Brain monitoring in the neonate - Brainz BRM aEEG

Indications

The following infants should be considered for Brainz BRM monitoring.

Infants ≥34/40 with:

• Definite or questionable seizures

• Muscle relaxed infants at risk of seizures that may not be clinically apparent

• Perinatal asphyxia (neonatal encephalopathy)

• Unexplained apnoea 

Monitoring should not be commenced unless directed by a doctor/NS-ANP.

Application

Electrodes to be applied by Newborn Services medical and nursing staff who have undertaken BrainZ BRM training.

Equipment required:

• BrainZ sensor set

• BrainZ sensor positioning strip

• Marker pen

• Skin prep gel (NuPrep®)

• Wrap hat

• Water / gauze/ cotton tips 

There are two electrode options available, hydrogel and sub-dermal needle electrodes.

Hydrogel Electrode Placement

1	• Position infant supine • Ensure head is clean • Place the wrap hat under the baby's head
2	Use the sensor positioning strip to identify location for the EEG electrodes. Position the strip vertical and parallel to the baby's face. Align so the letter (A-H) at the saggital suture is the same letter at the tragus
3	Use a marker pen, mark the two sensor sites at the ends of the arrows Note: DO NOT shave these placement marks
4	• Using sterile water and gauze, part the hair vertically at the mark • Pat dry with gauze keeping hair parted
5	Clean the parted line • Place a very small amount of preparation gel (NuPrep®) on a cotton tip. • Using an up and down action clean the parted line with NuPrep®. Hold the skin taut as you clean. • Using gauze and water clean off the NuPrep®; work outwards from the centre to maintain the parting. • Pat dry the area.
6	Site electrodes in the following manner. Apply the sensors directly over the cleaned spot, with the sensor wires directed to the top of the head. Ensure electrodes do not touch each other. Electrodes should be 5-8mm apart and paralleled to each other. Once applied, pat around edge of electrodes with a cotton wool swab
7	Turn infants head over and repeat procedure.
8	Site reference electrode • Select a site with no hair on or near the shoulder • Note the same cleaning process is required • Site electrode with lead directing towards the head
9	Plug into the data acquisition unit (DAU) •  Left anterior lead into C3 • Right anterior lead into C4 • Left posterior lead into P3 • Right posterior into P4
10	Check electrode signal quality, once green apply wrap hat with adequate tension to support electrodes
11	Note: If electrodes lift, reapply using a drop of sterile water. If not adequate, remove electrode, repeat cleaning process and replace. Do Not stop the machine. Continue monitoring, mark event.

Sub-dermal Needle Electrode Placement

1	• Position infant supine • Ensure head is clean • Place the wrap hat under the baby's head
2	Use the sensor positioning strip to identify location for the EEG electrodes. Position the strip vertical and parallel to the baby's face. Align so the letter (A-H) at the saggital suture is the same letter at the tragus
3	Use a marker pen, mark the two sensor sites at the ends of the arrows Note: DO NOT shave these insertion marks
4	Using gauze and cleaning solution appropriate for gestation age clean the insertion sites. • This is important to help the tape to adhere. • It may help to create a vertical part in the hair.
5	Site electrodes in the following manner. Hold skin taut Insert a needle electrode subdermally at insertion sites. Leads are directed to the top of the head Ensure all metal is under the dermal layer Secure electrode with a thin strip of hypafix tape under and over the needle (cross over method). Then place one strip across the top. Ensure tape is positioned so as not to completely obscure all the black area of the plastic sheath; this is important so that you can visualise whether the needle is becoming dislodged.
6	Turn infants head over and repeat procedure.
7	Site reference electrode • Select a site with no hair on or near the shoulder • Clean the area with water and gauze • Using cotton tips clean the area with a very small amount of NuPrep® • Using water and gauze clean of the NuPrep® • Site electrode with lead directed towards the head
8	Check electrode signal quality, once green apply wrap hat with adequate tension to support electrodes.
9	To prevent needle dislodgement and minimise motion artefact Loop sensor wires into two bundles and place near head of bed. (One bundle for the right electrodes and one for the left)
10	• Electrode sites must be checked with all cares for signs of infection and displacement. • Ensure all metal is under the dermal layer
	Note: To prevent likelihood of needle stick injury always check impedance signal before removing wrap hat or touching head.If at any stage the impedance colour turns amber or red, the needle is likely to be dislodged. Remove wrap hat with care NB. Needles can remain insitu for duration of monitoring but if dislodged, replace with new one.

Reporting

As a minimum the trace should be reviewed as part of the daily ward round. This needs to be documented on the sticker (stored on the machine) and shall be added to the clinical record. Additional reviews and reporting will occur as required and be documented in the clinical record.

Documentation

1. Document the time monitoring commenced on the infants observation chart

2. Document use of low impedance needles or hydrogel sensors

3. When using needle electrodes document that the site and needle position has been checked (with cares)

4. Document if needles or hydrogel sensors are replaced

Commence Assessment (CFM Natus Monitor)

1	Plug monitor into wall power supply.
2	Turn on the AC power switch (at back of monitor).
3	Touch the record button
4	Enter patient details, then press next
5	Select 5-electrode configuration
6	Press "Start Recording".
7	Select the Impedance selector button to check sensors	Electrode impedance figure will appear The top 2 electrode correspond to the left hand electrodes, bottom 2 to the right) OK (Green) = values <10 kO Marginal (Amber) = 10 - 20 kO Extremely poor (Red) = > 20 kO
8	Once impedance is satisfactory press EEG button to give you real time monitoring.
9	Press 2 channel aEEG seletor Icon

Mark events

During monitoring Mark events i.e. suctioning, cares, observation of seizure-like movements, administration of anticonvulsants

1. Select "markers" icon (bottom of screen)

2. Press one of the predefined events or type in event, then press add

3. Press home
   

   

4. A green line will appear on the aEEG graphics. To recall the event data touch screen above red marker line

Suspend and resume monitoring

1. Press "Record" button to stop recording.
   

   

2. Press "Stop recording"

3. The session is now suspended

4. To resume monitoring press "Record" button

5. Press "Resume Recording"

Turn monitor off

1. Press "Record" button to stop recording.

2. Press "Stop recording"

3. Press "Patient/Close" overlay, and press close session

4. Press "Tools" overlay, and press system

5. Press "Shut down"

Commence Assessment (BRM3 Monitor)

1. Plug monitor into wall power supply.

2. Turn on the AC power switch (at back of monitor).

3. On main menu screen touch the 'assess patient' button to display the new patient screen.

4. Touch the white field next to display the on-screen keypad.

5. Typing the appropriate data, touch enter at the end of each entry.

6. Touch the appropriate check box to select the gender.

7. Use arrows to adjust birth weight / current weight.

8. Touch appropriate date on calendar to enter birth date.

9. Patient name, NHI, and clinicians initials must be entered before assessment can commence.

10. Once assessment has commenced you can return to this page to complete if required

    1. press tools

    2. patient details

    3. enter any additional patient details (as above)

Check Contact Quality 

Contact impedance is displayed on the 'signal status screen'.

1. On main menu screen touch the 'check signal' button.

2. All 4 dots displayed on the graphics should be green.

3. If dots are yellow or red check the corresponding electrode.

4. Once all dots are green press the 'OK' button.

Mark events

During monitoring Mark events i.e. suctioning, cares, observation of seizure-like movements, administration of anticonvulsants

1. Touch 'mark events' button.

2. Touch white description area to display the onscreen keypad.

3. Enter a brief note.

4. Touch enter, then OK.

5. A green line and number will appear on the aEEG graphics. To recall the event data touch the green line on the screen.

Suspend monitoring

1. Press stop.

2. On confirmation screen, press suspend

3. Disconnect electrodes / cable from DAU (as required)

4. When ready to recommence, plug cable back into DAU and press resume assessment

Turn monitor off

1. On main menu screen touch 'shutdown' button.

2. On confirmation screen touch yes.

3. Once screen says shutdown complete, turn AC power off.

4. Remove sensors by dampening the gel with water.