Sedation Protocols for EEG Procedures
Non-Pharmacologic Approaches Should Be Prioritized First
Environmental modifications and behavioral preparation can dramatically reduce or eliminate the need for sedation during EEG procedures, with one pediatric center reducing sedation requirements from 32% to 2% through adequate preparation and creating a child-friendly environment 1.
- Creating a less-threatening environment with appropriate preparation is highly effective for reducing sedation needs in children undergoing EEG 1.
- For pediatric patients, distraction techniques and parental presence may reduce the need for or depth of pharmacologic sedation 2.
When Sedation Is Required: Pediatric Patients
First-Line Agent: Chloral Hydrate (Traditional)
- Chloral hydrate has historically been the most frequently administered sedative for pediatric EEG procedures, with a 91% success rate 1.
- However, 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 2.
- The liquid formulation is no longer commercially available, though some hospital pharmacies compound their own formulations 2.
Alternative Agent: Clonidine
- For children with autism and pervasive developmental disorders who are notoriously difficult to sedate, clonidine (0.05-0.2 mg orally) achieves sedation in 85% of cases with a mean induction time of 58 minutes and recovery time of 105 minutes 3.
- Clonidine has significant advantages: ease of oral administration, lack of EEG drug effect (critical for diagnostic accuracy), and high success rate even in patients who previously failed chloral hydrate sedation 3.
- Transient asymptomatic heart rate reductions (up to 40%) and blood pressure reductions (30-40%) occurred in 7% of patients but required no intervention 3.
Midazolam Protocols for Pediatric EEG
- For children 6 months to 5 years: initial IV dose 0.05-0.1 mg/kg administered over 2-3 minutes, with total doses up to 0.6 mg/kg (usually not exceeding 6 mg) 4.
- For children 6-12 years: initial dose 0.025-0.05 mg/kg, with total doses up to 0.4 mg/kg (usually not exceeding 10 mg) 4.
- Critical timing consideration: midazolam takes approximately three times longer than diazepam to achieve peak EEG effects, requiring a 2-3 minute wait after each dose before evaluating sedation depth or administering additional medication 4.
- The peak EEG effect of IV midazolam occurs at approximately 4.8 minutes compared to diazepam at 1.6 minutes 2.
Safety Requirements for Pediatric Sedation
- 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 2.
- Facilities must have immediately available equipment for airway management, as the most common serious complications involve airway obstruction, hypoventilation, laryngospasm, hypoxemia, and apnea 2.
- 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 2.
When Sedation Is Required: Adult ICU Patients
Monitoring Sedation Depth During EEG
- 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 2.
- For non-paralyzed adult ICU patients, objective EEG measures should not be used as the primary monitoring method, as they are inadequate substitutes for subjective sedation scoring systems 2.
- Electromyographic signals negatively affect the correlation between processed EEG indices and actual sedation depth 2.
Sedative Selection for Adult ICU Patients
- 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 2.
- 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 2.
- 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 2.
Critical Pitfalls to Avoid
- Never use promethazine (Phenergan) in children younger than 2 years due to black box warning for fatal respiratory depression 2.
- Avoid intramuscular pentobarbital and phenothiazines due to unpredictable responses and prolonged recovery requiring extended observation periods 2.
- When combining midazolam with opioids, reduce midazolam dose by at least 50% due to synergistic respiratory depression 2, 4.
- 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 2, 4.
- Calculate doses based on ideal body weight in obese pediatric patients 4.
- Ensure two adults accompany children still in car safety seats to prevent re-sedation-related airway obstruction during transport home 2.
EEG Monitoring for Seizure Detection
- 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 2.
- EEG monitoring should be used to titrate electrosuppressive medications to achieve burst suppression in patients with elevated intracranial pressure 2.
- Sedation and neuromuscular blockade may mask clinical manifestations of seizures, warranting either serial or continuous EEG monitoring 2.