Sedation Protocols for EEG Procedures

Pediatric Sedation Guidelines

• For pediatric patients, distraction techniques and parental presence may reduce the need for or depth of pharmacologic sedation, according to the American Academy of Pediatrics 1.
• Low-dose chloral hydrate (10-25 mg/kg) has fallen out of favor due to unpredictable responses and prolonged recovery times, which is particularly concerning for infants and toddlers who may experience re-sedation after discharge, as recommended by the American Academy of Pediatrics 1.
• The liquid formulation of chloral hydrate is no longer commercially available, though some hospital pharmacies compound their own formulations, as noted by the American Academy of Pediatrics 1.
• Practitioners must have rescue skills one level deeper than intended sedation: if targeting minimal sedation, must rescue from moderate; if targeting moderate, must rescue from deep; if targeting deep, must rescue from general anesthesia, according to the American Academy of Pediatrics 1.
• Facilities must have immediately available equipment for airway management, as the most common serious complications involve airway obstruction, hypoventilation, laryngospasm, hypoxemia, and apnea, as recommended by the American Academy of Pediatrics 1.
• Continuous monitoring with pulse oximetry is mandatory; capnography is valuable for detecting apnea or airway obstruction several minutes before desaturation would be detected by pulse oximetry alone, according to the American Academy of Pediatrics 1 and the American Society of Anesthesiologists 2.
• Never use promethazine (Phenergan) in children younger than 2 years due to black box warning for fatal respiratory depression, as warned by the American Academy of Pediatrics 1.
• Avoid intramuscular pentobarbital and phenothiazines due to unpredictable responses and prolonged recovery requiring extended observation periods, as recommended by the American Academy of Pediatrics 1.
• When combining midazolam with opioids, reduce midazolam dose by at least 50% due to synergistic respiratory depression, according to the American Academy of Pediatrics 1 and the American Gastroenterological Association 6.
• For infants less than 6 months, use particularly small incremental doses with careful titration, as this population is especially vulnerable to airway obstruction and hypoventilation, as recommended by the American Academy of Pediatrics 1.
• Ensure two adults accompany children still in car safety seats to prevent re-sedation-related airway obstruction during transport home, according to the American Academy of Pediatrics 1.

Adult ICU Sedation Guidelines

• For adult ICU patients receiving neuromuscular blocking agents during EEG procedures, processed EEG monitors (BIS, Narcotrend Index, Patient State Index, or State Entropy) should be used as adjuncts to subjective sedation assessments, since clinical assessment is impossible in paralyzed patients, as recommended by the Society of Critical Care Medicine 3 and the American Society of Anesthesiologists 4.
• Non-benzodiazepine sedatives (propofol or dexmedetomidine) are preferred over benzodiazepines (midazolam or lorazepam) to reduce ICU length of stay by approximately 0.5 days and potentially decrease mechanical ventilation duration, according to the Society of Critical Care Medicine 3 and the American Society of Anesthesiologists 4.
• For post-cardiac arrest patients receiving targeted temperature management, deeper sedation is often necessary to suppress shivering and prevent recall when neuromuscular blockade is required, as recommended by the European Society of Cardiology 5.
• Bispectral index (BIS) monitoring or alpha-delta ratios on EEG are useful surrogates for monitoring sedation depth in comatose post-cardiac arrest patients where clinical assessment is impossible, according to the European Society of Cardiology 5.

EEG Monitoring Guidelines

• Continuous EEG monitoring is strongly recommended for detecting nonconvulsive seizure activity in ICU patients with known seizures, unexplained depressed consciousness, traumatic brain injury, intracerebral hemorrhage, or cerebral vascular accidents, as recommended by the Society of Critical Care Medicine 3 and the American Society of Anesthesiologists 4.
• EEG monitoring should be used to titrate electrosuppressive medications to achieve burst suppression in patients with elevated intracranial pressure, according to the Society of Critical Care Medicine 3 and the American Society of Anesthesiologists 4.
• Sedation and neuromuscular blockade may mask clinical manifestations of seizures, warranting either serial or continuous EEG monitoring, as recommended by the European Society of Cardiology 5.