Avoiding Skin Damage with LTM EEGs
The use of long-term monitoring (LTM) EEG procedures in the U.S. continues to grow. For example, long-term video EEG Medicare claims increased more than 100 percent in a five-year period: from 53,000 in 2009 to 115,000 in 2014. 1 As the number of LTM EEGs increases, so do concerns regarding potential skin damage due to prolonged electrode exposure.
A literature review pertaining to EEG electrode use and skin breakdown reported a 10-11.4% incidence of skin injury in pediatric populations, with a projected incidence from 25-35% for all EEG patients. 2 Another study of 861 patients in an epilepsy monitoring unit undergoing video EEG monitoring found that skin irritation occurred in 27.3% of patients and was moderate or severe in 19.1%. 3 Significantly higher risk of irritation was associated with electrode placement on the face and with four days or more of monitoring. 3 A study of 1,519 hospitalized patients who received continuous EEG monitoring found that monitoring duration was a major predictor of skin breakdown risk with 3-, 5- and 10-day risks of 16%, 32% and 60%, respectively. 4
Fragile or delicate skin—for example, that of neonates, pediatric or geriatric patients—must be taken into account in the application of EEG electrodes. 5 However, many of the skincare considerations for these populations could benefit other patients undergoing EEG monitoring for longer than 48 hours. Long-term EEG monitoring is used both in inpatient and outpatient settings for epilepsy care, sleep disorders, cerebrovascular disease, psychiatric conditions, movement disorders and more. 6
Prevention of healthcare-acquired pressure ulcers (HAPU) remains a significant focus in hospitals and long-term EEG studies have been identified as a contributor to this issue. 4 A study examining hospital-acquired pressure ulcers in children indicated that that EEG leads rank 6th in a list of 18 identifiable HAPU causes. 8 Pressure ulcer risk is due in part to items used to secure the electrodes and moisture that can form between those layers. 7
Heat, either generated by the body or externally by sources such as incubators or heat lamps, is another factor to take into account in electrode application. ASET (The Neurodiagnostic Society) EEG procedure skin safety guidelines state that “it has been noted that the temperature of gold-plated electrodes seems to remain constant in comparison to other metals” 6 while others suggest using only gold disposable electrodes for neonates to prevent burns in the incubators. 8 Other factors such as air temperature, external direct pressure and a patient’s hydration or changing medical status should all be considered for maintaining skin integrity in relation to electrode use. 5
Of course, skin care for critically ill and/or unresponsive patients takes on an added level of responsibility for healthcare providers. ASET recommends disposable electrodes for use with critically ill patients. 5 A multicenter study of exploring contamination of reusable EEG cup electrodes and leadwires found bacteria on 22.6% of the electrodes and leadwires after they were cleaned. 9 The ASET guidance also states that flat-rimmed electrodes and lighter-weight electrode wires/cables reduce pressure on the skin. 6 LTM patients should be checked daily for evidence of skin breakdown or infection. 5
In general, EEG-related skin care strategies fall within three primary categories: prepare, monitor and respond:
1. Prepare: Be vigilant about avoiding over-preparation of the skin. Avoid using abrasive prepping gels or tight head wraps 6 for LTM patients. Use stretchable, breathable gauze, with sufficient space to place two fingers under the head wrap. 5 Consider hypoallergenic gels and pastes as one more protection against skin reactions. For reusable electrodes, follow institutional cleaning and infection prevention policies. Adopt a uniform electrode type to help staff more easily train other caregivers about electrode application, removal and safety.
2. Monitor: Monitor skin under and around electrodes. Develop and follow a formal monitoring protocol that defines skin check intervals and locations—for example, every 12-24 hours and in areas like the face where electrodes are more likely to cause irritation. Include nursing staff and wound care specialists in consistent monitoring efforts. Document changes in the medical record.
3. Respond: As part of institutional protocols, have a response plan in place that clearly outlines steps to take quickly in the event of skin breakdown. Ensure that electrodes are moved from sites where the skin is adversely affected. Adjust the homologous electrode while maintaining symmetry to the extent possible, following lab protocols. Document changes in the medical record and involve other healthcare professionals, such as wound care teams, as needed.
Continuous EEG (cEEG) monitoring has increased dramatically in the last decade in part to provide more accurate information related to epilepsy diagnoses 10--12 and also due to monitoring of elderly hospitalized patients who present with new-onset seizures. 4 Advanced age is associated with both higher incidence and severity of EEG monitoring-related pressure ulcers. 4 Given the growing elderly patient population in the U.S., it is useful to explore recommendations specific to these patients.
Disk or cup electrodes (gold, silver, or silver chloride) are typically used for critical care continuous EEG (CCEEG) monitoring. When possible, the American Clinical Neurophysiology Society (ACNS) guidelines suggest that CT- and/or MRI-compatible electrodes be used, 13 especially if the patient is likely to require repeated neuroimaging studies. 14 More than 50% of patients will require neuroimaging with MRI or CT during the course of CCEEG monitoring. 13 These compatible electrodes (e.g., conductive plastic electrodes, subdermal wire electrodes) can remain in place during imaging, reducing both electrode application time and skin breakdown caused by frequent electrode removal and reapplication. 9
Neurodiagnostic professionals have long had to balance skin safety with optimizing signal and minimizing artifacts in EEG procedures for accurate results. The ability to maintain skin integrity is one important factor among several associated with electrode selection and application. Ease of use, cost, imaging compatibility, durability, and EEG study requirements all affect the types of electrodes that are best for facilities and their patients. Fortunately, simple-to-implement technique and protocol changes and a growing array of innovative EEG electrodes support patient skincare and comfort while achieving accurate test results.
LifeSync Neuro is a leading provider of neurodiagnostic and neuromonitoring products that deliver patient comfort, excellent signal quality and accurate test results. For more information, visit the LifeSync Neuro website or call 1-800-328-5544 to request more information or a product catalog.
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- References
1. Fountain NB, Barkley GL, Nuwer MR, Herman ST. 2020 Coding Changes for Long Term EEG/VEEG Services. Presentation. American Epilepsy Society 2109 Annual Meeting. 9 Dec.2019. Baltimore Accessed at: https://www.naec-epilepsy.org/wp-content/uploads/NAEC-AES-Coding-Session-Slide-Deck-FINAL.pdf
2. Urrea-Mendoza E, Smith S, Eskew A, Hasegawa H, Hakimi A, Laforce L. Skin breakdown in electroencephalography (EEG), how often? How rare? Abstracts/Clinical Neurophysiology 129 (2018) e29-e30.
3. Drees C, Makic MB, Case K, Mancuso MP, Hill A, Walczak P, Limon S, Biesecker K, Frey L.
Skin Irritation during Video-EEGMonitoring. Neurodiagn J. 2016;56(3):139-150.
4. Moura LM, Carneiro TS, Kwasnik D, Moura VF, Blodgett CS, Cohen, et al. cEEG electrode-related pressure ulcers in acutely hospitalized patients. Neurol Clin Pract. 2017; 7(1):15-25. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5310208/pdf/NEURCLINPRACT2016016998.pdf
5. Skin Safety During EEG Procedures, ASET Position Statement. Skin Safety During EEG Procedures – A Guideline to Improving Outcome. Accessed at: https://www.aset.org/m/pages.cfm?pageID=4134
6. Tatum WO 4th. Long-termEEGmonitoring: aclinicalapproachtoelectrophysiology.
J Clin Neurophysiol. 2001 Sep;18(5):442-55. Review.
7. Murray JS, Noonan C, Quigley S, Curley MA. Medical device-related hospital-acquired
pressure ulcers in children: an integrative review. J Pediatr Nurs. 2013 Nov-Dec; 28(6):585–95.
8. Cheng CE and Kroshinsky D. Iatrogenic skin injury in hospitalized patients. Clin Dermat. 2011 Nov-Dec;29(6):622–32.
9. Albert NM, Bena JF, Ciudad C, Keleekia-Brapoh N, Morrison SL, Rice K, et al. Contamination of reusable electroencephalography electrodes: A multicenter study. Am J Infect Control.2018;46:1360-4.
10. Knox A, Arya R, Horn PS, Holland K. The Diagnostic Accuracy of Video Electroencephalography Without Event Capture. Ped Neur. 2018 Feb;(79)8-13.
11. Asano E , Pawlak C, Shah A, Shah J, Luat AF, Ahn-Ewing J, Chugani HT. The diagnostic value of initial video-EEG monitoring in children—review of 1000 cases. Epilepsy Res. 2005 Aug-Sep;66(1-3):129-35.
12. Bennett-Back O,Uliel-Siboni S, Kramer U. The yield of video-EEG telemetry evaluation for non-surgical candidate children.Eur J Paediatr Neurol. 2016 Nov;20(6):848-854.
13. Herman ST, Abend NS, Bleck TP, Chapman KE, Drislane FW, Emerson RG, et al. Consensus Statement: Indications, Technical Specifications and Clinical Practice of Continuous EEG Monitoring of Critically Ill Adults and Children. American Clinical Neurophysiology Society. 2014. Accessed at: https://www.acns.org/UserFiles/file/ICU_EEG_Guidelines_FinalDraft_2014-09-22.pdf
14. Vulliemoz S, Perrig S, Pellise D, Vargas MI, Gasche Y, Ives JR, et al. Imaging compatible electrodes for continuous electroencephalogram monitoring in the intensive care unit. J Clin Neurophysiol 2009;26:36-243.