Use of EEG monitoring and management of non-convulsive seizures in critically ill patients: a survey of neurologists

Abstract

Background: Continuous EEG monitoring (cEEG) of critically ill patients is frequently utilized to detect non-convulsive seizures (NCS) and status epilepticus (NCSE). The indications for cEEG, as well as when and how to treat NCS, remain unclear. We aimed to describe the current practice of cEEG in critically ill patients to define areas of uncertainty that could aid in designing future research.

Methods: We conducted an international survey of neurologists focused on cEEG utilization and NCS management.

Results: Three-hundred and thirty physicians completed the survey. 83% use cEEG at least once per month and 86% manage NCS at least five times per year. The use of cEEG in patients with altered mental status was common (69%), with higher use if the patient had a prior convulsion (89%) or abnormal eye movements (85%). Most respondents would continue cEEG for 24 h. If NCS or NCSE is identified, the most common anticonvulsants administered were phenytoin/fosphenytoin, lorazepam, or levetiracetam, with slightly more use of levetiracetam for NCS than NCSE.

Conclusions: Continuous EEG monitoring (cEEG) is commonly employed in critically ill patients to detect NCS and NCSE. However, there is substantial variability in current practice related to cEEG indications and duration and to management of NCS and NCSE. The fact that such variability exists in the management of this common clinical problem suggests that further prospective study is needed. Multiple points of uncertainty are identified that require investigation.

Fig. 1

Which indications lead you to order cEEG to detect non-convulsive seizures or non-convulsive status epilepticus? (296 respondents)

Fig. 2

If NCS (non-convulsive seizures) or NCSE (non-convulsive status epilepticus) is suspected then what type of EEG do you obtain and how urgently do you obtain the EEG? (294 respondents). * Including initiation by a 24/7 in-hospital EEG technologist or calling in an on-call technologist

Fig. 3

How long do you continue cEEG if no seizures are detected in a patient who is comatose (292 respondents), obtunded/lethargic (291 respondents), or if PEDs (periodic epileptiform discharges) were detected (289 respondents)?

Fig. 4

How long do you continue cEEG after non-convulsive seizures terminated? (288 respondents)

Fig. 5

What anticonvulsant do you administer as a first, second, and third line medication of (a) non-convulsive seizures (271 respondents) or (b) non-convulsive status epilepticus? (268 respondents). FOS fosphenytoin, LEV levetiracetam, LZP lorazepam, MDZ midazolam, PB phenobarbital, PHT phenytoin, VPA valproic acid

Fig. 6

If non-convulsive seizures or status epilepticus persist despite initial anticonvulsants and you want to initiate coma, which medications do you use as first, second, and third line choices? (267 respondents)

Fig. 7

If non-convulsive seizures or non-convulsive status epilepticus is present, are you willing to intubate the patient to escalate treatment? (273 respondents)