PEDIATRICS Vol. 108 No. 1 July 2001, pp. 178

COMMENTARY:
The Risks of Sedation for Electroencephalograms: Data at Last

Olson and colleagues¹ have performed an important service with their analysis of the need for sedation for electroencephalograms (EEGs) and their studies of the effectiveness and consequences of chloral hydrate for such sedation.

They have documented that sedation is rarely needed to obtain an EEG in children. Using behavioral techniques to decrease the child's fear, they were able to decrease the proportion of children requiring sedation from 32% to just 2%. These techniques included having the parent stay in the room to hold and comfort the child during electrode placement, distracting the child with a toy or video, and having the technologist speak and behave in a calm and unthreatening manner. These approaches should be the guidelines, or indeed the standards, for every EEG lab. The sleep state, useful for detecting EEG abnormalities, was promoted by having the child go to bed later and awakening earlier, not sleeping in the car, darkening the room, and having the child bring a toy or a blanket. This approach has no adverse consequences and is far less expensive than the published guidelines for sedation.²

Olson's group also evaluated the risks of moderate sedation, when needed. The Joint Commission on Accreditation of Healthcare Organizations defines moderate sedation/analgesia (also termed conscious sedation) as "A drug-induced depression of consciousness during which patients respond purposefully to verbal commands either alone or accompanied by light tactile stimulation." Anything deeper is called deep sedation or anesthesia. New regulations, which went into effect January 1, 2001,³ require that even for moderate sedation, "... qualified individuals, ... with competency-based education, training, and experience, ... be present during the procedure, ... to monitor the patient's physiologic status during sedation and during the postsedation period." These regulations hold even when only chloral hydrate is used for sedation.

The best way to avoid any possible complication is to question whether the benefit of information to be provided by the EEG is worth the risk, however small. Not all EEGs performed are needed, and many seem to be repeated for the benefit of the electroencephalographer rather than for the benefit of the patient. When, however an EEG is needed, and when sedation is needed, Olson and colleagues have provided a measure of the risk. All sedated children in their study were monitored by a sedation team in accordance with the published guidelines.² Ninety-one percent of the EEGs were successfully completed, most with chloral hydrate alone at an average dose of 55 mg/kg. Twenty-nine percent of these received a second dose of 25 mg./kg. Only 3 of the 513 children given chloral hydrate had complications, and those consisted of a decrease in oxygen saturation to between 82% and 88%. All 3 children had indications for exercising extra caution: 1 had a history of sleep apnea and a recent adenoidectomy; 1 had Down syndrome with a large tongue; and 1 had Duchenne muscular dystrophy, a previous history of sleep apnea and previous desaturations during sleep. Not knowing the children's oxygen saturations during natural sleep, it is difficult to ascribe these complications to the sedation with chloral hydrate. Each easily responded to awakening or repositioning. There were no short-term or long-term consequences of these complications.

The impetus for the published standards, and those newly developed by the Joint Commission on Accreditation of Healthcare Organizations³ working with various professional organizations, was "anecdotal evidence from the field that adult and pediatric patients were experiencing negative outcomes and even death as a result of conscious sedation." Coté and colleagues^4,5 culled adverse sedation events from 118 case reports and found 95 incidents resulting in 60 deaths or permanent neurologic injuries. Chloral hydrate was the only drug administered to 7 of the affected children. Four received an overdose (amount unstated in 3; 1 received 6000 mg). Nine other children had additional medications and readily identifiable preexisting medical conditions. There has been no denominator in these critical incident analyses, and no evidence that the guidelines produce safer sedation.⁶ Olson and his colleagues have at last produced some data.

Where should this leave us? Overdoses of chloral hydrate (or other medications) never should be given. A dose of 55 mg/kg of chloral hydrate usually appears to be sufficient to provide sedation for an EEG. A second dose, usually 25 mg/kg, may be required to achieve adequate sedation and appears safe. A pulse oximeter is advisable and far cheaper than an independent observer. But is a qualified and credentialed individual needed to manage patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally. Perhaps the EEG technicians could be trained to respond to the monitor's beep. One would feel more comfortable if the current costly recommendation were developed by a group with less potential conflict of interest than anesthiologists, and validated with empirical data. Perhaps we should be equally concerned about the prevention of sudden infant death syndrome by requiring every sleeping child to have an oximeter in place and a trained credentialed practitioner in attendance.

John M. Freeman, MD
Johns Hopkins Medical Institutions
Baltimore, MD 21287-7247

FOOTNOTES

Received for publication Mar 12, 2001; accepted Mar 12, 2001.

Reprint requests to (J.M.F.) Departments of Pediatrics and Neurology, Meyer 2-147, Johns Hopkins Medical Institutions, Baltimore, MD 21287-7247. E-mail: jfreema{at}jhmi.edu

ABBREVIATIONS

EEG, electroencephalogram.

REFERENCES

1. Olson DM, Sheehan MG, Thompson W, Hall PT, Hahn J Sedation of children for electroencephalograms. Pediatrics. 2001; 108:163-165 [Abstract/Free Full Text]
2. American Academy of Pediatrics, Committee on Drugs Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992; 89:1110-1115 [Abstract/Free Full Text]
3. Joint Commission on Accreditation of Healthcare Organizations. New definitions, revised standards address the continuum of sedation and anesthesia. Joint Commission Perspect. July/August 2000:10-12
4. Coté CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics 2000; 106:633-644 [Abstract/Free Full Text]
5. Coté CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics 2000; 105:805-814 [Abstract/Free Full Text]
6. Freeman JM, Vining EPG Oranges and apples: sedation and analgesia [letter]. Pediatrics. 2000; 106:1519 [Free Full Text]