neuro-monitoring in the nicu: aeeg /eeg in term and ......neuro-monitoring in the nicu: aeeg /eeg in...

Neuro-monitoring in the NICU: aEEG/EEG in Term and Preterm Neonates

Sonia L. Bonifacio MD / Susan Peloquin RN, MS, CN-IV

November 1, 2014 1

Sonia Bonifacio, MDSusan Peloquin, PNP

November 2014

Department of Pediatrics


VON Annual Quality Meeting 2014

Disclosures

Sonia Bonifacio

• Content Expert for VON Brainshapers NICQ Next Homeroom

Susan Peloquin

• No conflicts to disclose

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3

Objectives

1. Identify the population of neonates at risk for seizure using

the ACNS guidelines, improve identification of electrographic

seizures using aEEG, describe process of evaluation of

aEEG at the bedside over time

2. Describe potential barriers with using aEEG as a bedside

tool that may inhibit practice changes

3. Discuss the critical role of the bedside nurse in application

and interpretation of aEEG and role in alerting staff of

findings

Use of Brain Monitoring – VVV

• Insert Chapter 2

– 00:00:15 to 00:00:52

– 00:01:29 to 00:04:43

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Role of Brain Monitoring in the NICU

Monitoring allows us to answer these questions:

• Has this child suffered brain injury?

• How is the brain adapting to illness?

• Is further neurologic evaluation needed?

• Is the baby having seizures?

• When and how long should we treat with AEDs?

Monitoring – Seizure Detection & Treatment

• Clinical detection of seizures in neonates is not reliable

– Physicians and nurses cannot distinguish clinical seizures from non-seizure events

– Seizures are often electrographic only and without obvious clinical manifestation

– Electroclinical dissociation (i.e. EEG seizures without clinical correlate) is especially common after therapy

• Potential Best Practice - Treatment should be guided by results of monitoring and not our best guess

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Malone, Epilepsia 2009Clancy, et al. Epilepsia. 1988Scher, et al. Pediatrics. 1993Scher, et al. Pediatric Neurology. 2003



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Why is Seizure Detection Important?

• Seizures likely contribute to brain injury and may impact brain

development and influence development of epilepsy

• Phenobarbital is first line treatment but also associated with

apoptosis in animal models

• Monitoring improves our diagnostic accuracy before treatment

– avoid over treatment of paroxysmal movements that are not

seizures

• Monitoring improves treatment and reduces seizure burden

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Indications for monitoring

1. Differential diagnosis of paroxysmal events

2.To judge the severity of encephalopathy

3. Detect EEG seizures in selected high-risk populations (table)

Shellhaas R et al, J Clin Neurophysiol 2011

Clinical Scenarios With High Risk of Seizures• Term neonates

– Acute encephalopathy – perinatal asphyxia, post CPR

– Cardiac & pulmonary illness with risk of acute brain injury

• PPHN, ECMO, cardiac surgery requiring bypass

– CNS infection & trauma

– Inborn errors of metabolism

– Perinatal stroke

– Sinovenous thrombosis

• Preterm neonates

– With acute high grade hemorrhage or encephalopathy

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Shellhaas R et al, J Clin Neurophysiol 2011

Who & How Long to Monitor

Recommendations from the American Clinical Neurophysiology Society • Monitor those at risk of seizure or those who are suspected of

having seizures

• Minimum of 24 hours or until

• 3-4 spells (seizures) are captured

• If no seizures identified and the EEG background is stable, then can stop after 24 hours of monitoring

Shellhass R, et al. J Clin Neurophysiol 2011

Amplitude Integrated EEG (aEEG)

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Pro• Apply & interpret at

bedside• Track trendsCon• Lower sensitivity

and specificity for seizure detection

P3 P4 Filter, rectify, smooth, compress, amplitude-integrate

15 seconds

Conventional Video-EEG

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Pro• Gold standard for seizure detection

- More leads (better coverage, artifact- Video

Con• Trained technician• Experienced reader

International 10-20 System adapted for

newborns



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Bedside nurse applies aEEG leads

Nursing staff• Review and document background pattern• Screen for seizures and notify physicians

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Technician applies full EEG montage

aEEG Seizure Detection• Seizures may be detected as a sharp rise in upper

and lower margins of tracing

• Correlated with raw EEG trace

• Raw EEG should show gradual build-up and then decline (aka ‘evolve’) in frequency and amplitude and last >10 seconds.

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L S de Vries and L Hellstrom-Westas. Role of cerebral function monitoring in the newborn 2005 Arch. Dis. Child. Fetal Neonatal Ed.

Lower Margin

Upper Margin

* * *

* Seizures

*

Status Epilepticus – Saw-tooth Pattern

Subclinical Status Epilepticus



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Varied Appearance of Seizures

• Term baby readmitted on DOL#8 for lethargy, apneas, progressive encephalopathy (HSV)

• Difficult to see the background pattern

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• 35 weeks, vasa previa, hypoglycemia

• Within 6 hours had multiple episodes of apnea without bradycardia

• Neuro exam –‘appropriate for age, no asymmetry’

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Apnea


• Seizures treated and background aEEG pattern emerges

• Stroke on MRI

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Change in background after meds given

Seizures in the setting of a very abnormal background (emerged from Flat Trace) ** *

Limitations

• Seizures are harder to detect if they are:

• Brief

• Infrequent

• Low amplitude

• Very focal

• Distal from recording electrodes

• Interpretation is aided by analysis of the “raw” EEG

• Experience counts!

Hellstrom-Westas L. Acta Paediatr 1992Toet MC. Pediatrics 2002

Rennie JM. Arch Dis Child Fetal Neonatal Ed 2004Shellhaas et al. Pediatrics 2008

Shah et al. Pediatrics 2008

Common Pitfalls

• Artifacts

- EKG

- Hand ventilation

- Patting

- Sucking

- HFOV

- Vent/ECMO tubing

• High amplitude background – caution may be seizures

HFOV Artifact



November 1, 2014 5

High Amplitude Background - Seizures

• Can be misinterpreted as Continuous Normal Voltage or technical problem leading to delay in diagnosis

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Initially thought to be artifact and leads replaced multiple times; later thought

to maybe be CNV

Look at Upper and Lower margins –both higher thanexpected for CNV

Vein of Galen Malformation

• Term infant

• Critically ill

• Abnormal mental status

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Medical Illness & Neurologic Compromise

Term infant with large hemangioma on chest

- Kaposiform Hemangioendothelioma with Kasabach-Merritt

- On MRI for hemangioma, brain injury identified

- Abnormal mental status – seizures

Preterm – Monitored for Critical Illness

• Rh Isoimmunization

• Developed Status Epilepticus

• HUS identified new grade III IVH

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Preterm Infant – Placental Abruption

• 25 5/7 weeks, 933 grams, Apgar 8, 8, vigorous

• Initial Hct 37% ->33% -> transfused

• New metabolic acidosis; code event, Hct down to 10%

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Monitoring – Review Process

• Neonatal team reviews aEEG at 20 min, 40 min and at 1hour after recording initiated

– Review background pattern

– Look for seizures or EEG correlate of suspicious clinical activity

– Frequency of review dependent on seizures or risk of seizures

• If video-EEG also initiated – reviewed after 1 hour of recording by neurophysiology service

• If seizures are identified

– Treat per institutional guidelines

– Review closely after AED administered – electro-clinical dissociation, change in background

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aEEG Barriers to Implementation

• Knowledge

– Nursing and medical staff need basic training in application and interpretation

– Seizures are not all the same – there is variation

– aEEG is a bedside monitor not the gold standard but it likely better than best guess

• Staff

– Can not be one person in unit with knowledge of aEEG

– Train a group

• Support

– Child Neurology/Neurophysiology

– Need assistance in responding to seizures

– Status Epilepticus – emergency31

Quality Improvement

• Seizures in HIE pre-monitoring vs. monitoring era

– Lower seizure burden in those treated with hypothermia

– Length of stay decreased for survivors – 4 fewer days

– Decreased cumulative phenobarbital in those with seizures related to monitoring - 28mg/kg less (95% CI 12 to 45 mg/kg)*

– Monitoring and care by NICN service allowed for better identification of which neonates to treat and gave confidence to providers to stop treatment

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Orbach S, et al. PAS 2013; Accepted to J Child Neurology

*Adjusted for seizure burden; P<0.01

Importance of Monitoring to Parents & Improving Care for All

• Insert Chapter 2

– 00:06:10 to 00:07:12

– 00:09:40 to 00:10:30

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Standardization, Role of Nurse, Process & Teamwork, Guidelines

• Chapter 4

– 00:00:13 to 00:02:30

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Critical Role of the NurseMinimize Brain Injury & Optimizing Neurodevelopment

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Nursing ObjectivesDescribe and Discuss:

• Potential nursing barriers with using aEEG

– Knowledge

– Staffing

– Support

– Teamwork

• Critical Role of the bedside nurse

– Application of leads

– Operating aEEG machine

– Recognizing aEEG patterns

– Integrating monitoring into care

– Communicating findings to medical team

– Collaborating with the team

• 36



November 1, 2014 7

Potential Nursing BarriersKnowledge

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Potential Nursing BarriersStaffing

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Potential Nursing BarriersSupport

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Potential Nursing BarriersTeamwork

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Critical Role of the Bedside Nurse – Application of leads

– Operating aEEG machine

– Recognizing aEEG patterns

– Integrating monitoring at the bedside

– Communicating and collaborating

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Critical Role of the Bedside RNLead Application

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wwwrhythmlink.com

www.natus.com

Imimed.jp



November 1, 2014 8

Critical Role of the Bedside RNLead Application

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Critical Role of the Bedside RN Operating the aEEG Machine

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Critical Role of the RN aEEG interpretation

• Maturation

• Classification

• Effects of Medication

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www.nature.com

www.perinatology.com

Critical Role of the Bedside RNaEEG Interpretation

Critical Role of the Bedside RNIntegrating Monitoring into Care

• Knowledge of:

– Importance of timely monitoring

– Risk factors for secondary brain injury

– Effects of medications and treatment on aEEG tracings

– Risk factors for seizures

– Assessment of clinical and electrographic seizures

– Typical AED’s used

• Anticipate medications for seizures

• Skin issues with leads

• Troubleshooting aEEG

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Critical Role of the RNIntegrating Monitoring at the Bedside

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November 1, 2014 9

Critical Role of the RNIntegrating Monitoring at the Bedside

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www.dailymail.co.uk

Communicating and CollaboratingMedical Team

• Confirm suspicious pattern

• Discuss with medical team

• Treatment

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www.commons.wikimedia.org

aEEG TracingInitially Applied

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aEEG TracingInitially Applied

• When aEEG is 1st applied

– Missed Seizure

• Best practice

– Review after 20 minutes

– Seek colleague for review

• Best Practice

– Anticipate medications

– Medication preparation

– Administration of medications

– Monitoring of seizures and effects of AED(s)

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aEEG TracingSeizures are Identified

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aEEG TracingStatus Epilepticus

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aEEG TracingSE

• Status Epilepticus

• Best Practice

– Assess for clinical correlate

– Get help if needed

– Notify provider immediately

– Anticipate medications

– Administer medications

– Notify neurology

– Apply (c) EEG

– Document

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aEEG TracingCommunication and Collaboration

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aEEG TracingCommunication and Collaboration

• Initial change in pattern

• If 1st one was missed, high suspicion of 2nd

• Notify medical provider

• Notify neurology

• Anticipate medications

• Observe for effects of medications

– Seizures extinguished or not

– Pattern changes as a result of AED

• Document

• 57

aEEG TracingCommunicating and Collaborating

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Critical Role of the Bedside Nurse

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Preventing Brain Injury Optimizing Development

Summary

• Brain monitoring is the best way to accurately identify seizures

• PBP – seizure treatment should be guided by results of

monitoring and not our best guess

• Seizures may have a varied appearance but all have common

features

• Seizures may be observed in all types of aEEG background

patterns

• Bedside nurses play a critical role in application, interpretation,

communication of aEEG

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Links to VON Resources

• Please add links to VVV

• Please add links to NICQpedia

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