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eeg policy and procedure manual

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eeg policy and procedure manualClose this message to accept cookies or find out how to manage your cookie settings. Core reader This list is generated based on data provided byPanzica, FerruccioAldosari, M.Mirsattari, S.M.Vol. 111. Issue.,Thorpe, Lilian. Dash, Dianne. Hussein, Tabrez. Hunter, Gary. Waterhouse, Karen. Laboni Roy, PragmaTellez-Zenteno, Jose F.Routine EEG for First Single Unprovoked Seizures and Seizure Recurrence: The DX-Seizure Study. Frontiers in Neurology. Vol. 11. Issue.,If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.It is the most efficient way to diagnose and classify epilepsy syndromes as well as define the localization of the epileptogenic zone. The EEG is useful for management decisions and for establishing prognosis in some types of epilepsy. Electroencephalography is an evolving field in which new methods are being introduced. The Canadian Society of Clinical Neurophysiologists convened an expert panel to develop new national minimal guidelines. A comprehensive evidence review was conducted. This document is organized into 10 sections, including indications, recommendations for trained personnel, EEG yield, paediatric and neonatal EEGs, laboratory minimal standards, requisitions, reports, storage, safety measures, and quality assurance. The first description of this procedure in humans was published in 1929. However, technological changes in recent decades have led to vast improvements in the recording and reviewing quality of the electroencephalogram (EEG), in addition to storage demands and capabilities and data transmission over long distances.window.parent.OnUploadCompleted(201,"/userfiles/d22-service-manual-free(1).xml">http://www.oncopathologie.com/text/javascript">window.parent.OnUploadCompleted(201,"/userfiles/d22-service-manual-free(1).xml

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Reference Velis, Plouin and Gotman Reference Andre-Obadia, Parain and Szurhaj Reference Varelas, Spanaki, Hacein-Bey, Hether and Terranova Reference Andrade, Tai, Dalmau and Wennberg Reference Smith These guidelines will not specify equipment or protocols that must be used; rather, we discuss the available technologies in terms of diagnostic and clinical value and make recommendations concerning the indications for which EEGy is best suited. The purpose of these minimal standards will serve as a benchmark for further development, standardization, and quality care in clinical neurophysiology laboratories in Canada. The search incorporated Medical Subject Headings and text words for literature on Standards for Electroencephalography.We included patients irrespective of age. Children were considered to be those under 16 years old. We excluded studies with non-consistent data or any overlapping patient populations from the same centre. A total of 1,655 articles were initially identified; 196 were included for full-text screening; and 61 articles, websites, and other documents were included. It included a panel of clinical neurophysiologists, electroencephalographers, epileptologists, and EEG technologists from across the country. The expert panel reviewed the recommendations in the 2002 guidelines At this meeting, work teams were formed to discuss and develop the topics of this document. In 2015, three teleconferences with the CSCN executive and membership were carried out, and all of the statements were integrated into a single document. The entire document was prepared in 2016 in accordance with the CAET minimal technical standards and organized into 10 sections. The new guidelines added literature related to the era of digital media, including such new practical sessions as indications: EEG yield and activation procedures, cEEG, video, neonatal and paediatric EEG, digital EEG media, electrodes, montages, and filters.http://www.czerwoneiczarne.pl/files/d2190-a-manual.xml The new guidelines additionally update the previous sections: electroencephalographers, technologists, laboratory standards and procedures, EEG requisitions, records and reports, informed consent, and quality improvement. The possibility of a seizure is considered for a patient who reports paroxysmal clinical events involving sensory, motor, and psychic phenomena, including alteration of consciousness. However, because of the unpredictable and intermittent nature of seizures, there is only a small chance of recording the patient’s stereotypic events during a routine EEG recording. Reference Lagerlund and Worrell Reference Maganti and Rutecki Similarly, the rates of spontaneous IEDs in healthy adult volunteers vary from 0.1 to 6.6 (So, 2010). Reference Bihege, Langer, Jenke, Bast and Borusiak Reference Reeves and Ladner Reference Rowan EEGy may be the only modality that can distinguish an epileptic seizure from a PNES. Reference Reeves and Ladner For example, generalized periodic discharges (GPDs) with triphasic morphology waves may point to hepatic encephalopathy, and an excess of beta activity may suggest a barbiturate or benzodiazepine overdose. Reference Rowan Reference Reeves and Ladner EEGy is also useful in establishing neurological prognosis after cardiorespiratory arrest Reference Varelas, Spanaki, Hacein-Bey, Hether and Terranova Reference Stecker, Sabau and Sullivan Reference Coburn, Lauterbach, Boutros, Black, Arciniegas and Coffey Reference Guerrini, Duchowny and Jayakar Reference Andrade, Tai, Dalmau and Wennberg Psychiatrists should base their use of EEGy on robust clinical assessment and should be aware of the limitations inherent in the procedure. Reference Badrakalimuthu, Swamiraju and de Waal The CSCN strongly recommends that provinces that do not have a provincial qualifying examination use the successful passing of this examination as a prerequisite for the practice of interpreting EEGs.http://gbb.global/blog/boss-bv8220-manual All electroencephalographers entering EEGy practice should have the following qualifications: Reference Smith Individual regular review of journals and attendance at related conferences are strongly encouraged. It is also recommended that the electroencephalographer regularly meet with technologists for reading sessions and, if possible, other electroencephalographers in the area. Reference Smith The responsibilities of the director should include the following: Reference Smith Reference Smith Reference Smith Reference Smith Reference Smith Finally, it is recommended that they have membership in the CAET as well as the provincial technologist organization if applicable. Such training should involve: the use and maintenance of equipment, safety protocols, management of seizures and seizure-related emergencies, recognition of ictal and interictal electrographic patterns, artefactual signals, data retrieval, reduction, and storage. The LTME electroencephalographer should have similar training or be under the direction of the laboratory director. Continuous recordings should employ such quantitative analysis tools as a compressed spectral array whenever possible in order to demonstrate trends over time and graphically represent long recordings in easy-to-understand formats, which can facilitate communication with intensivists and nurses, as well as reduce reviewing time. Electrodes should be checked at a maximum interval of every 24 hours, or more frequently based on individual patient factors and the quality of recordings. This procedure has been shown to be effective in differentiating between epileptic and non-epileptic events, especially in children whose spells occur on a daily basis.http://eastwestrubbertrading.com/images/case-1830-skid-steer-manual.pdf Reference Wirrell, Kozlik, Tellez, Wiebe and Hamiwka A study performed in adult patients Reference Dash, Hernandez-Ronquillo, Moien-Afshari and Tellez-Zenteno Reference Wirrell, Kozlik, Tellez, Wiebe and Hamiwka Reference Flink, Pedersen and Guekht Reference Smith When a routine EEG fails to show IEDs in a patient with a suspected seizure disorder, repeating the EEG and using additional activation procedures such as sleep deprivation (SD) and repeating hyperventilation (HV) or intermittent photic stimulation (IPS) may increase diagnostic sensitivity. Reference Lagerlund and Worrell Additionally, an abnormal EEG demonstrating IEDs does not itself indicate that an individual has epilepsy. Reference Smith Reference Smith Occasionally, longer recordings may be necessary to adequately assess the presence of IEDs. Reference Maganti and Rutecki HV is contraindicated in patients with the following medical conditions: recent brain surgery, stroke, intracranial haemorrhage, uncontrolled hypertension, severe cardiovascular or pulmonary disease, exertion-induced asthma, brain tumour, moyamoya disease, sickle-cell disease, or trait or another cause of blood hyperviscosity. It should also be avoided in patients with an inability or unwillingness to cooperate (intellectual disability, dementia). The contraindication is selective during pregnancy, and clinical judgment should be used for patients over the age of 65. Obtaining an adequate history, which may contraindicate HV, is often difficult with patients from nursing homes and assisted-living facilities. Precaution with HV should be higher in the elderly. Reference Smith Reference Maganti and Rutecki Reference Flink, Pedersen and Guekht Events or responses should be documented on the EEG at the time of their occurrence. Attempts to confirm sensitivity to a particular frequency should be separated in time to prevent specific habituation of the responses. Electromyogram (EMG) electrodes may be necessary to detect myoclonus during a photoparoxysmal response (PPR). Photic stimulation should be stopped immediately if any generalized epileptiform activity occurs. Additional attempts at that specific frequency may be required to confirm photosensitivity. Reference Seshia and Carmant Reference Seshia and Carmant Reference Flink, Pedersen and Guekht It is known that sleeping during an inappropriate circadian phase (i.e., in the morning) enhances sleep instability and causes the occurrence of epileptiform discharges. Reference Giorgi, Maestri and Guida Additional time is required for a period of wakefulness before and after sleep, plus HV and IPS, unless contraindicated.In some circumstances, video is required. When suspecting abnormal movements, it is necessary to perform an EMG of relevant muscles coupled with video recording. In cEEG at an ICU and in LTME, video recording is essential, with strict synchronization of the EEG signal and video. The video is useful for interpreting clinical events as well as identifying artefacts; however, the use of video does not reduce the importance of having an attentive technologist. Reference Sinha, Sullivan and Sabau The yield of capturing epileptiform (seizures or IEDs) is dependent upon aetiology, as well as the patient’s clinical state and age. As a general rule, the chances of capturing seizures or IEDs increases with duration of cEEG recording. In critically ill children, a 24-hour recording will capture 72-80 of seizures, while a 1-hour recording will do so in 50 of cases. Reference Jette, Claassen, Emerson and Hirsch In critically ill patients, cEEG should be recorded for at least 24 hours following cessation of seizures when medication changes are no longer needed (titration or weaning). This should include tapping and auditory, visual, painful, and somatosensory stimuli. Reference Flink, Pedersen and Guekht Reference Andre, Lamblin and d’Allest EEGy is also useful in elucidating the timing and mode of brain injuries in the preterm newborn. Regardless of aetiology, the efficacy of treatment should be evaluated using cEEG monitoring in the acute stages of brain insult. Reference Okumura It is essential that HV be performed during the EEG in children with suspected absence seizures in the absence of contraindications. Reference Tyner A single-channel ECG should be included on one EEG channel. This is helpful in distinguishing between epileptiform discharges and ECG artefacts, so as to identify pulse and movement artefacts. Reference Acharya, Hani and Cheek Yearly checks and documentation on equipment safety must be maintained. Acquisition of EEG data into a digital storage medium should occur at a minimum sampling rate of 256 per second. Digitization should use a resolution of at least 16 bits per sample, including any sign bit. The common mode rejection ratio should be at least 90 dB for each of the channels. Additionally, video recording should be synchronized with the EEG to facilitate review, especially for identification of artefacts and clinical events. Reference Halford, Sabau, Drislane, Tsuchida and Sinha A standard vertical scaling with a minimum spacing of 10 mm per channel should be employed for a display of up to 21 channels. Reference Halford, Sabau, Drislane, Tsuchida and Sinha All electrodes, whether used for routine or otherwise, must adhere to CAET technical standards. Ordinarily, all electrode impedances should be equal and not exceed 5000 ? (ohms) in routine settings. In LTME and cEEG, where electrode application is prolonged and patient skin is susceptible to breakdown, it is more important to have balanced electrode impedances that do not exceed the upper limit of 10,000 ?. Electrode impedance should be rechecked during the recording when any pattern that might be artefactual appears. On the other hand, the additional, more closely spaced electrodes in the 10-10 system clearly provide better spatial resolution. In patients undergoing pre-surgical evaluation, they can provide precise localizing information with regard to IED and ictal EEG onsets. However, placement of several additional electrodes requires increased time and effort on the part of technologists, potentially reducing the number of studies that can be performed in a day. Finally, additional electrodes need to be purchased, thus increasing the cost. Reference Acharya, Hani and Cheek Appropriate calibrations should be made at the beginning of every EEG recording. This includes at least 10 seconds (or the duration needed to reach a stable recording) of a square wave calibration. Reference Sinha, Sullivan and Sabau Using their best judgment and erring on the side of patient safety, technologists should notify the appropriate electroencephalographer about significant findings that require urgent attention. The ACNS published a proposal for montages to be employed in EEGy for standard use by clinical laboratories. A logical order of arrangement should prevail in each montage. The electrode connections for each channel should be clearly indicated at the beginning of each montage, the electrode connections should be made as simple as possible, and montages should be easily comprehended. Tracings from the more anterior electrodes should be placed above those from the more posterior electrodes on the recording page; similarly, a “left-above-right” order of derivations should be utilized. Mild modifications of the recommended montages may be applied for monitoring other physiologic variables, so long as these modifications do not conflict with the principles set forth in the previous recommendations. Reference Acharya, Hani and Cheek They also provide more consistent recording information, do not result in pain and discomfort for patients, and do not require physician expertise. Reference Acharya, Hani and Thirumala Analog filters are applied to the incoming signal in the actual amplifier before digitization. These are dependent on the specific amplifier being used and are not modifiable by the user. The second level of filtering comprises digital filters that are applied before display of the digitized data. The use of these filters does not permanently alter the recorded data; it only processes the data for display. Reference Sinha, Sullivan and Sabau A low-frequency filter setting higher than 1 Hz could attenuate slow-wave activity in the record. Vital information may be lost when pathologic activity in the delta range is present. The high-frequency filter should be no lower than 70 Hz, as a setting lower than 70 Hz for high-frequency filters can distort, attenuate, or transform spikes and other pathologic sharp features into unrecognizable forms and can cause muscle artefacts to resemble spikes. Reference Sinha, Sullivan and Sabau Its use should be restricted to hostile recording environments (i.e., the ICU), where 60-Hz interference cannot be readily eliminated by proper troubleshooting techniques. Reference Flink, Pedersen and Guekht In addition, medications, relevant clinical history and observations, hand dominance, time of last nourishment, skull anomalies, name of the technologist, and the technologist’s impression should be noted. Abbreviations used for annotations should be standardized within each laboratory. Technical, clinical, and behavioural changes should be indicated on the recording at the time of their occurrence. Signals or commands to the patient, the presence or absence of clinical responses to stimuli, onset and conclusion of activation procedures, and movements should also be annotated. Careful observation of the patient with frequent notations is essential, particularly when unusual waveforms are observed in the tracing. For inpatient referrals, the unit should be included. Reference Smith The report should comprise three main sections: introduction, description, and interpretation. When interpreting topographic mapping, frequency or power spectral analyses and other quantitative assessments of a digital EEG should also involve assessment of the standard EEG. The use of quantitative EEGy alone can yield misleading information. Other channels of physiologic display should be described, such as those reserved for measurement of the ECG, breathing, as well as limb and chin movements. Reasons should be given if the electrode positions or recording techniques vary from the routine laboratory protocol. Documentation should also be provided to indicate where an EEG is being performed, if outside the EEG laboratory, use of any special electrodes or techniques, and conditions prevalent at the time of recording (e.g., fasting, SD, and sedatives or other drugs used for the recording). Reporting the duration of the recording should also be considered if it deviates from a typical recording. The purpose for this is to produce a complete report that will allow another electroencephalographer to arrive at a similar conclusion without the benefit of looking at the EEG. Background activity should be described along with its frequency, quantity, amplitude, location, persistence (continuous or intermittent), symmetry, and rhythmicity. In order to facilitate inter-reader agreement, the report should include either the exact time of key abnormalities or whether such abnormalities are marked on the recording. The type and range of frequencies of IPS used should be stated. If HV and IPS are not performed, the reason for this omission should be documented. Normal and abnormal responses to background activation procedures should be described (e.g., touch, sound, eye opening, nasal tickling, mouth or tracheal suctioning, or sternal pressure). Reference Kaplan and Benbadis If the record is considered abnormal, it is desirable to grade the abnormality in order to facilitate comparison between successive records. When dealing with several types of abnormal features, the list should be limited to the two or three most important abnormalities.The electroencephalographer should not suggest changes in medications, new treatments, or other clinical tests in the EEG report, with the exception of repeating the EEG with SD and sleep recording when a suspicious finding may result in an unquestionable one during sleep (i.e., focal IEDs). If prior EEGs are available, comparison with those tracings must be discussed. As such, it is not mandatory to use an EEG classification system. An old and arbitrary classification of the EEG in post-cardiac-arrest patients is sometimes extrapolated to other aetiologies and is still presently used. Reference Herman, Abend and Bleck A consistent form of classification should be standardized within each laboratory at the discretion of the laboratory director. Reference Smith It is recommended that the timing of a report be based on the purpose and findings of the EEG. An outpatient routine EEG report is expected to be available within five working days of completion. If significant abnormalities exist (e.g., a recorded seizure), the report should be generated within 24 hours of completion with immediate notification to the referring physician. Inpatient routine EEG reports should be generated within 24 hours. Potential indications could include an abnormal or unexpected result or patients in a critical-care unit or emergency department, where timely EEG reports can alter patient management. Reference Smith The first hour of cEEG recording should be reviewed immediately, and a verbal report provided after it is acquired. Reference Herman, Abend and Bleck Unfortunately, this is not available at all centres across Canada. Reference Smith Storage of video EEG data via business-grade server storage solutions minimizes the chance of data loss by incorporating built-in data storage redundancy and regular data backup. Additionally, using a server storage solution enables full Health Insurance Portability and Accountability Act compliance because it can record a full audit trail for every person who accesses the patient record. Optical storage devices are not recommended. Reference Halford, Sabau, Drislane, Tsuchida and Sinha It is therefore recommended by the ILAE to have safety protocols or manuals in place. Reference Labiner, Bagic and Herman Interdisciplinary team members must comply with their governing body’s code of ethics. Acetone is the most effective agent for removing collodion-applied electrodes; however, acetone inhalation can produce nasal and conjunctival irritation, respiratory effects, nausea and vomiting, and a sensation of muscle weakness. Proper ventilation is required when using ether-based products (e.g., collodion) as per the Material Safety Data Sheet. It has been demonstrated that a simple vapour extraction system available during electrode application and removal improves safety in EEG laboratories. Reference Young, Blais and Campbell In addition to occupational safety and emergency preparedness, personnel must comply with their local facilities’ occupational health and safety policies and procedures. All procedures should be initially approved and signed by the medical director. The document should be reviewed annually by the director or a designate. The review should include the documentation of any changes made during the year. Table 1 summarizes the information that should be contained in the manual. Reference Smith If exceptional circumstances necessitate their use (burns to the head, intraoperative procedures), sterilized single-use needle electrodes should be used and disposed of after testing has been completed, and CAET guidelines should be enforced. Disk electrodes as applied for routine EEG procedures are classified as semi-critical (due to skin abrasion), requiring high-level disinfection as per the facility’s infection control policies. If no other options exist (e.g., in exceptional circumstances when patient cooperation is such that use of an electrode cap is the only way to obtain an EEG), then such a system may be used. When using an electrode cap, the technologist must clearly document this on the recording. It is strongly recommended that electrical interference be promptly investigated, as this may be indicative of current leakage through the patient. Reference Tyner Written consent is not necessary for routine EEGs. All patients or their substitute decision makers should be informed that they have the right to consent to or refuse the test in whole or in part at any time during the procedure without prejudice. When activating procedures (i.e., reduction of medications, SD, or use of sedative drugs) put the patient at risk of seizures, excessive sedation, or other complications, it is recommended that the patients or their caregivers be at least verbally informed about this. It is strongly recommended that a factsheet that provides the aforementioned general information be utilized for elective EEGs. Reference Smith The process should monitor participation and compliance with established professional and departmental practices and should focus on patient quality and safety as well as the services provided. Quality-assurance checks can be completed quarterly or semiannually to identify areas of concern. Appropriate documentation and a collaborative, continuous improvement process approach is beneficial. This should be undertaken to more fully reflect the needs and satisfaction of patients, staff, and referring medical officers. This is actively encouraged at all levels to ensure that program objectives and client needs are met consistent with governing policies. Reference Hamilton-Bruce, Black and Stratos Audits examine and reflect the range of procedures undertaken, their quality, and outcome, and they provide evidence of their benefits. Reference Brodie, Shorvon and Canger Research should be encouraged because it improves knowledge and standards of care. Reference Brodie, Shorvon and Canger Increased awareness of departmental quality assurance, program evaluations, and staff participation should increase the quality of services. The facility standard should reflect the agreed-upon standard turnaround time between reception of the EEG requisition to delivery of the results. Every step in the process should be evaluated for continuous improvements. Delays in critical test results may result in serious adverse outcomes for patients. Acceptable waitlist timeframes should be established by departments, local facilities, health regions, or within the province. We present herein an updated version with the minimal standards for the practice of conventional EEG. The purpose of these minimal standards will serve as a benchmark for further development, standardization, and quality care in clinical neurophysiology laboratories in Canada. Recommendations regarding the requirements and applications for long-term recordings in epilepsy. Epilepsia. 2007; 48 ( 2 ): 379 - 384. Continuous EEG monitoring in adults in the intensive care unit (ICU). Neurophysiol Clin. 2015; 45 ( 2 ): 39 - 46. Emergent EEG: indications and diagnostic yield. Neurology. 2003; 61 ( 5 ): 702 - 704. Subcommittee on Neurophysiology. Recommendations regarding the requirements and applications for long-term recordings in epilepsy. Epilepsia. 2007; 48 ( 2 ): 379 - 384. Tonic seizures: a diagnostic clue of anti-LGI1 encephalitis? J Neurol Neurosurg Psychiatry. 2005; 76 ( Suppl 2 ): ii2 - ii7. Minimal standards for electroencephalography in Canada. Can J Neurol Sci. 2002; 29 ( 3 ): 216 - 220. The role of routine scalp electroencephalography. In: Cascino GD, Sirven JL editors Adult Epilepsy.EEG and epilepsy monitoring. Continuum (Minneap Minn). 2013; 19 ( 3 Epilepsy ): 598 - 622. Prevalence of epileptiform discharges in healthy infants. J Child Neurol. 2015; 30 ( 11 ): 1409 - 1413. Prevalence of epileptiform discharges in healthy children: new data from a prospective study using digital EEG. Epilepsia. 2010; 51 ( 7 ): 1185 - 1188. Effect of inpatient electroencephalography on clinical decision making: EEG is more valuable than findings suggest. J Am Osteopath Assoc. 2014; 114 ( 6 ): 425 - 426. In: Rowan AJ, Tolunsky E editors. Primer of EEG: With a Mini-Atlas. Philadelphia: Elsevier Science; 2003. Consensus statement on continuous EEG in critically ill adults and children, part 1: indications. J Clin Neurophysiol. 2015; 32 ( 2 ): 87 - 95. Standardized EEG interpretation accurately predicts prognosis after cardiac arrest. Neurology. 2016; 86 ( 13 ): 1482 - 1490. American Clinical Neurophysiology Society guideline 6: minimum technical standards for EEG recording in suspected cerebral death. J Clin Neurophysiol. 2016; 33 ( 4 ): 324 - 327. The value of quantitative electroencephalography in clinical psychiatry: a report by the Committee on Research of the American Neuropsychiatric Association. J Neuropsychiatry Clin Neurosci. 2006; 18 ( 4 ): 460 - 500. Electroencephalography for diagnosis and prognosis of acute encephalitis. Clin Neurophysiol. 2015; 126 ( 8 ): 1524 - 1531. Diagnostic methods and treatment options for focal cortical dysplasia. Epilepsia. 2015; 56 ( 11 ): 1669 - 1686. Extreme delta brush: a unique EEG pattern in adults with anti-NMDA receptor encephalitis. Neurology. 2012; 79 ( 11 ): 1094 - 1100. EEG in psychiatric practice: to do or not to do? CAET minimal technical standards: routine adult, routine paediatric, routine neonatal, routine ECS. Saskatoon, Saskatchewan: CAET; 2016.. Accessed June 7, 2017. Core competencies for electroencephalography; 2016. www.acmdtt.com. Accessed June 7, 2017.