7 Simple Steps to Assess & Document any Neonatal aEEG · 7 Simple Steps to Assess & Document any...

7 Simple Steps to Assess & Document any Neonatal aEEG

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How to use the

Seven Simple Steps Checklist

Hi!

It’s Kathi Randall here – Your aEEG coach. I’m so excited to share this new e-work

book with you.

Feel free to print the checklist on the next page and use as a guide the next time you

are standing in front of your aEEG monitor or need to write up a summary of aEEG to

include in your progress note.

If you’d like more details about each of the seven steps in my method for assessing

neonatal aEEG, read on in this workbook or join me for a free upcoming live training.

To be registered for the next online course go to www.aEEGcoach.com

I promise after reading this or watching the video you will feel confident to assess

any neonatal aEEG.

Enjoy,

Kathi Salley Randall, RNC MSN CNS NNP

Owner of www.aEEGcoach.com Contents:

7 Step Checklist .......... .....

Story ................................. ..... Page 3

Signal Quality ................ ..... Page 4

Shape & Voltage ......... ..... Page 5

Sleep ................................ ..... Page 7

Symmetry ...................... ..... Page 8

Suspicious Areas ........ ..... Page 9

Stability ............................ ...... Page 10

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http://www.aeegcoach.com/


The 7 Step Checklist for Complete

aEEG Review & Documentation

STEP 1: Describe the background Story or Infant History

_______________________________________________________________________________

STEP 2: Evaluate the Sensors and Signal Quality

How well are the sensors attached? _____________________________________________

How low are the Impedance values? ____________________________________________

STEP 3: Classify the Shape of the aEEG Waveform using Pattern Descriptions or Voltage:

Continuous Normal Voltage (Min > 5, Max > 10)

Discontinuous Normal Voltage (Min < 5, Max > 10)

Burst Suppression (Min < 5 with no variability, Max >10 with hi-voltage bursts)

Continuous Low Voltage ( Min < 5, Max < 10)

Inactive ( Min and Max < 5)

STEP 4: Identify Sleep-Wake Cycling on the aEEG ( Describe as: Present, Absent, Regular, Interrupted)

_______________________________________________________________________________

STEP 5: Evaluate the aEEG pattern for Symmetry (if more than 1 channel is available for comparison)

_______________________________________________________________________________

STEP 6: Identify Suspicious Areas and examine EEG closely. Be sure to look for:

Evidence of EEG Seizure Activity (spike-wave, repetitive patterns on the EEG)

Marked Events on the tracing may contain valuable clinical notes (medications given, infant activity)

Artifacts within the EEG signal (look for EKG, respiratory, movement, EMG)

STEP 7: Describe the Stability (or long term trend) of the aEEG pattern. Consider the last shift,

hour, or day: _________________________________________________________________________________________

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Consider the Infant’s Story

Before you assess the aEEG tracing itself, stop and think about why you have

decided to put the monitor on this baby.

What information are you seeking

Are you hoping to identify electrographic and sub-clinical seizures?

Are you using the aEEG to manage anti-epileptic medication dosage?

Are you screening the infant to determine if he/she is eligible for hypothermia

treatment?

Are you using the aEEG to trend the baby’s background brain activity over a few days to

determine the severity of injury or watch the recovery of injury?

Consider the Infant’s Birth, Labor, and Prenatal history

Take the Physical & Neurological Exam in to account:

What is the condition of the scalp?

Is there evidence of trauma on the scalp?

Does the infant show evidence of encephalopathy?

Are there tone issues?

Sudden episodes of vital sign instability that make you think seizure?

Medications

Has the baby received any anti-convulsant medications?

When was the last dose of sedation and analgesics?

Is the baby chemically paralyzed?

What medications were given during delivery? Before admission? On transport?

Age

Gestational age and corrected age both impact EEG and aEEG waveforms.


At all costs, avoid high impedance values

Before you go any further, do you have a quality tracing?

If the aEEG recording you are about to assess has high impedance, then

stop here. Only spend your time analyzing aEEG tracings that have

acceptable impedance levels.

Have you felt like this when you step up to your aEEG monitor??

Train everyone to read the impedance

graphs.

Have you ever walked up to the aEEG monitor

after several hours of monitoring and found

that there is not even one minute of quality

tracing to review?? To avoid this frustration,

you must make sure that everyone on the

team knows how to identify when the monitor

impedance levels are increasing and when

they must be addressed.

The two most common causes of sensors not sticking

(and then getting high impedance levels) are ….

#1: Inadequate skin exfoliation before placing the sensors and

#2: Just too much hair!!


Rate the Shape & Voltage of the aEEG

The whole reason you decided to monitor a baby with your aEEG monitor is to

determine if the tracing you see reflects normal or abnormal brain activity.

In order to know this, you must, assess the actual aEEG waveform that appears on

your screen.

There are a few different approaches that you can take.

By far the simplest way to assess the aEEG is using standard voltage definitions on the next page. To determine the aEEG voltage just trace the top and bottom margins of the aEEG using your eyes. This tells you the maximum and minimum voltage.

The second option is to compare the shape of the pattern with standard patterns described in journal articles and books. There are only five basic shapes. (I’ve included four shapes below).

Or you can use a combination of both the voltage and shape. (This is by far the most popular way in the literature today).

The most common aEEG patterns– Compare the shapes!

After you have examined the shape and the voltage of the

aEEG waveform, you will need to assign it a name.

Continuous

Normal Voltage

Burst

Suppression Inactive

Discontinuous

Normal Voltage


Just like a judge at a sporting event, you will need to judge the

aEEG’s form (the shape) and performance (the voltage).

Below, are the standard definitions used today to describe the

most common Neonatal aEEG Patterns (Using both shape and voltage which is now the most popular method):

Continuous Normal Voltage – A narrow band with minimum voltage above 5

microvolts. Maximum voltage above 10.

Discontinuous Normal Voltage – A moderately wide band. Minimum voltage below 5 microvolts, but variable. Maximum voltage above 10.

Burst Suppression – An extremely wide band with maximum and minimum

voltages both very low and very high, and without variability to the lower margin.

Continuous Low Voltage – A narrow band with the maximum and minimum

voltages below 10 microvolts (not shown below).

Inactive – A very narrow band with all activity below 5 microvolts


Look for Sleep-Wake Cycling

While we can look at an infant and

determine if they are asleep or awake, we

know very little about the quality of their

sleep by just looking at them.

Sleep-wake cycling can be seen on aEEG

even in extremely premature infants (as

young as 28-30 weeks). Sleep-wake cycling

becomes more organized and well defined

as the infant matures.

A mature sleep-wake pattern lasts for

approximately 20-40 minutes (if not

interrupted) and has a smooth entry and

exit. (I’ll be showing examples of this during

the live training on July 27 – be sure you are

registered at www.aEEGcoach.com)

For infants with HIE, the presence and onset

of sleep-wake patterns on aEEG during the first

three days of life has been shown to be very

highly predictive of long-term

neurodevelopmental outcome.


Symmetry of the aEEG – The blessing & curse

Many new aEEG monitors give you the ability to apply more than one pair of sensors to the

baby’s head (this is the curse – you have to actually apply more sensors to the baby). But, here

is the blessing, the extra sensors allow you to compare the electrical signal from each

hemisphere of the brain.

To assess for symmetry apply more than one pair of electrodes. You must apply

one pair of sensors to each side of the baby’s head. Each electrode pair will collect and display

one channel of EEG signal. Each channel of EEG will become its own separate aEEG waveform.

Assess each aEEG pattern separately. Evaluate the shape and voltage of each of the

aEEG patterns (just like in STEP 3) and then compare them.

Are the patterns similar or different? If asymmetries are present, then the infant may

have a unilateral or focal ischemic injury. You may also be able to see that seizures arise more

from one hemisphere than the other.

LEFT SIDE

RIGHT SIDE


Suspicious Areas on the aEEG

Is that a seizure?

Any suspicious areas along the aEGG should be examined more closely. Focus on the following three

areas during your detailed review of any suspicious areas of aEEG.

EEG – Electrographic seizures have been defined as repetitive,

spike-wave patterns which repeat for more than 10 seconds.

The sample EEG recording on the right shows one channel of

EEG with seizures and one channel without.

Marked Events – Review any marked/flagged events that have

been documented on the monitor. Staff often provide vital clues that

can explain changes seen in the aEEG.

Events that might be marked include:

Hands-on care and suctioning

Changes in vitals like apnea, bradycardia, desaturations,

Clinical seizure movements,

Crying and patting to console,

Medications given

Ventilator changes

Artifacts – Artifacts can obscure your raw EEG making it very difficult to see any true patterns. The

sample EEG recording to the right show a “fuzzy” artifact throughout this tracing and caused a drastic

shift in the aEEG baseline that looked like a seizure. Another common pitfall is that artifacts can cause a

“drift” to the lower margin of the aEEG giving the impression that the infant’s minimum baseline activity

is better than it is in reality. You must always be on the lookout for

artifacts.

Artifacts may be caused by:

movement

EMG (muscle-nerve activity

Ventilators pulsations, especially high frequency oscillating

ventilators,

EKG breaking through the EEG.

Remember, that the only way to know if a suspicious area on the aEEG is really

being caused by a seizure is to open up the original EEG and check it out.


The power of the aEEG is in the long term trend

In order to see the trends emerge, you really should be

looking at the aEEG every few hours: It is fascinating to observe

changes in the aEEG trend from hour to hour, shift to shift, and day to

day. Especially in combination with other changes in the infant’s clinical

picture.

The first 6 hours: The aEEG has been shown to be very predictive of

long term neurodevelopmental outcomes in infants who have

experienced perinatal crisis and who demonstrate evidence of hypoxic-

ischemic encephalopathy. (See E. Spitzmiller Meta-Analysis)

Keep the aEEG on for long periods of time: You will gain

additional prognostic value by reviewing trends over long periods of time

(I’m talking days, not just hours).

Improving aEEG is a good thing.

An aEEG trend that improves within the first 36 hours

after a hypoxic event at birth is very reasurring. Also,

there is strong positive predictive value for the timing of

onset of sleep-wake cycling during this early time

period (with or without therapeutic hypothermia).

Remember, sleep wake cycling is much easier to

discover using aEEG than traditional EEG recordings.

Worsening or no change in the aEEG is a bad thing.

Many infants with HIE at birth will display an abnormal aEEG. If the

aEEG trend does not improve within the first three days after birth

is worrisome and has been shown to be highly predictive of poor

long term outcome in a number of studies. (To see more examples,

join my next online training – go to: www.aEEGcoach.com)


Bibliography

1. al Naqeeb N, Edwards AD, Cowan FM, Azzopardi D. Assessment of neonatal encephalopathy by amplitude-integrated electroencephalography. Pediatrics. 1999;103(6 Pt 1):1263-71.

2. de Vries LS, Toet MC. Amplitude Integrated Electroencephalography in the Full-Term Newborn. Clin Perinatol. 2006 Sep;33(3):619-32.

3. de Vries LS, Hellstrom-Westas L. Role of cerebral function monitoring in the newborn. Arch Dis Child Fetal Neonatal Ed. 2005; 90:F201–F207.

4. Hellstrom-Westas, L. Continuous electroencephalography monitoring of the preterm infant. Clinics in Perinatology. 2006 Sep;33(3):633-647.

5. Hellstrom-Westas L, de Vries LS, Rosen I. Atlas of amplitude-integrated EEGs in the newborn. 2nd ed. London: Informa Healthcare; c2008. 183 p

6. Hellstrom-Westas L, Rosen I, Svenningsen NW. Predictive value of early continuous amplitude integrated EEG recordings on outcome after severe birth asphyxia in full term infants. Arch Dis Child Fetal Neonatal Ed. 1995;72(1):F34-8.

7. Hellstrom-Westas L, Rosen I, de Vries LS & Greisen G. Amplitude-integrated EEG classification and interpretation in preterm and term infants. NeoReviews. 2007;7(2):76–86.

8. Lavery, S, Randall K. Minding the baby’s brain: cerebral monitoring of the term infant.

Neonatal Netw, 2006 Sep/Oct;27(5):329-37. 9. Lavery S, Shah DK, Hunt RW, Filan PM, Doyle LW, Inder TE. (2008). Single versus

bihemispheric amplitude-integrated electroencephalography in relation to cerebral injury and outcome in the term encephalopathic infant. Journal of Paediatrics and Child Health. 2008;44:285–290.

10. Spitzmiller RE, Phillips T, Meinzer-Derr J, Hoath SB. Amplitude-Integrated EEG is useful in predicting neurodevelopmental outcome in full-term infants with hypoxic-ischemic encephalopathy: A meta-analysis. J Child Neurol. 2007;22(9):1069-78.

11. ter Horst HJ, Sommer C, Bergman KA, Fock JM, van Weerden TW, Bos AF. Prognostic significance of amplitude-integrated EEG during the first 72 hours after birth in severely asphyxiated neonates. Ped Research. 2006;55(6):1026-33.

12. Toet MC, Hellstrom-Westas L, Groenendaal F, Eken P, de Vries LS. Amplitude integrated EEG 3 and 6 hours after birth in full term neonates with hypoxic-ischaemic encephalopathy. Arch Dis Child Fetal Neonatal Ed. 1999;81(1):F19-23.

13. Toet, MC, van Rooij LG, de Vries, LS. The use of amplitude integrated electroencephalography for assessing neonatal neurologic injury. Clin in Perinatol. 2008 Dec; 35(4):665-78.

14. Toet MC, van der Meij W, de Vries LS, Uiterwaal CS, van Huffelen KC. Comparison between simultaneously recorded amplitude integrated electroencephalogram (cerebral function monitor) and standard electroencephalogram in neonates. Pediatrics. 2002;109(5):772-9.

15. van Rooij LG, Toet MC, Osredkar D, van Huffelen AC, Groenendaal F, de Vries LS. Recovery of amplitude integrated electroencephalographic background patterns within 24 hours of perinatal asphyxia. Arch Dis Child. Fetal Neonatal Ed. 2005;90(3):F245-51 .

16. Whitelaw A, White RD. Training Neonatal Staff in Recording and Reporting Continuous Electroencephalography. Clin in Perinatol. 2006 September;33(3):667-77.


Nurse Kathi– Your aEEG Coach

Kathi was first introduced to aEEG in 2004 and was responsible for creating the first clinically‐based education program for aEEG monitoring in North America. For nearly 5 years Kathi and her team of Clinical Educators conducted on‐site education and training on neonatal aEEG monitoring with the primary goal of empowering staff to integrate aEEG monitoring into daily NICU practice.

Kathi is an international clinical educator known for programs which are tailored to those with varying levels of experience. Her passion extends beyond aEEG to all topics related to

neonatal neurology, and is available for on-site lectures and consultations.

Kathi has been a neonatal nurse since 1994 and a board‐certified NNP since 2006. She is a California native and resides in Southern California near her family. Kathi is an avid hiker, traveler and dog lover.

Kathi Salley Randall, RNC, MSN, CNS, NNP‐BC Email: [email protected]

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