aEEG – Mystery Solved - Florida Association of Neonatal Nurse

Transcription

FANNP 23RD NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
A12b
aEEG – Mystery Solved
Michael D. Weiss, MD
Associate Professor
University of Florida, Gainesville, FL
The speaker has signed a disclosure form and indicated he has no significant financial interest or relationship with companies or the
manufacturer(s) of any commercial product/service that will be discussed as part of this presentation.
Session Summary
This presentation will provide an overview of the basic patterns of aEEG. The strengths and limitations of
monitoring will be addressed. The lecture will conclude with several practice strips.
Session Objectives
Upon completion of this presentation, the participant will:
 understand the principles of aEEG;
 understand the basics of pattern recognition and how it changes with different gestational ages;
 understand how the aEEG relates to HIE;
 have information on aEEG and seizures.
References
Bisson, J. & Younker, J. (2006). Correcting arterial blood gases for temperature: (When) is it clinically significant? Nursing Critical
Care, 11(5): 232-8.
Delhaye, C., Mahmoudi, M. & Waksman, R. Hypothermia therapy: Neurological and cardiac benefits. Journal of the American
College of Cardiology, 59(3): 197-210.
Hagmann, C.F., Robertson, N.J. & Azzopardi, D. (2006). Artifacts on electroencephalograms may influence the amplitudeintegrated EEG classification: A qualitative analysis in neonatal encephalopathy. Pediatrics, 118(6): 2552-4.
Hellstrom-Westas, L., Rosen, I. (2006). Continuous brain-function monitoring: State of the art in clinical practice. Seminars in Fetal
and Neonatal Medicine, 11(6): 503-11.
Ketola, S., Lehtinen, J., Arnala, I., Nissinen, M., et al. (2009). Does arthroscopic acromioplasty provide any additional value in the
treatment of shoulder impingement syndrome?: A two-year randomised controlled trial. Journal of Bone and Joint Surgery
British Volume, 91(10): 1326-34.
Shah, D.K., Boylan, G.B. & Rennie, J.M. Monitoring of seizures in the newborn. Archives of Disease in Childhood, Fetal & Neonatal
Edition, 97(1): F65-9.
Shah, D.K., de Vries, L.S., Hellstrom-Westas, L., et al. (2008). Amplitude-integrated electroencephalography in the newborn: a
valuable tool. Pediatrics, 122(4): 863-5.
Tao, J.D. & Mathur, A.M. Using amplitude-integrated EEG in neonatal intensive care. Journal of Perinatology, 30 Suppl: S73-81.
Thoresen, M. (2008). Supportive care during neuroprotective hypothermia in the term newborn: Adverse effects and their
prevention. Clinics in Perinatology, 35(4): 749-63, vii.
A12b: aEEG--MYSTERY SOLVED
Page 1 of 11
Toet, M.C., van Rooij, L.G. & de Vries, L.S. (2008). The use of amplitude integrated electroencephalography for assessing neonatal
neurologic injury. Clinics in Perinatology, 35(4): 665-78, v.
van Rooij, L.G., de Vries, L.S., van Huffelen, A.C. & Toet, M.C. Additional value of two-channel amplitude integrated EEG recording
in full-term infants with unilateral brain injury. Archives of Disease in Childhood, Fetal & Neonatal Edition, 95(3): F160-8.
Yenari, M.A. & Han, H.S. Neuroprotective mechanisms of hypothermia in brain ischaemia. Nature Reviews Neuroscience,
13(4): 267-78.
Session Outline
See handout on the following pages.
Page 2 of 11
Lecture Outline
aEEG- Mystery Solved
Michael D. Weiss, M.D.
University of Florida
Department of Pediatrics
Division of Neonatology
• I. aEEG principles- How it works
• II. aEEG basics
– Patterns of reading
– Effect of gestational age
• III. aEEG and HIE
• IV. aEEG and seizures
• VI. Quiz Time
I. aEEG principles- How it works
Conventional EEG:
Olympic Brainz Monitor:
16 channels; 21 Electrodes
3 channels/5electrodes
Easier to apply and manage electrodes at the bedside
– aEEG can be used as a monitoring tool by
bedside staff right on the unit
• Validate suspicious
p
behaviour/movements
• Escalate care based on what is seen
– aEEG provides information during off hours
• Especially nights, weekends, holidays
• Babies are often admitted when neurologists
and EEG techs are not readily available.
CFM 6000
Olympic Brainz Monitor
Page 3 of 11
cEEG vs aEEG
Conventional EEG, 16
channels
Olympic Brainz Monitor : 3
channels aEEG and raw EEG
Easier to see long-term trends at the bedside
II. aEEG Basics
II aEEG
II.
EEG Basics
B
Page 4 of 11
II. aEEG Basics
II. aEEG Basics
3. Burst suppression: discontinuous background
with minimum amplitude without variability at 0
to 1 µV, and bursts with amplitude more than 25
µV.
1. CNV: continuous activityy with lower ((minimum))
amplitude around (5) to 7 to 10 µV and maximum
amplitude 10 to 25 µV.
4. CLV: continuous background pattern of
very low voltage (around or below 5 µV).
2. DNC: discontinuous background with
minimum amplitude variable, but less than 5 µV,
and maximum amplitude more than 10 µV.
5. Inactive, flat trace: mainly inactive (isoelectric
tracing) background below 5 µV.
II. aEEG Basics
II. aEEG Basics
Using amplitude-intergrated EEG in neonatal intensive care- Tao and Mathur. Journal of Perinatology 2010.
II. aEEG Basics
II. aEEG Basics
Gestation or
Postconceptional
age
24-27
28-29
30-38+
Dominant
Background
Pattern
DC
DC/C
C/DC in QS
SWC
immature
immature-mature
mature
Hellstrom-Westas and de Vries; Toet et al.
Page 5 of 11
II. aEEG Basics
HIE
General
– Background and Sleep wake cycling
• maturing baby
• HIE
–Reasons for Power
• Background pattern changes with
HI
III. aEEG and HIE
Normal pattern
Moderate (Discontinuous pattern)
Severe
Al Naqeeb
–http://www.neoweb.org.uk/CFM/CFM_quiz3.htm
Page 6 of 11
III. aEEG and HIE
• Outcome prediction using aEEG:
III. aEEG and HIE
• Outcome prediction using aEEG:
– For normothermia HIE babies, the best single early predictor
(<6h) of neurological outcome at 18 months is based on
pattern recognition scoring of single channel aEEG (PPV
0 86)
0.86)
– Hypothermia changes the predictive value of early aEEG
• Normalization of an infant’s aEEG while being cooled occurs later
– Infants with good outcome had normalized background
pattern by 24 hours when treated with normothermia and by
48 hours when treated with hypothermia
Thorasen. Pediatrics 2010
– Reappearance of SWC within 36 h gives a good
prognosis in normothermic infants
– In hypothermic infants, the reappearance of
SWC could be as late as 60 h in infants who
developed normally
– Time to normal trace (TTNT) is a better
predictor than time to normal SWC appearence
• never achieving SWC always predicts poor outcome
Thorasen. Pediatrics 2010
Studies Predicting Prognosis in Hypothemia
Treated Infants with HIE Thorasen et al 2010
Time to regain normal aEEG trace is shown on the y-axis, and infants who never regained a normal trace within the
recording period are plotted on top of the figure
Studies Predicting Prognosis in Hypothemia
Treated Infants with HIE Thorasen et al 2010
Time to develop SWC is shown on the y-axis, and infants who never developed SWC within the recording
period are plotted on the top of the figure
Hypothermia and Rewarming
Seizures
Seizures treated with
Clonazepam 100 g/kg
CFM (V)
35.0 C rectal
35.06C
36.6C
Infant
recooled
35.0C 35.0C
100
50
25
10
5
0
2
3
4
5
6
7
8
9
IV. aEEG and Seizures
Hours since start rewarming
aEEG trace during rewarming and the occurence of nonconvulsive seizures that stopped after treatment
(clonazepam). The core temperature was reduced again and rewarming was halted for 3 hours. There
were no further seizures and total rewarming time was 11 hours in this baby.
Thorasen, Clin. Perinatol 2008
Page 7 of 11
A Few Facts About Seizures During the
Newborn Period…
• Seizures are more common in
the neonatal period than any
other time in life
– as high as 57.5/1000 in <
1500g and 2.8/1000 in 25003999g Volpe JJ. Neonatal Seizures. In:
3999
Neurology of the Newborn,
4th
Electroclinical Seizure
Electrographic Electrograph
ic Seizure
Clinical Seizure
edition. 2000.
• With moderate-severe HIE the
incidence of seizures is > 50%
Gluckman, Lancet 2005; Cool Cap Trial.
• % of electrographic neonatal
seizures provoke no obvious
clinical signs
– Some infants have all
subclinical seizures Mizrahi,
Epilepsia 2001; Clancy, Epilepsia 2001
• Difficult to identify by clinical observation alone
– Very subtle presentation
– Become less apparent when patient sedated or paralysed
– Up to 80% of seizures are subclinical (Flanigan 1995)
– After giving phenobarbital, at least 50% of seizures continue but are subclinical (Scher 1993) = false sense of confidence
• Multiple causes with varying timing of onset
– hypoxia, trauma, infection, metabolic disorders, cardiac surgery
• Anticonvulsant medications
– Unpredictable results
– Effectiveness is difficult to evaluate
– Clinicians need a reliable way to know when seizures have been controlled
• 80-90% of neonates with EEG confirmed seizures
were identified by aEEG.
• Lawrence et al. found that 73% of seizures >30s
and 87% of >60s.
• Availability of raw signal enhances accuracy.
• Using 2 channel aEEG 76% of non-status seizures
were identified.
• Slightly better performance with 2 channel.
Page 8 of 11
Page 9 of 11
IV. Quiz Time
Page 10 of 11
Page 11 of 11

aEEG – Mystery Solved - Florida Association of Neonatal Nurse

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