0); lorazepam (1,0); pento- barbital (1,0); pentobarbital