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Filename: Cerebral function monitor protocol.doc 1

NURSING PROTOCOL - MUHC Medication included No Medication included

THIS IS NOT A MEDICAL ORDER

Title: Cerebral function monitoring using amplitude-integrated electroencephalogram

Classification number:

This nursing protocol is attached to:

Therapeutic hypothermia

1. PURPOSE

To outline the clinical indications, setup process, the application that a cerebral function monitor (CFM) can provide to NICU patients and a few examples.

2. PROFESSIONALS AND PATIENT POPULATION

Patient population: all infants who are admitted to the NICU with the following diagnosis:

• Hypoxic ischemic encephalopathy

• Seizures or clinical scenario mimicking seizure disorders

• Significant neurological disorders (congenital brain malformations, vascular lesions)

• Post cardiac arrest

• Inborn errors of metabolism

• Neonatal abstinence syndrome

Professionals involved in the installation and analysis of the data.

• Neonatal Nursing staff – a specific group of nurses to be identified will be responsible for the application and securing of the electrodes to the scalp of the infant. They will also be responsible for entering the patient data and changes in status during the recording.

o Observe for clinical signs of seizures

o Track times of when procedures are done and when anti-convulsant and sedative therapy is given (bedside nurse)

o Communicate problems or questions to staff neonatologist or NNP

o Inform NNP or Neonatologist of alarms or major trace changes

Nursing Protocol - MUHC


• Neonatologist – on service at the time of admission is responsible for:

o Ordering and/or discontinuing the CFM

o Evaluating for trace changes on the CFM (at least twice/shift)

o Medical management of abnormalities detected on the CFM

o Analyzing and documenting the data in the chart.

• Neonatal Nurse Practitioner – in collaboration with the staff neonatologist

o Ordering and /or discontinuing the CFM

o Evaluating for trace changes on the CFM (at least twice/shift)

o Medical management of abnormalities detected on the CFM

o Analyzing and documenting the data in the chart

3. ELEMENTS OF CLINICAL ACTIVITY

Professionals are responsible to know the limits and extent of their practice as related to the particular protocol.

Equipment needed:

• Stellate cerebral function monitor.

• Package of 3 CFM - disposable subdermal needle electrodes (12mm - 29 gauge)

• Package of CFM – disposable neonatal hydrogel electrodes

• EEG abrasive skin preparing gel (NUPREP) if using hydrogel electrodes

• 2x2 gauzes

• Template drawing about where to position the electrodes

• Hat for securing electrodes

Procedure:

1. Obtain order for initial monitoring

2. Obtain necessary equipment (needles vs hydrogel electrodes)

3. Plug CFM in the a/c outlet and turn the power on (located at the bottom of the screen)

4. Connect cable to portable Stellate amplifier

5. Secure amplifier in the bed of the infant

6. On the screen (touch screen):

a. A window will open and show a box with 3 sections:

i. New patient

ii. Find patient

iii. Last patient

b. Click on “new patient” to create a new patient

Note: In case the screen does not open with this window, click on the icon “Vital ICU recorder”, and enter these information: Username: administrator



Password: eeg

Domain: VITAICU And then press ok. It should open the window described just above.

7. Enter the patient information

a. last name

b. unit number

c. date of birth

d. press next

8. Choose recording template

a. Click on arrow on bar and the choices will drop

b. Depending on prescription – choose between two methods of recording to be identified by Neonatologist/NNP

i. 4 leads: 4 needles electrodes

1. NICU P3P4

2. NICU P3P4 + DV (video)

ii. 6 leads: 6 needles electrodes

1. NICU

2. NICU P3P4 + DV (video)

9. Picture will appear showing position of electrodes

10. Click the “next” button when choice done

11. A window will open and asks: “send notifications to the following address” Left it blank, and click the “next” button

12. A window will open and shows: “Created by” choose ICU nursing or ICU physician “Assigned to” choose ICU physician and then click the “next” button

13. A window will open and asks to enter filename and choose media By default: Filename: last name/date/hour Media: D: VITA D Do not modify this part.

14. Press start recording, and wait a little bit until the next window opens

15. A window with the recording will open, and an additional window will directly open, asking to “please perform impedance test” Click on “start test”

16. Impedance test will appear showing the leads you have position – color indicates the effectiveness of the contact:

a. Green – good contact

b. Yellow – fair contact

c. Red – poor contact – will need to verify that all



connections are good – may need to reassess leads and readjust

17. Use template drawing for identifying where the electrodes will be placed on the head – two methods of recording to be identified by Neonatologist/NNP

a. Identified as NICU P3P4 4 electrodes: 3 needles and 1 hydrogel electrodes

b. Identified as NICU 6 electrodes: 6 needles electrodes

18. Insertion of needle electrodes

19. Placement of hydrogel electrodes – apply small amount of NUPREP to a 2x2 gauze and scrub each lead area with circular motion for 30 seconds. Wipe excess off, wash with a 2x2 gauze and saline, dry the area with another 2x2 gauze and apply the hydrogel electrodes.

20. Secure electrodes into place with tape

21. Connect leads to amplifier in the bed.

a. For NICU P3P4 – P3 is on the left (connected to C3 on the amplifier) – P4 is on the right (connected to C3 on the amplifier) – another wire is the reference on the left side of the amplifier – another wire is the ground and goes on the upper part of the amplifier

b. For NICU – C3 and P3 are on the left with two yellow wires – C4 and P4 are on the right with two yellow wires – a black wire is the reference on the left side of the amplifier – another black wire is the ground on the upper part of the amplifier

22. Confirm your electrode position with the impedance test on the screen All the colors should be green or yellow on the screen!!!!

23. When satisfied, press “close” the impedance test

24. Apply hat on head for securing electrodes

25. The recording screen will appear and is split into two parts:

a. Top: actual EEG recording

b. Bottom: actual CFM/aEEG recording for each side of the brain

26. Monitor the recording, observe the tracing, and watch for trace changes

27. Recording of events

a. click on icon “Annotate”

b. List of choices will appear for example:



i. Free text head ultrasound, x-ray, …

ii. Crying

iii. Suction

iv. Diapering

v. Care change position, …

vi. Possible seizure

vii. Medications opiates

viii. Medications anti-convulsivant

ix. Medications midazolam

c. Once annotation done, click on “close” to come back to the recording window.

28. Check the impedance while recording, if tracing looks abnormal

a. click on icon “Advanced Mode”

b. a new window will open click on the icon “Ω” (Impedance Mode) on the second line, near the left corner

c. the impedance test will open check that all your electrodes are still green or yellow, reposition them if necessary

d. when satisfied, press “close” the impedance test

e. to go back to the recording window, go under “View” and choose “ICU”

29. To stop the recording, click on exit

30. The window asking to choose patient will open again

31. If the patient go for a test

a. let the machine on this window during the test

b. remove electrodes (if necessary)

c. then click on “last Patient” to resume the recording after an interruption

d. replace electrodes

Note: You will have to reconnect the patient as per all the steps described above.

32. If the patient does not need anymore recording

a. remove electrodes

b. press exit from that window

c. choose “shut down the computer” and the computer will be turned off.

33. Clean the scalp after.

Risk of Complication:[Delete explanatory text then click here to enter content] Include infection control measures, assessment



parameters, intervention, monitoring and elements of emergency care, patient teaching and discharge planning.

Medications: No medications are required

Main author: Linda Morneault NNP Pia Wintermark MD

4. EXAMPLES

aEEG background activity:

1. Normal tracing

a. Lower margin > 5 µV

b. Upper margin > 10 µV

c. Widening and narrowing of the trace within the above margins (Sleep Wake Cycling, SWC), variation from approximately 10-40 µV

i. Trace wider during quiet sleep

ii. Trace narrower in active sleep or when awake

2. Moderately abnormal function

a. Lower margin < 5 µV

b. Upper margin > 10 µV

c. No sleep wake cycling

Corresponds to discontinuous voltage on standard EEG

3. Severely abnormal function

a. Lower margin < 5 µV

b. Upper margin < 10 µV

c. No sleep wake cycling

d. Periodic bursts of higher voltage electrical activity (spikes)

Corresponds with burst suppression or continuous low voltage on standard EEG



Seizure activity on aEEG:

Sudden rise and narrowing pattern in the CFM tracing (prolonged periods of sudden elevation in both the lower and upper margins)

suspicion of seizures (increase in EEG voltage?)

Look at EEG tracing in the gaps of the rising and narrowing: if distinct repetitive spike and wave discharge pattern on EEG tracing diagnosis of seizures

The trace returns to the previous appearance on CFM tracing when seizure activity stops

Seizures may only be identified if sufficiently prolonged (more than 2-3 min) shorter lasting discharges may be missed since the CFM is recorded at a very slow speed

Note: difficult to distinguish burst suppression from brief seizures in a severely abnormal trace the distinction can be made by inspecting the underlying EEG

Note: difficult to comment on CFM background amplitude if very frequent seizures



7. REFERENCES

AL NAQEEB N, EDWARDS AD, COWAN FM, AZZOPARDI D. ASSESSMENT OF NEONATAL ENCEPHALOPATHY BY AMPLITUDE-INTEGRATED ELECTROENCEPHALOGRAPHY. PEDIATRICS 1999; 103:1263-1271.

DE VRIES LS, HELLSTROM-WESTAS L. ROLE OF CEREBRAL FUNCTION MONITORING IN THE NEWBORN. ARCH DIS CHILD FETAL NEONATAL ED 2005; 90:F201-207.

GLUCKMAN PD, WYATT JS, AZZOPARDI D, BALLARD R, EDWARDS AD, FERRIERO DM, POLIN RA, ROBERTSON CM, THORESEN M, WHITELAW A, GUNN AJ. SELECTIVE HEAD COOLING MITH MILD SYSTEMIC HYPOTHERMIA AFTER NEONATAL ENCEPHALOPATHY: MULTICENTRE RANDOMISED TRIAL. LANCET 2005;365:663-670.

THORESEN M, HELLSTROM-WESTAS L, LIU X, DE VRIES LS. EFFECT OF HYPOTHERMIA ON AMPLITUDE-INTEGRATED ELECTROENCEPHALOGRAM IN INFANTS WITH ASPHYXIA. PEDIATRICS 2010; 126:131-139.

TOET MC, LEMMERS PMA. BRAIN MONITORING IN NEONATES. EARLY HUMAN DEVELOPMENTAL 2009;85:77-84.

C3 C4

P4 P3

R

G

75 mm

75 mm 25 mm tragus tragus

vertex

nose

6 needle electrodes

“NICU” set-up

P4 P3

R

G

75 mm

75 mm 25 mm tragus tragus

vertex

nose

4 needle electrodes

“NICU P3P4” set-up

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