An electroencephalogram (EEG) reflects the summation of electrical activity arising from excitatory and inhibitory post-synaptic potentials of pyramidal neurons. EEG electrodes are traditionally placed on the scalp according to the International 10–20 system of electrode placement to reproducibly record cortical electrical activity. There are a number of different montages that may be used to best analyze an EEG, and allow for interpretation of the spatial distribution and localization of the EEG activity across the cortex. Neonates may require a reduced montage. Raw EEG data remain the gold standard of neurophysiological monitoring; however, reduced-montage and quantitative EEG techniques have allowed providers, particularly in the neonatal and pediatric intensive care units, to have supplementary data to interpret, in real time, at the patient’s bedside or via remote access. This chapter reviews the technical aspects of neurophysiological monitoring, including the practice and underlying principles of initiating, recording, displaying, and interpreting EEG. Quantitative trends, including CDSA and aEEG, are included.

The abnormal electroencephalogram (EEG) that attracts the most attention is that showing a seizure. In the intensive care unit (ICU), EEG monitoring is most commonly used for seizure detection; however, EEG can provide additional useful information. The background pattern can be used to evaluate encephalopathy and to assess cerebral function in patients who are sedated and paralyzed. EEG background can inform prognostication after hypoxic ischemic injury. EEG can serve as an ancillary investigation in the determination of brain death. Finally, EEG changes guide titration of treatments, such as continuous infusions administered for status epilepticus or increased intracranial pressure. Quantitative EEG (QEEG) is increasingly used by bedside clinicians for rapid assessment of cerebral function and facilitation of rapid interventions for critically ill patients.

Neurological injury is extremely common among children admitted to the intensive care unit. The importance of recognizing and treating seizures in this vulnerable pediatric population is supported by a growing body of evidence, suggesting that seizures, both clinical and subclinical, negatively impact short- and long-term clinical outcomes. Continuous EEG monitoring offers the only noninvasive means to detect subclinical seizures and to confirm whether paroxysmal events suspicious for seizures do in fact represent clinical seizure activity. This chapter will discuss the evidence to support screening for seizures in specific disease states encountered in the PICU population where clinical and subclinical seizures are common. We begin by outlining the key clinical and EEG risk factors for the development of seizures shared by children admitted to the PICU across all etiologies. We then discuss the etiology-specific risk factors. Finally, considerations related to the timing and duration of cEEG monitoring are discussed.

Recognizing a normal recording is the first, but not the simplest, step of EEG analysis. Normal EEG patterns evolve in a predictable, age-dependent manner. In reviewing EEG and qEEG trends, clinicians must identify normal patterns and common artifacts that may mimic seizures or other abnormalities. This chapter provides a guide for practitioners reviewing neonatal and pediatric EEG to help recognize normal tracings. Instruction is given for how to systematically approach EEG and QEEG analysis. Age-specific aspects are reviewed with example findings. Common artifacts are shown.

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