Sedation of Children for Electroencephalograms

Donald M. Olson, Maureen G. Sheehan, William Thompson, Phyllis T. Hall and Jin
Hahn
Pediatrics 2001;108;163-165
DOI: 10.1542/peds.108.1.163

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 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*‡
ABSTRACT. Objective. Sedation sometimes is neces-
sary to perform an electroencephalogram (EEG) on a
child. A dramatic decline in the need to use conscious
sedation in our EEG laboratory prompted this review of
our sedation experience. The purpose of this review was
to determine the incidence of adverse sedation effects
and to determine why the need for sedation had de-
clined.
Methods. All 513 attempts to administer sedation to
children who were undergoing EEG studies during a
4-year period were reviewed retrospectively. Parameters
studied included type and amount of the sedative agents,
need for repeated dosing, successful completion of the
EEG, and complications attributed to the sedative.
Results. Sedation was attempted in 513 (18%) of 2855
EEGs performed during the 4-year period. Ninety-one
percent of the EEGs performed with sedation were com-
pleted successfully. Chloral hydrate was the most fre-
quently administered sedative. Complications (transient
oxygen desaturation) occurred in 3 children, all of whom
had recognized risk factors for airway compromise. The
proportion of children who required sedation decreased
from 32% to just 2% during that time period.
Conclusion. Sedation of children who are undergoing
EEG examinations is effective and safe. Complications
are infrequent. The need for sedation can be decreased
greatly by adequate preparation and by creating a less-
threatening, child-friendly environment in which to per-
form the study. Pediatrics 2001;108:163–165; electroen-
cephalography, child, conscious sedation.
ABBREVIATION. EEG, electroencephalogram.
I
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 permits
recordings with less muscle and movement artifact,
and it allows the recording of the drowsy and asleep
states. EEG recordings of these states often are nec-
essary to provide the most complete data possible.1
For most children, conscious sedation is completed
easily and without complications.2– 6 However, some
children are at increased risk for complications from
sedation, particularly those who have an underlying
problem with control of secretions or their airway.7
From the Departments of *Neurology and ‡Pediatrics, Stanford University
Medical Center, Stanford, California.
Received for publication Oct 24, 2000; accepted Jan 16, 2001.
Reprint requests to (D.M.O.) Department of Neurology, Stanford University
Medical Center, 300 Pasteur Dr, MC5235, Stanford, CA 94305-5235. E-mail:
dmolson@stanford.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad-
emy of Pediatrics.
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During a 4-year period, we noticed a dramatic
decline in the need to use conscious sedation in our
EEG laboratory. We reviewed our experience with
sedation to determine whether this was attributable
to a perceived improvement in the preparation of
children for EEG or to some other variable such as an
unacceptably high complication rate or an excessive
sedation failure rate. In addition, a number of differ-
ent sedation paradigms were used in our laboratory
and prompted additional scrutiny of our sedation
practice.
METHODS
Between January 1995 and December 1998, 2855 EEGs were
performed. Conscious sedation was attempted during 513 (18%)
of these tests. A database has been maintained by the sedation
team 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 children
were sedated under supervision of a sedation nurse and closely
monitored in accordance with the guidelines suggested by the
American Academy of Pediatrics.8
RESULTS
A total of 210 children who received sedative med-
ication were girls (age: 2 months to 20 years; average
age: 3 years), and 303 were boys (ages: 2 months to 19
years; average age: 4 years). The vast majority of the
EEGs performed with the use of sedation were com-
pleted successfully (469 [91%] of 513). A total of 44
studies (9%) were incomplete (including 4 children
who underwent 2 unsuccessful sedation attempts)
(Table 1). An additional EEG with sedation was not
attempted for the remainder.
Diagnoses before the attempt at sedation were
available for 31 of the 40 patients whose studies
could not be completed. Only 2 of the 31 children did
not have complicating medical conditions or devel-
opmental delay. Twenty-nine of the children who
could not be sedated adequately had a history of
developmental delay or autism.
Chloral hydrate alone was the most commonly
administered sedative, followed by a combination of
chloral hydrate and hydroxyzine. Other sedatives
occasionally were used alone or in combination.
When medications other than chloral hydrate were
used, the reason usually was that a previous sedation
attempt with chloral hydrate had failed (Table 2).
There was no significant difference between the av-
erage dose of chloral hydrate (55 mg/kg) used for
successful and unsuccessful sedation.
PEDIATRICS Vol. 108 No. 1 July 2001 163
TABLE 1. Total Number of EEGs for Each Year and Number head. He had received a single 50 mg/kg dose of
of EEGs Performed With the Use of Sedation chloral hydrate.
Year Total Sedation Incomplete EEGs For 468 children, there was information about the
EEGs (% of Total EEGs) (% of Total EEGs, time it took to become sedated. The average time to
% of Sedations) sedation was 38 minutes. Recorded times ranged
1995 740 236 (32) 21 (3,9) from 5 minutes to 180 minutes. Sedation usually
1996 705 179 (25) 16 (2,9) lasted ⬃30 minutes.
1997 708 81 (11) 7 (1,9)
1998 702 17 (2) 0 (0,0) DISCUSSION
Total 2855 513 (18) 44 (2,9)
Our findings demonstrate that sedation of children
in an EEG laboratory is safe and effective. Sedation
TABLE 2. Number of EEGs Attempted With a Given Sedative
(most often with chloral hydrate) took effect rapidly
Medication and Number of Unsuccessful EEGs (Failed) and lasted long enough to permit electrode applica-
tion or recording of sleep or both. The sedation team
Sedative EEGs Failed Complications
(%) member easily treated the 3 children who experi-
enced complications. All of those who had compli-
Chloral hydrate 459 30 (7) 3 cations were at risk of airway compromise because of
Chloral hydrate ⫹ hydroxyzine 26 8 (31) 0
Hydroxyzine 12 2 (17) 0 their underlying medical condition.
Other sedation* 16 4 (25) 0 Most studies of the use of conscious sedation in
Total sedations 513 44 (9) 3 children concern painful and frightening procedures,
Total number of EEGs 2856 44 (2) such as suturing, or procedures during which chil-
* Amitriptyline (3 patients, 0 failed); meperidine ⫹ phenergan ⫹ dren must be kept very still to obtain an artifact-free
chlorpromazine (3,0); hydroxyzine ⫹ pentobarbital (3,0); hy- study, such as radiologic imaging.4,9 –11 Little has
droxyzine ⫹ pentobarbital (2,1); amitriptyline ⫹ hydroxyzine been written about the effectiveness and safety of
(1,0); diphenhydramine (1,1); hydroxyzine ⫹ diphenhydramine
(1,1); hydroxyzine ⫹ meperidine ⫹ phenergan ⫹ chlorpromazine
sedation in the EEG laboratory in general and in
(1,1); hydroxyzine ⫹ pentobarbital (1,0); lorazepam (1,0); pento- children in particular.
barbital (1,0); pentobarbital ⫹ diphenhydramine (1,0). For EEG recording, issues other than the depth of
sedation must be considered when choosing a seda-
tive medication. It is not sufficient merely to be able
Success Rate After Second Dose of Sedation to apply recording electrodes to the scalp and sample
Medication often was repeated if the first dose did brain activity during the drowsy and asleep states.
not sedate the child successfully. A total of 147 chil- The ideal sedative agent will not suppress abnormal
dren (29% of all patients sedated for EEGs) received EEG activity (ie, provoke a false-negative recording)
a second dose of sedative medication. EEGs were or induce changes in the background activity that
completed successfully in 114 cases (78%). A repeat might obscure subtle abnormalities.12 Sedative drugs
dose of chloral hydrate usually was the second med- such as benzodiazepines and barbiturates may in-
ication given (most often 25 mg/kg). Sometimes hy- crease the amount of faster background EEG activity
droxyzine was the second medication. and make interpretation more difficult.13 Deep seda-
tion and anesthesia may not only affect the back-
Complications ground EEG activity but also suppress interictal
Complications were rare. Only 3 children required spike discharges.14 Chloral hydrate has been the
supplemental oxygen or airway manipulation be- most frequently used sedation for our EEG record-
cause of desaturation as measured by transcutaneous ings. This medication generally is considered safe
oxygen saturation. One child, a 5-year-old with when used at sedative doses.15 It has little effect on
Smith-Magenis syndrome, had a history of sleep ap- the background EEG activity.16
nea and just 2 weeks earlier had undergone adenoid- Airway compromise is the most likely acute com-
ectomy. He had received a second dose of chloral plication of conscious sedation.5 When complications
hydrate (25 mg/kg) after the first dose (50 mg/kg) occurred in our laboratory, they were in children
failed to provide adequate sedation. He had transcu- who were readily recognized as being at risk. Con-
taneous oxygen saturation that dropped from 98% to scious sedation is recognized as conferring increased
88%. After repositioning of his head on several occa- risk of complications for children with airway abnor-
sions, he was awakened. He was observed in the malities, including those that are the result of neuro-
postanesthesia recovery unit and then sent home. logic disorders such as trisomy 21.7 The 3 children in
The second child, a 3-year-old, had Duchenne mus- our series who became hypoxic (as indicated by
cular dystrophy, was sedated with 50 mg/kg of chlo- transcutaneous oxygen saturation monitoring) were
ral hydrate, and had oxygen desaturation that fell identified quickly, and complications were pre-
from 98% to 82% when he was asleep during his vented. All had identifiable risk factors for airway
EEG. Airway obstruction with oxygen saturation as compromise. The necessity of close monitoring of
low as 77% had prompted tonsillectomy and ade- normal children (without identified risk factors for
noidectomy 6 months earlier. He needed to be stim- airway compromise) remains unresolved by this re-
ulated and awakened. The third was a 2-year-old view. At most, we can conclude that complications of
child with Down syndrome and a large tongue. Ox- conscious sedation in the EEG laboratory are rare
ygen saturation dropped transiently to 85% (from when established guidelines are followed8 and sed-
94%), but the child responded to repositioning of his ative dosage is not extreme. A cost– benefit analysis

164 SEDATION OF CHILDREN FOR ELECTROENCEPHALOGRAMS

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of close monitoring of all children who undergo con-
scious sedation in the EEG laboratory is beyond the
scope of this article.
There was no difference between the average dose
of chloral hydrate used for successful versus failed
sedation. If the first dose of sedative fails to produce
the desired result, then the test should not be aban-
doned before a second dose is given. In this case
series, the second dose of sedation was effective in
permitting completion of the EEG 78% of the time.
There was no greater risk of complications in the
group of children who received a second sedative
dose.
The ideal situation for recording EEGs of children
in the EEG laboratory is to proceed without the need
for medical sedation.1 A gradually decreasing pro-
portion of children required sedation to complete
their studies in our laboratory during the period
reviewed as a result of the behavior techniques prac-
ticed by an experienced and skilled technologist.
These techniques decrease fear before and during
electrode application and increase the likelihood of
child’s sleeping during the recording.
Ideally, the parent should be called a day ahead of
time, and expectations for parental behavior should
be discussed before the electrode application is
started. Techniques used to decrease anxiety and fear
during electrode application include 1) having par-
ents stay in the EEG laboratory with the child, 2)
having a parent hold and comfort the child, 3) having
the child bring a familiar toy or blanket to the labo-
ratory, 4) giving lots of positive feedback and praise,
5) distracting the child with videos or books, 6) dec-
orating the laboratory with pictures and objects that
are familiar to most young children, and 7) having
the technologist behave, dress, and speak in a calm
and unthreatening manner.
Measures to promote sleeping during the EEG
include 1) sleep deprivation the night before the test
(going to sleep an hour later and arising an hour
earlier than normal), 2) staying awake in the car on
the way to the laboratory, 3) avoiding hunger and
thirst with reasonable fasting (NPO) time require-
ments, 4) emptying the bladder before starting the
test, 5) allowing parents to hold the child, 6) darken-
ing the room, and 7) playing soft background music.
CONCLUSION
Sedation of children who are undergoing EEG ex-
aminations is effective and safe when parents are
well prepared and children’s oxygen saturation is
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monitored carefully. Complications will be infre-
quent and often can be anticipated in children who
are at increased risk because of their underlying
medical condition. The need for sedation can be de-
creased greatly by adequate preparation of the pa-
tient and parents and by creating a less-threatening,
child-friendly environment in which to perform the
study.
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ARTICLES 165
 Sedation of Children for Electroencephalograms
Donald M. Olson, Maureen G. Sheehan, William Thompson, Phyllis T. Hall and Jin
Hahn
Pediatrics 2001;108;163-165
DOI: 10.1542/peds.108.1.163
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