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Fung FW, Carpenter JL, Chapman KE, Gallentine W, Giza CC, Goldstein JL, Hahn CD, Loddenkemper T, Matsumoto JH, Press CA, Riviello JJ, Abend NS. Survey of Pediatric ICU EEG Monitoring-Reassessment After a Decade. J Clin Neurophysiol 2024; 41:458-472. [PMID: 36930237 PMCID: PMC10504411 DOI: 10.1097/wnp.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
PURPOSE In 2011, the authors conducted a survey regarding continuous EEG (CEEG) utilization in critically ill children. In the interim decade, the literature has expanded, and guidelines and consensus statements have addressed CEEG utilization. Thus, the authors aimed to characterize current practice related to CEEG utilization in critically ill children. METHODS The authors conducted an online survey of pediatric neurologists from 50 US and 12 Canadian institutions in 2022. RESULTS The authors assessed responses from 48 of 62 (77%) surveyed institutions. Reported CEEG indications were consistent with consensus statement recommendations and included altered mental status after a seizure or status epilepticus, altered mental status of unknown etiology, or altered mental status with an acute primary neurological condition. Since the prior survey, there was a 3- to 4-fold increase in the number of patients undergoing CEEG per month and greater use of written pathways for ICU CEEG. However, variability in resources and workflow persisted, particularly regarding technologist availability, frequency of CEEG screening, communication approaches, and electrographic seizure management approaches. CONCLUSIONS Among the surveyed institutions, which included primarily large academic centers, CEEG use in pediatric intensive care units has increased with some practice standardization, but variability in resources and workflow were persistent.
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Affiliation(s)
- France W Fung
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - Jessica L Carpenter
- Departments of Pediatrics and Neurology, University of Maryland School of Medicine, Baltimore, Maryland, U.S.A
| | - Kevin E Chapman
- Division of Neurology, Phoenix Children's Hospital and University of Arizona School of Medicine Phoenix, Arizona, U.S.A
| | - William Gallentine
- Division of Neurology, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California, U.S.A
| | - Christopher C Giza
- Division of Neurology, Department of Pediatrics, Mattel Children's Hospital and UCLA Brain Injury Research Center, Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Joshua L Goldstein
- Division of Neurology, Children's Memorial Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Cecil D Hahn
- Division of Neurology, The Hospital for Sick Children and University of Toronto, Toronto, U.S.A
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, U.S.A.; and
| | - Joyce H Matsumoto
- Division of Neurology, Department of Pediatrics, Mattel Children's Hospital and UCLA Brain Injury Research Center, Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California, U.S.A
| | - Craig A Press
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, U.S.A
| | - Nicholas S Abend
- Departments of Pediatrics and Neurology, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Chang N, Louderback L, Hammett H, Hildebrandt K, Prendergast E, Sperber A, Casazza M, Landess M, Little A, Rasmussen L. Multidisciplinary Consensus on Curricular Priorities for Pediatric Neurocritical Care Nursing Education: A Modified Delphi Study in the United States. Neurocrit Care 2024:10.1007/s12028-024-01976-6. [PMID: 38570410 DOI: 10.1007/s12028-024-01976-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/07/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Nurses are vital partners in the development of pediatric neurocritical care (PNCC) programs. Nursing expertise is acknowledged to be an integral component of high-quality specialty patient care in the field, but little guidance exists regarding educational requirements to build that expertise. We sought to obtain expert consensus from nursing professionals and physicians on curricular priorities for specialized PNCC nursing education in pediatric centers across the United States. METHODS We used a modified Delphi study technique surveying a multidisciplinary expert panel of nursing professionals and physicians. Online surveys were distributed to 44 panelists over three rounds to achieve consensus on curricular topics deemed essential for PNCC nursing education. During each round, panelists were asked to rate topics as essential or not essential, as well as given opportunities to provide feedback and suggest changes. Feedback was shared anonymously to the panelist group throughout the process. RESULTS From 70 initial individual topics, the consensus process yielded 19 refined topics that were confirmed to be essential for a PNCC nursing curriculum by the expert panel. Discrepancies existed regarding how universally to recommend topics of advanced neuromonitoring, such as brain tissue oxygenation; specialized neurological assessments, such as the serial neurological assessment in pediatrics or National Institutes of Health Stroke Scale; and some disease-based populations. Panelists remarked that not all centers see specific diseases, and not all centers currently employ advanced neuromonitoring technologies and skills. CONCLUSIONS We report 19 widely accepted curricular priorities that can serve as a standard educational base for PNCC nursing. Developing education for nurses in PNCC will complement PNCC programs with targeted nursing expertise that extends comprehensive specialty care to the bedside. Further work is necessary to effectively execute educational certification programs, implement nursing standards in the field, and evaluate the impact of nursing expertise on patient care and outcomes.
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Affiliation(s)
- Nathan Chang
- Pediatric Neurocritical Care, Lucile Packard Children's Hospital Stanford, 725 Welch Rd., Palo Alto, CA, 94404, USA.
| | - Lauren Louderback
- Pediatric Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heather Hammett
- Pediatric Critical Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Kara Hildebrandt
- Pediatric Neurocritical Care, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Erica Prendergast
- Pediatric Neurocritical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Amelia Sperber
- Pediatric Neurocritical Care, Lucile Packard Children's Hospital Stanford, 725 Welch Rd., Palo Alto, CA, 94404, USA
| | - May Casazza
- Pediatric Neurocritical Care, Lucile Packard Children's Hospital Stanford, 725 Welch Rd., Palo Alto, CA, 94404, USA
| | - Megan Landess
- Pediatric Critical Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Aubree Little
- Pediatric Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsey Rasmussen
- Pediatric Neurocritical Care, Lucile Packard Children's Hospital Stanford, 725 Welch Rd., Palo Alto, CA, 94404, USA
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Benedetti GM, Guerriero RM, Press CA. Review of Noninvasive Neuromonitoring Modalities in Children II: EEG, qEEG. Neurocrit Care 2023; 39:618-638. [PMID: 36949358 PMCID: PMC10033183 DOI: 10.1007/s12028-023-01686-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
Critically ill children with acute neurologic dysfunction are at risk for a variety of complications that can be detected by noninvasive bedside neuromonitoring. Continuous electroencephalography (cEEG) is the most widely available and utilized form of neuromonitoring in the pediatric intensive care unit. In this article, we review the role of cEEG and the emerging role of quantitative EEG (qEEG) in this patient population. cEEG has long been established as the gold standard for detecting seizures in critically ill children and assessing treatment response, and its role in background assessment and neuroprognostication after brain injury is also discussed. We explore the emerging utility of both cEEG and qEEG as biomarkers of degree of cerebral dysfunction after specific injuries and their ability to detect both neurologic deterioration and improvement.
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Affiliation(s)
- Giulia M Benedetti
- Division of Pediatric Neurology, Department of Neurology, Seattle Children's Hospital and the University of Washington School of Medicine, Seattle, WA, USA.
- Division of Pediatric Neurology, Department of Pediatrics, C.S. Mott Children's Hospital and the University of Michigan, 1540 E Hospital Drive, Ann Arbor, MI, 48109-4279, USA.
| | - Rejéan M Guerriero
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Craig A Press
- Departments of Neurology and Pediatric, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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McDevitt WM, Farley M, Martin-Lamb D, Jones TJ, Morris KP, Seri S, Scholefield BR. Feasibility of non-invasive neuro-monitoring during extracorporeal membrane oxygenation in children. Perfusion 2023; 38:547-556. [PMID: 35212252 DOI: 10.1177/02676591211066804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Detection of neurological complications during extracorporeal membrane oxygenation (ECMO) may be enhanced with non-invasive neuro-monitoring. We investigated the feasibility of non-invasive neuro-monitoring in a paediatric intensive care (PIC) setting. METHODS In a single centre, prospective cohort study we assessed feasibility of recruitment, and neuro-monitoring via somatosensory evoked potentials (SSEP), electroencephalography (EEG) and near infrared spectroscopy (NIRS) during venoarterial (VA) ECMO in paediatric patients (0-15 years). Measures were obtained within 24h of cannulation, during an intermediate period, and finally at decannulation or echo stress testing. SSEP/EEG/NIRS measures were correlated with neuro-radiology findings, and clinical outcome assessed via the Pediatric cerebral performance category (PCPC) scale 30 days post ECMO cannulation. RESULTS We recruited 14/20 (70%) eligible patients (median age: 9 months; IQR:4-54, 57% male) over an 18-month period, resulting in a total of 42 possible SSEP/EEG/NIRS measurements. Of these, 32/42 (76%) were completed. Missed recordings were due to lack of access/consent within 24 h of cannulation (5/42, 12%) or PIC death/discharge (5/42, 12%). In each patient, the majority of SSEP (8/14, 57%), EEG (8/14, 57%) and NIRS (11/14, 79%) test results were within normal limits. All patients with abnormal neuroradiology (4/10, 40%), and 6/7 (86%) with poor outcome (PCPC ≥4) developed indirect SSEP, EEG or NIRS measures of neurological complications prior to decannulation. No study-related adverse events or neuro-monitoring data interpreting issues were experienced. CONCLUSION Non-invasive neuro-monitoring (SSEP/EEG/NIRS) during ECMO is feasible and may provide early indication of neurological complications in this high-risk population.
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Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Margaret Farley
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK
| | - Darren Martin-Lamb
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Timothy J Jones
- Department of Cardiac Surgery, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Stefano Seri
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK.,Aston Brain Centre, School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Bruns N, Schara-Schmidt U, Dohna-Schwake C. [Pediatric neurocritical care]. DER NERVENARZT 2023; 94:75-83. [PMID: 36645451 DOI: 10.1007/s00115-022-01424-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 01/17/2023]
Abstract
Pediatric neurocritical care requires multidisciplinary expertise for the care of critically ill children. Approximately 14-16% of critically ill children in pediatric intensive care suffer from a primary neurological disease, whereby cardiac arrest and severe traumatic brain injury play major roles in Europe. The short-term goal of interventions in the pediatric intensive care unit is to stabilize vital functions, whereas the overarching goal is to achieve survival without neurological damage that enables fulfillment of the individual developmental physiological potential. For this reason, evidence-based methods for brain monitoring during the acute phase and recovery are necessary, which can be performed clinically or with technical devices. This applies to critically ill children with primary neurological diseases and for all children at risk for secondary neurological insults. Patients with diseases of the peripheral nervous system are also treated in pediatric intensive care medicine. In these patients, the primary aim frequently consists of bridging the time until recovery after acute deterioration, for example during an infection. In these patients, monitoring the cerebral function can be especially challenging, because due to the underlying disease the results of the examination cannot be interpreted in the same way as for previously neurologically healthy children. This article summarizes the complexity of pediatric neurocritical care by presenting examples of diagnostic and therapeutic approaches in the context of various neurological diseases that can be routinely encountered in the pediatric intensive care unit and can only be successfully treated by multidisciplinary teams.
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Affiliation(s)
- Nora Bruns
- Zentrum für Kinder- und Jugendmedizin, Klinik für Kinderheilkunde I (Neonatologie, Pädiatrische Intensivmedizin, Neuropädiatrie), Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
- Center for Translational and Behavioral Sciences (TNBS), Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Ulrike Schara-Schmidt
- Zentrum für Kinder- und Jugendmedizin, Klinik für Kinderheilkunde I (Neonatologie, Pädiatrische Intensivmedizin, Neuropädiatrie), Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
- Center for Translational and Behavioral Sciences (TNBS), Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - Christian Dohna-Schwake
- Zentrum für Kinder- und Jugendmedizin, Klinik für Kinderheilkunde I (Neonatologie, Pädiatrische Intensivmedizin, Neuropädiatrie), Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
- Center for Translational and Behavioral Sciences (TNBS), Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
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Greve S, Löffelhardt VT, Della Marina A, Felderhoff-Müser U, Dohna-Schwake C, Bruns N. The impact of age and electrode position on amplitude-integrated EEGs in children from 1 month to 17 years of age. Front Neurol 2022; 13:952193. [PMID: 36090865 PMCID: PMC9452771 DOI: 10.3389/fneur.2022.952193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
AimAmplitude-integrated electroencephalography (aEEG) is used to monitor electrocortical activity in critically ill children but age-specific reference values are lacking. We aimed to assess the impact of age and electrode position on aEEG amplitudes and derive normal values for pediatric aEEGs from neurologically healthy children.MethodsNormal EEGs from awake children aged 1 month to 17 years (213 female, 237 male) without neurological disease or neuroactive medication were retrospectively converted into aEEGs. Two observers manually measured the upper and lower amplitude borders of the C3 – P3, C4 – P4, C3 – C4, P3 – P4, and Fp1 – Fp2 channels of the 10–20 system. Percentiles (10th, 25th, 50th, 75th, 90th) were calculated for each age group (<1 year, 1 year, 2–5 years, 6–9 years, 10–13 years, 14–17 years).ResultsAmplitude heights and curves differed between channels without sex-specific differences. During the first 2 years of life, upper and lower amplitudes of all but the Fp1–Fp2 channel increased and then declined until 17 years. The decline of the upper Fp1–Fp2 amplitude began at 4 years, while the lower amplitude declined from the 1st year of life.ConclusionsaEEG interpretation must account for age and electrode positions but not for sex in infants and children.
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Affiliation(s)
- Sandra Greve
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Verena Tamara Löffelhardt
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Adela Della Marina
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- *Correspondence: Nora Bruns
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Effects of a reduction of the number of electrodes in the EEG montage on the number of identified seizure patterns. Sci Rep 2022; 12:4621. [PMID: 35301386 PMCID: PMC8930978 DOI: 10.1038/s41598-022-08628-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/04/2022] [Indexed: 12/02/2022] Open
Abstract
Continuous EEG monitoring (cEEG) is frequently used in neurocritical care. The detection of seizures is one of the main objectives. The placement of the EEG electrodes is time consuming, therefore a reduced montage might lead to an increased availability in the ICU setting. It is unknown whether such a reduction of electrodes reduces the number of seizure patterns that are detected. A total of 95 seizure and 95 control EEG sequences from a pediatric epilepsy monitoring unit (EMU) were anonymized and reduced to an eight-lead montage. Two experts evaluated the recordings and the seizure detection rates using the reduced and the full montage were compared. Sensitivity and specificity for the seizure detection were calculated using the original EMU findings as gold standard. The sensitivity to detect seizures was 0.65 for the reduced montage compared to 0.76 for the full montage (p = 0.031). The specificities (0.97 and 0.96) were comparable (p = 1). A total of 4/9 (44%) of the generalized, 12/44 (27%) of the frontal, 6/14 (43%) of the central, 0/1 (0%) of the occipital, 6/20 (30%) of the temporal, and 5/7 (71%) of the parietal seizure patterns were not detected using the reduced montage. The median time difference between the onset of the seizure pattern in the full and reduced montage was 0.026s (IQR 5.651s). In this study the reduction of the EEG montage from 21 to eight electrodes reduced the sensitivity to detect seizure patterns from 0.76 to 0.65. The specificity remained virtually unchanged.
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Lalgudi Ganesan S, Hahn CD. Spectrograms for Seizure Detection in Critically Ill Children. J Clin Neurophysiol 2022; 39:195-206. [PMID: 34510096 DOI: 10.1097/wnp.0000000000000868] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Electrographic seizures are common in critically ill children and a significant proportion of these seizures are nonconvulsive. There is an association between electrographic seizures and neurophysiological disturbances, worse short- and long-term neurologic outcomes, and mortality in critically ill patients. In this context, timely diagnosis and treatment of electrographic seizures in critically ill children becomes important. However, most institutions lack the resources to support round-the-clock or frequent review of continuous EEG recordings causing significant delays in seizure diagnosis. Given the current gaps in review of continuous EEG across institutions globally, use of visually simplified, time-compressed quantitative EEG trends such as spectrograms has the potential to enhance timeliness of seizure diagnosis and treatment in critically ill children.
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Affiliation(s)
- Saptharishi Lalgudi Ganesan
- Paediatric Critical Care Medicine, Children's Hospital of Western Ontario, London Health Sciences Centre, London, ON, Canada
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Cecil D Hahn
- Division of Paediatric Neurology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada; and
- Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Butler E, Mills N, J P Alix J, Hart AR. Knowledge and attitudes of critical care providers towards neurophysiological monitoring, seizure diagnosis, and treatment. Dev Med Child Neurol 2021; 63:976-983. [PMID: 33913148 DOI: 10.1111/dmcn.14907] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 12/19/2022]
Abstract
AIM To explore the attitudes of paediatric intensive care unit (PICU) health care professionals towards diagnosis and neurophysiological monitoring of seizures. METHOD This study used an explanatory sequential mixed-methods approach, interconnecting quantitative and qualitative features, comprising questionnaires and interviews, with equal weighting between stages, of health care professionals working in UK PICUs. Interview data were analysed using thematic analysis and triangulated with questionnaire data. RESULTS Seventy-two questionnaires were returned: 49 out of 60 (71.0%) of respondents reported that seizures were extremely hard or somewhat hard to diagnose in a critically ill child, and 81.2% had seen misdiagnosis occur. Thematic analysis revealed two main themes: (1) feeling out of control when faced with 'grey areas'; and (2) regaining control, which compromised three subthemes: aggressive intervention, accurate diagnosis, and eschewing diagnosis. INTERPRETATION Health care professionals find accurate diagnosis of seizures difficult, particularly in sedated/paralysed children and those with chronic neurological disorders. They report they would like better educational opportunities on discriminating between epileptic and non-epileptic events to improve their confidence. Professionals want routine neurophysiological monitoring that can be applied and interpreted at the bedside throughout the day to regain a sense of control over their patient, direct treatment appropriately, and, potentially, improve outcomes, but report appropriate training and peer review are essential if it is to be introduced into routine care. What this study adds Paediatric intensive care unit (PICU) staff feel out of control when faced with diagnosing seizures. Neurophysiological monitoring is wanted to help diagnosis and treatment. Amplitude-integrated electroencephalography is the preferred, pragmatic tool by PICU staff.
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Affiliation(s)
- Evie Butler
- University of Sheffield Medical School, Sheffield, UK
| | - Nicholas Mills
- Department of Paediatric Intensive Care Unit, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - James J P Alix
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Anthony R Hart
- Department of Paediatric and Neonatal Neurology, Ryegate Children's Centre, Sheffield Children's NHS Foundation Trust, Sheffield, UK
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Bruns N, Felderhoff‐Müser U, Dohna‐Schwake C. aEEG as a useful tool for neuromonitoring in critically ill children - Current evidence and knowledge gaps. Acta Paediatr 2021; 110:1132-1140. [PMID: 33210762 DOI: 10.1111/apa.15676] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 12/28/2022]
Abstract
AIM Amplitude-integrated electroencephalography (aEEG) is used in children beyond neonatal age, but systematic investigations have been lacking. This mini-review summarised aEEG studies on children aged one month to 18 years, evaluated the usefulness of aEEG and identified knowledge gaps or limitations. METHODS We searched the PubMed database for articles published in English up to September 2020, and 23 papers were identified. RESULTS aEEG was frequently used to compensate for the absence of continuous full-channel EEG monitoring, particularly for detecting seizures. Interpreting background patterns was based on neonatal classifications, as reference values for older infants and children are lacking. It is possible that aEEG could predict outcomes after paediatric cardiac arrests and other conditions. Gaps in our knowledge exist with regard to normal values in healthy children and the effects of sedation on aEEG background patterns in children. CONCLUSION The main application of aEEG was detecting and treating paediatric seizures. Further research should determine reference values and investigate the potential to predict outcome after critical events or in acute neurological disease. It is likely that aEEG will play a role in paediatric critical care in the future.
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Affiliation(s)
- Nora Bruns
- Department of Paediatrics I University Hospital Essen University of Duisburg‐Essen Essen Germany
| | - Ursula Felderhoff‐Müser
- Department of Paediatrics I University Hospital Essen University of Duisburg‐Essen Essen Germany
| | - Christian Dohna‐Schwake
- Department of Paediatrics I University Hospital Essen University of Duisburg‐Essen Essen Germany
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Rimensberger PC, Kneyber MCJ, Deep A, Bansal M, Hoskote A, Javouhey E, Jourdain G, Latten L, MacLaren G, Morin L, Pons-Odena M, Ricci Z, Singh Y, Schlapbach LJ, Scholefield BR, Terheggen U, Tissières P, Tume LN, Verbruggen S, Brierley J. Caring for Critically Ill Children With Suspected or Proven Coronavirus Disease 2019 Infection: Recommendations by the Scientific Sections' Collaborative of the European Society of Pediatric and Neonatal Intensive Care. Pediatr Crit Care Med 2021; 22:56-67. [PMID: 33003177 PMCID: PMC7787185 DOI: 10.1097/pcc.0000000000002599] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES In children, coronavirus disease 2019 is usually mild but can develop severe hypoxemic failure or a severe multisystem inflammatory syndrome, the latter considered to be a postinfectious syndrome, with cardiac involvement alone or together with a toxic shock like-presentation. Given the novelty of severe acute respiratory syndrome coronavirus 2, the causative agent of the recent coronavirus disease 2019 pandemic, little is known about the pathophysiology and phenotypic expressions of this new infectious disease nor the optimal treatment approach. STUDY SELECTION From inception to July 10, 2020, repeated PubMed and open Web searches have been done by the scientific section collaborative group members of the European Society of Pediatric and Neonatal Intensive Care. DATA EXTRACTION There is little in the way of clinical research in children affected by coronavirus disease 2019, apart from descriptive data and epidemiology. DATA SYNTHESIS Even though basic treatment and organ support considerations seem not to differ much from other critical illness, such as pediatric septic shock and multiple organ failure, seen in PICUs, some specific issues must be considered when caring for children with severe coronavirus disease 2019 disease. CONCLUSIONS In this clinical guidance article, we review the current clinical knowledge of coronavirus disease 2019 disease in critically ill children and discuss some specific treatment concepts based mainly on expert opinion based on limited experience and the lack of any completed controlled trials in children at this time.
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Affiliation(s)
- Peter C Rimensberger
- Division of Neonatology and Paediatric Intensive Care, Department of Paediatrics, University Hospital of Geneva, University of Geneva, Geneva, Switzerland
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Critical Care, Department of Anaesthesiology, Peri-operative & Emergency Medicine, University of Groningen, Groningen, The Netherlands
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital, London, United Kingdom
| | - Mehak Bansal
- Paediatric Intensive Care, SPS Hospitals, Ludhiana, India
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Heart and Lung Directorate, NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Etienne Javouhey
- Paediatric Intensive Care Unit, Hospices Civils de Lyon, University of Lyon, Lyon, France
- University Claude Bernard Lyon 1, Hospices Civils of Lyon, Lyon, France
| | - Gilles Jourdain
- Division of Paediatrics, Neonatal Critical Care and Transportation, Medical Centre "A.Béclère", Paris Saclay University Hospitals, APHP, Paris, France
| | - Lynne Latten
- Critical Care, Nutrition and Dietetics, Alder Hey Children's, NHS Foundation Trust, Liverpool, United Kingdom
| | - Graeme MacLaren
- Cardiothoracic ICU, National University Hospital, Singapore, Singapore
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Luc Morin
- Paediatric Intensive Care, AP-HP Paris-Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Marti Pons-Odena
- Department of Paediatric Intensive Care and Intermediate Care, Sant Joan de Déu University Hospital, Universitat de Barcelona, Esplugues de Llobregat, Spain
- Immune and Respiratory Dysfunction, Institut de Recerca Sant Joan de Déu, Santa Rosa 39-57, 08950 Esplugues de Llobregat, Spain
| | - Zaccaria Ricci
- Paediatric Cardiac Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Yogen Singh
- Department of Paediatrics-Paediatric Cardiology and Neonatology, Cambridge University NHS Foundation Trust, Hospitals and University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Luregn J Schlapbach
- Child Health Research Centre, The University of Queensland, and Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia
- Department of Intensive Care Medicine and Neonatology, and Children's Research Centre, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Barnaby R Scholefield
- Department of Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Ulrich Terheggen
- Department of Critical Care, Paediatric and Cardiac Intensive Care Unit, Al Jalila Children's Hospital, Dubai, United Arab Emirates
| | - Pierre Tissières
- Paediatric Intensive Care, AP-HP Paris-Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Lyvonne N Tume
- University of Salford, Manchester UK and Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Sascha Verbruggen
- Intensive Care Unit, Department of Paediatric Surgery and Paediatrics, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joe Brierley
- Paediatric Intensive Care Unit, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, United Kingdom
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Löffelhardt VT, Della Marina A, Greve S, Müller H, Felderhoff-Müser U, Dohna-Schwake C, Bruns N. Characterization of aEEG During Sleep and Wakefulness in Healthy Children. Front Pediatr 2021; 9:773188. [PMID: 35127587 PMCID: PMC8814596 DOI: 10.3389/fped.2021.773188] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/31/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Interpretation of amplitude-integrated EEG (aEEG) is hindered by lacking knowledge on physiological background patterns in children. The aim of this study was to find out whether aEEG differs between wakefulness and sleep in children. METHODS Forty continuous full-channel EEGs (cEEG) recorded during the afternoon and overnight in patients <18 years of age without pathologies or only solitary interictal epileptiform discharges were converted into aEEGs. Upper and lower amplitudes of the C3-C4, P3-P4, C3-P3, C4-P4, and Fp1-Fp2 channels were measured during wakefulness and sleep by two investigators and bandwidths (BW) calculated. Sleep states were assessed according to the American Academy of Sleep Medicine. Median and interquartile ranges (IQR) were calculated to compare the values of amplitudes and bandwidth between wakefulness and sleep. RESULTS Median age was 9.9 years (IQR 6.1-14.7). All patients displayed continuous background patterns. Amplitudes and BW differed between wakefulness and sleep with median amplitude values of the C3-C4 channel 35 μV (IQR: 27-49) for the upper and 13 μV (10-19) for the lower amplitude. The BW was 29 μV (21-34). During sleep, episodes with high amplitudes [upper: 99 μV (71-125), lower: 35 μV (25-44), BW 63 μV (44-81)] corresponded to sleep states N2-N3. High amplitude-sections were interrupted by low amplitude-sections, which became the longer toward the morning [upper amplitude: 39 μV (30-51), lower: 16 μV (11-20), BW 23 μV (19-31)]. Low amplitude-sections were associated with sleep states REM, N1, and N2. With increasing age, amplitudes and bandwidths declined. CONCLUSION aEEGs in non-critically ill children displayed a wide range of amplitudes and bandwidths. Amplitudes were low during wakefulness and light sleep and high during deep sleep. Interpretation of pediatric aEEG background patterns must take into account the state of wakefulness in in clinical practice and research.
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Affiliation(s)
- Verena T Löffelhardt
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Adela Della Marina
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,TNBS, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sandra Greve
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Hanna Müller
- Department of Pediatrics, Neonatology and Pediatric Intensive Care, University of Marburg, Marburg, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,TNBS, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.,TNBS, Centre for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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