CSW Epilepsy Monitoring Pathway

Last Updated: September 2014

Valid Until: July 2015

For questions concerning this pathway,

contact: [email protected]© 2014, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

OUTPATIENT PREPARATION

Order Video EEG 24hr Telemetry Study

Referring provider

· Places procedure orders for Video EEG 24hr Telemetry

study

Neurology Family Services Coordinator

· Calls family to schedule video EEG admission

Is patient

compliant with

EEG without

sedation?

Executive Summary

Explanation of Evidence Ratings

Summary of Version Changes

Order Sedated Hook-up for

Video EEG 24hr Telemetry w/ Anesthesia Study

Referring provider

· Places orders for Video EEG 24hr Telemetry w/

Anesthesia

· Completes and faxes to Neurology Family Services

Coordinator

Neurology Procedure Scheduling Worksheet and

PASS Screening Questionnaire

Neurology Family Services Coordinator

· Calls family to schedule sedated video EEG admission

Epilepsy Monitoring (Video EEG) v2.2

Maybe

No Sedation

Video EEG 24hr Telemetry

inpatient admission

Sedated

Video EEG 24hr Telemetry

inpatient admission

Diagnostic:

Inclusion Criteria· Patients with paroxysmal events with clinical

presentation concerning for epileptic seizure

· Known epilepsy with new events

· Unclassified seizure type or Epilepsy

syndrome

· Outpatient EEG studies are not diagnostic

· Family brings “Seizure log” or calendar

Exclusion Criteria· Patients not seen by Neurology

· No previous outpatient EEG studies

·

Phase

Change

Suspected Epileptic

Encephalopathy:

Inclusion Criteria· Patient with language delay or developmental

regression incurred at age 3 years or older

· From Seattle Children’s Autism Center or

Neurology

Exclusion Criteria· Patients with language delay or

developmental delay incurred at age <3 years

· Patients seen in other clinics

· Diagnosed epileptic aphasia and on daily

· benzodiazepines or corticosteroids

Presurgical:

Inclusion Criteria· Diagnosis of epilepsy established

by prior EEG studies

· Criteria for medically intractable

met

Exclusion Criteria· Patients not seen by Neurology

· No previous outpatient EEG

· studies

Presurgical Workup

Assessment

Provider

· Page EEG Technologist to come to clinic to assess

EEG Technologist

· Asks parent with regard to child:

· Are they sedated for other procedures?

· Are they able to lie unassisted for 1 hour without sitting up numerous times

· Are they able to follow simple commands?

· How are they for having haircuts?

· Explains what is needed for an EEG

· Measures patient’s head, touches head, shows the headbox and electrodes to patient and

parent

· Reports to provider and documents in the medical record whether sedation is needed

No,

patient unable

to tolerate EEG

without sedation

No,

patient unable

to tolerate EEG

without sedation

Yes,

patient able

to tolerate EEG

without sedation

Yes,

patient able

to tolerate EEG

without sedation

Citation

INPATIENT VIDEO EEG

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Epilepsy Monitoring (Video EEG) v2.2

Discharge Criteria· Ensure data integrity/quality

· Study discontinued (acquisition machine

disconnected, electrodes removed)

· Scalp examined for skin breakdown

Study Reviewed· Communication of critical values (for SCH only)

· Report dictated or typed in template

· Report signed

· Copy sent to referring provider

Discharge Instructions· Activity restrictions if

indicated

· Skin Care after EEG Lead

Removal PE1518 (for SCH

only)

· Follow-up appointment with

referring provider

· Medication changes if

indicated

EEG Lead Placement

Orders

· Team places admission orders (Video EEG Admit Orderset)

· Select “Follow Video EEG Monitoring Pathway” order

· Seizure precautions

· Casper for violent behavior

· Child Life consult

· Notify Dietitian if ketogenic diet

· If history of epileptic seizures, Video EEG Acute Seizure

Management Plan

Lead Placement

· Child life (if needed, page inpatient)

· Electrodes placed in treatment room

· Presurgical: special electrodes if indicated

· Baseline EEG study if needed

· Place arm restraints, if ordered

· Patient/family escorted to room

Continue Monitoring· EEG tech initiates another 24-hour recording

· Team and family consider activation procedures

· Adjust orders including medications if necessary

Daily Assessment

Longer study needed

Study objectives met

or maximum number of

scheduled days completed

Monitoring Begins/Admission Assessment

Patient checks in at 4th

floor admitting· Patient transported to room

Patient checks in at 4th

floor admitting· Patient transported to OPC

EEG Lead Placement

Sedation and Lead Placement

· Sedation for video EEG hook-up

· Outpatient Procedure Center (OPC) calls EEG technologist

· Labs if needed: CBC, PT/INR, PTT, drug levels, BUN/

creatinine, glucose, lytes, LFTs

· Electrodes placed in OPC

· Presurgical: special electrodes if indicated

· Order and place arm restraints (page provider if order

needed) per Neuro Diagnostics Sedation Policy for

Patients Undergoing Neurodiagnostic Studies

· Transfer to recovery

Orders

· Team places admission orders (Video EEG Admit Orderset)

· Select “Follow Video EEG Monitoring Pathway” order

· Seizure precautions

· Casper for violent behavior

· Child Life consult

· Notify Dietitian if ketogenic diet

· If history of epileptic seizures, Video EEG Acute Seizure

Management Plan

· EEG technologist assures EEG data quality

· Patient seen and examined by NP/PA / Epilepsy Fellow /

Epileptologist and writes daily note

· Examination findings presented to attending

· Preliminary EEG results discussed among Team

· Team sees family

· Renew orders for arm restraints, if needed

· Report any falls using eFeedback

Daily

Review

· Team sees family

· Determine medication hold plan, if needed

· Presurgical considerations:

· IV placement

· Bleeding history and lab studies (PT/INR, PTT)

· Social work consult

· Electrodes connected to acquisition machine, and study started

· Patient/family receives education by tech and RN

· EEG technologist assures EEG data quality

· Patient seen by ARNP NP/PA / Epilepsy Fellow

· Examination findings presented to attending

SedationNo Sedation





· Sedation for video EEG hook-up

Video EEG Seizure Acute Management – Midazolam

Return to Inpatient

Min

ute

0

1st S

tep

Min

ute

3

2n

d S

tep

Min

ute

13

3rd

Ste

p

Drug TreatmentIV access

· Midazolam 0.1 mg/kg max 5mg/

dose administered IV 4mg/min

No IV access

· Midazolam 0.2mg/kg max 10mg/

dose, ½ dose in each nostril

· Midazolam 0.5mg/kg buccally max

dose 10mg if nares not available


· Midazolam 0.1 mg/kg max 5mg/

dose administered IV 4mg/min

No IV access

· Midazolam 0.2mg/kg max 10mg/

dose, ½ dose in each nostril

· Midazolam 0.5mg/kg buccally max

dose 10mg if nares not available

Drug Treatment· None unless customized plan

ordered for this admission

General Measures· Continued cardiorespiratory

monitoring

· Notify Epileptologist and Contact

Provider if medication given

· Vital signs q 5 minutes

· Request next medication

· Call Rapid Response Team

General Measures· Prepare/obtain next medication

· Notify Contact Provider if medication

given

· SpO2 and cardiorespiratory

monitoring; support respiration

including provision of high

concentration oxygen

seizure continues

seizure continues

Min

ute

23

4th

Ste

p

Min

ute

>3

8

5th

Ste

p

Drug Treatment· Customize treatment plan if available.

If not available, use default below:Age <2 months old· Phenobarbital 20mg/kg loading dose

Age ≥ 2 months old· Fosphenytoin 20mg PE/kg

General Measures· Above plus

· Blood pressure support

if needed

· Identify and treat

medical complications

· Request next

medication

General Measures· As above

seizure continues

Po

st-

Icta

l

General Measures· Ongoing vital signs q 10 minutes

until stable

· Ongoing cardiorespiratory and

SpO2 monitoring until return to

baseline

· Family support

seizure continues

Drug TreatmentAge <2 months old· May give additional phenobarbital

5mg/kg doses every 15-30 minutes until 30mg/kg maximum is met

Age ≥ 2 months old· Phenobarbital 20mg/kg if seizure

continues 15 minutes after phosphenytoin load

· May give 2 additional phenobarbital 5mg/kg doses every 15-20 minutes (max total 30mg/kg maximum)

seizure

stops

General MeasuresParent presses the event button to

document the episode and call RN

Position child to avoid injury

Document seizure start time

Optimize view of the child (for SCH only)

· Nursing assessment and

narration (for SCH only)

· Cardiorespiratory support as

needed

seizure

stops

Off

Pathway

seizure continues

seizure

stops





http://www.crlonline.com/lco/action/home/switch


Video EEG Seizure Acute Management – DiazepamM

inu

te 0

1st S

tep

Min

ute

3

2n

d S

tep

Min

ute

18

3rd

Ste

p


· Diazepam 0.1 mg/kg max 10mg/

dose administered IV over at least

3 min (max 5mg/min)


· Diazepam 0.1 mg/kg max 10mg/

dose administered IV over at least

3 min (max 5mg/min)

Drug Treatment· None unless customized plan

ordered for this admission

General Measures· Continued cardiorespiratory

monitoring

· Notify Epileptologist and Contact

Provider if medication given

· Vital signs q 5 minutes

· Request next medication

· Call Rapid Response Team

General Measures· Prepare/obtain next medication

· Notify Contact Provider if

medication given

seizure continues

seizure continues

Min

ute

33

4th

Ste

p

Min

ute

>4

0

5th

Ste

p

Drug Treatment· Customize treatment plan if available.

If not available, use default below:Age <2 months old· Phenobarbital 20mg/kg loading dose

Age ≥ 2 months old· Fosphenytoin 20mg PE/kg

General Measures· Above plus

· Blood pressure support

if needed

· Identify and treat

medical complications

· Request next

medication

seizure continues

Po

st-

Icta

l

General Measures· Ongoing vital signs q 10 minutes

until stable

· Ongoing cardiorespiratory and

SpO2 monitoring until return to

baseline

· Family support

seizure continues

Drug TreatmentAge <2 months old· May give additional phenobarbital

5mg/kg doses every 15-30 minutes until 30mg/kg maximum is met

Age ≥ 2 months old· Phenobarbital 20mg/kg if seizure

continues 15 minutes after phosphenytoin load

· May give 2 additional phenobarbital 5mg/kg doses every 15-20 minutes (max total 30mg/kg maximum)

seizure

stops

General Measures· Parent presses the event button to

document the episode and call RN

· Position child to avoid injury

· Document seizure start time

· Optimize view of the child (for SCH only)

· Nursing assessment and

narration (for SCH only)

· Cardiorespiratory support as

needed

seizure

stops

Off

Pathway

seizure continues

seizure

stops

General Measures· As above

· SpO2 and cardiorespiratory

monitoring; support respiration

including provision of high

concentration oxygen

Return to Inpatient







Return to Inpatient

Executive Summary

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Executive Summary

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Evidence Ratings

We used the GRADE method of rating evidence quality. Evidence is first assessed as to

whether it is from randomized trial, or observational studies. The rating is then adjusted in the following manner:

Quality ratings are downgraded if studies:• Have serious limitations

• Have inconsistent results• If evidence does not directly address clinical questions• If estimates are imprecise OR

• If it is felt that there is substantial publication bias

Quality ratings can be upgraded if it is felt that:• The effect size is large• If studies are designed in a way that confounding would likely underreport the magnitude

of the effect OR• If a dose-response gradient is evident

Quality of Evidence: High quality

Moderate quality

Low quality

Very low quality

Expert Opinion (E)

Reference: Guyatt G et al. J Clin Epi 2011: 383-394

To Bibliography

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Summary of Version Changes

· Version 1 (12/22/2012): Go live, epilepsy monitoring for patients with suspected epileptic

encephalopathy

· Version 2 (7/11/2012): Added diagnostic and presurgical epilepsy monitoring

· Version 2.1 (10/30/2013): Reduced IV midazolam dosing

· Version 2.2 (9/30/2014): Changed assessment for tolerance of EEG leads from Child Life to

EEG Technologist, added approval and citation pages

Medical Disclaimer

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Medicine is an ever-changing science. As new research and clinical experience

broaden our knowledge, changes in treatment and drug therapy are required.

The authors have checked with sources believed to be reliable in their efforts to

provide information that is complete and generally in accord with the standards

accepted at the time of publication.

However, in view of the possibility of human error or changes in medical sciences,

neither the authors nor Seattle Children’s Healthcare System nor any other party

who has been involved in the preparation or publication of this work warrants that

the information contained herein is in every respect accurate or complete, and

they are not responsible for any errors or omissions or for the results obtained

from the use of such information.

Readers should confirm the information contained herein with other sources and

are encouraged to consult with their health care provider before making any

health care decision.

Bibliography

61 records identified through database searching

2 additional records identified through other sources

64 records after duplicates removed

64 records screened 40 records excluded

24 full-text articles assessed for eligibility17 full-text articles excluded, did not answer clinical question

7 studies included in pathway

Identification

Screening

Eligibility

Included

Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

To Bibliography Pg 2 Return to Home

Search Methods for Sedation for EEG Hook-up

Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian, Jamie Graham. Searches were performed on July 11th, 12th & 14th, 2011 in the following databases: on the Ovid platform – Medline (1996 to date), Cochrane Database of Systematic Reviews (2005 – June 2011), PsycInfo (1987-2011); elsewhere – National Guidelines Clearinghouse, Clinical Evidence, DynaMed and TRIP. Retrieval was limited to literature from 2001 forward, and children between the ages of 0-18. Originally the publication limiters for the Scout Search were applied (Consensus Development Conference; Consensus Development Conference, NIH; Guideline; Meta Analysis; Practice Guideline); additional searches were conducted using the clinical queries filters and exp epidemiologic studies command where appropriate. In Medline and PsycInfo, appropriate Medical Subject Headings (MeSH) were used, along with keyword searching, and the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words. Search terms are listed below.

Search Terms: electroencephalography, EEG, epileptic seizures, seizures, audiogenic seizures, petit mal seizures, grand mal seizures, sedatives, sedation, dexmedetomidine, autism, deep sedation, conscious sedation, hypnotics & sedatives, seizures febrile,

Jamie Graham, MLS

December 21, 2011

Sedation for EEG Hook-Up

· Aksu R, Kumandas S, Akin A, Bicer C, Gümüş H, Güler G, Per H, Bayram A, Boyaci A. The comparison of the effects of dexmedetomidine and midazolam sedation on electroencephalography in pediatric patients with febrile convulsion. Paediatr Anaesth. 2011 Apr;21(4):373-8. doi: 10.1111/j.1460-9592.2010.03516.x. PubMed PMID: 21371166.

· Al-Ghanem SS, Al-Oweidi AS, Tamimi AF, Al-Qudah AA. Anesthesia and electrocorticography for epilepsy surgery: A jordanian experience. Middle East J Anesthesiol [sedation]. 2009 Feb;20(1):31-7.

· Berkenbosch JW, Wankum PC, Tobias JD. Prospective evaluation of dexmedetomidine for noninvasive procedural sedation in children. Pediatr Crit Care Med [seizures]. 2005 Jul;6(4):435,9; quiz 440.

· Everett LL, van Rooyen IF, Warner MH, Shurtleff HA, Saneto RP, Ojemann JG. Use of dexmedetomidine in awake craniotomy in adolescents: report of two cases. Paediatr Anaesth. 2006 Mar;16(3):338-42. PubMed PMID: 16490103.

· Mehta UC, Patel I, Castello FV. EEG sedation for children with autism. Journal of Developmental & Behavioral Pediatrics [sedation]. 2004 Apr;25(2):102-4.

· Meyer S, Shamdeen MG, Kegel B, Mencke T, Gottschling S, Gortner L, et al. Effect of propofol on seizure-like phenomena and electroencephalographic activity in children with epilepsy vs children with learning difficulties. Anaesthesia [sedation]. 2006 Nov;61(11):1040-7.

· Ray T, Tobias JD. Dexmedetomidine for sedation during electroencephalographic analysis in children with autism, pervasive developmental disorders, and seizure disorders. J Clin Anesth [seizures]. 2008 Aug;20(5):364-8.

Additional References for Epilepsy Monitoring

· American Clinical Neurophysiology Society. Guideline twelve: guidelines for long-term monitoring for epilepsy. Am J Electroneurodiagnostic Technol. 2008 Dec;48(4):265-86. PubMed PMID: 19203080.

· Atkinson M, Hari K, Schaefer K, Shah A. Improving safety outcomes in the epilepsy monitoring unit. Seizure. 2012 Mar;21(2):124-7. Epub 2011 Nov 16. PubMed PMID: 22093593.

· Labiner DM, Bagic AI, Herman ST, Fountain NB, Walczak TS, Gumnit RJ; National Association of Epilepsy Centers. Essential services, personnel, and facilities in specialized epilepsy centers--revised 2010 guidelines. Epilepsia. 2010 Nov;51(11):2322-33. PubMed PMID: 20561026.

· Noe KH, Drazkowski JF. Safety of long-term video-electroencephalographic monitoring for evaluation of epilepsy. Mayo Clin Proc. 2009 Jun;84(6):495-500. PubMed PMID: 19483165; PubMed Central PMCID: PMC2688622.

· Perkins AM, Buchhalter JR. Optimizing patient care in the pediatric epilepsy monitoring unit. J Neurosci Nurs. 2006 Dec;38(6):416-21, 434. PubMed PMID: 17233511.

· Velis D, Plouin P, Gotman J, da Silva FL; ILAE DMC Subcommittee on Neurophysiology. Recommendations regarding the requirements and applications for long-term recordings in epilepsy. Epilepsia. 2007 Feb;48(2):379-84. PubMed PMID: 17295634.

Bibliography

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Epilepsy Monitoring Citation

Title: Epilepsy Monitoring

Authors:

· Seattle Children’s Hospital

· John Kuratani

· Jennifer Hrachovec

· Ryan Leininger

· Mike Leu

· Delia Nickolaus

· Coral Ringer

Date: 7/30/12

Retrieval Website: http://www.seattlechildrens.org/pdf/video-EEG-monitoring-for-suspected-

epileptic-pathway.pdf

Example:

Seattle Children’s Hospital, Kuratani J, Hrachovec J, Leininger R, Leu M, Nickolaus D, Ringer C.

2012 July. Epilepsy Monitoring Pathway. Available from: http://www.seattlechildrens.org/pdf/video-

EEG-monitoring-for-suspected-epileptic-pathway.pdf

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http://www.seattlechildrens.org/pdf/video-EEG-monitoring-for-suspected-epileptic-pathway.pdf

CSW Epilepsy Monitoring Pathway

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