To assess adherence to continuous EEG (cEEG) monitoring indications in a tertiary care pediatric intensive care unit (PICU), barriers to cEEG initiation, as well as optimize cEEG monitoring in critically ill children.

Non-convulsive seizures are common in critically ill children and can be detected by cEEG monitoring. A recent consensus statement from the American Clinical Neurophysiology Society (ACNS) outlines the indications for cEEG monitoring in critically ill patients. However, adherence to these cEEG monitoring criteria amongst PICU physicians is unknown.

We conducted a 6-month retrospective review of patients admitted to our PICU. This was followed by an 8-week mentorship period. A didactic lecture regarding the ACNS indications for cEEG monitoring was provided to all PICU physicians and summary handouts of the guidelines were displayed on the unit. All patients were independently screened by a pediatric neurologist and adherence to cEEG monitoring guidelines as well as delays between ordering cEEG and initiation of monitoring were assessed.

A total of 234 PICU admissions (183 unique patients) were studied. Prevalence of patients meeting cEEG monitoring indications were similar in both the retrospective (18%) and mentorship period (19%). During the retrospective period, 23% of patients meeting ACNS criteria had a request for cEEG monitoring, which increased to 83% during the mentorship period. The median delay to cEEG initiation was 16.7 hours during the mentorship period, largely due to limited hours of EEG availability. The majority (79%) of cEEGs informed clinical management. 

Our study demonstrated under-monitoring of patients at risk of subclinical seizures, which significantly improved through teaching interventions. However, there were long delays to cEEG initiation. In order to promptly recognize subclinical seizures in the PICU, a care model which allows for cEEG initiation outside of regular hours should be considered in all PICUs.