Nurses & Bedside Brain Monitoring

Transcription

1 Nurses & Bedside Brain Monitoring Kathi S. Randall MSN, CNS, NNP BC What you have already learned Pros & Cons of aeeg How to Read aeeg Populations for Potential Use Term PreTerm Seizures ROLES & RESPONSIBILITIES To use aeeg 1

2 ROLES & RESPONSIBILITY Equipment and Supplies Management RN NNP NEO NEURO NEURO PHYS IT Policy Unit Clerk Parent Rep EEG Lab or Tech aeeg Device Options Patient Identification Sensor Application Sensor Maintenance Event Marking Pattern Recognition Pattern Notification Event Marking Documentation Medical Record Data Archiving and Storage Equipment Issues Parent Education Research STAND ALONE aeeg EEG and aeeg Multi-Modal PROGRAM ROLES PROGRAM ROLES Equipment Selection Equipment Selection Protocol Development 2

3 WHO TO MONITOR? And when?? Who to monitor? Term Infants HIE With/without cooling Induced Hypothermia Seizures Meningitis Stroke ECMO Neonatal Abstinence Hyperbili Metabolic Disease CHD Post op Post arrest Preterm infants Maturation Developmental Interventions Evolution of Sleep Sepsis/Meningitis Seizures IVH Post cardiac arrest Dividing up the Roles When to use aeeg? WRITE YOUR PROTOCOL OR POLICIES Monitoring Use it frequently or staff won t get enough exposure Create a priority list of patients to be monitored not just cooling! 3

4 aeeg Processing Courtesy of Dr. Krisa Van Meurs Nurses Roles with aeeg EEG to aeeg HOW does it happen? 1. SENSORS 2. PATTERNS 3. DOCUMENTATION 4. EDUCATION 4

5 EEG graph (Scale is Modifiable) X axis = time Y axis = voltage (in microvolts) Micro volts 0 Micro volts 0 Peak Detection seconds seconds Micro volts 0 Rectification of Voltage Micro volts seconds seconds 5

6 The absolute value of the amplitude peaks is plotted on a semi logarithmic scale Three sensor options Hydrogels 100 Needles Micro-volts Metal cups and disks minutes It starts with the sensors Who will place the sensors? 6

7 When to place the sensors? HOW TO APPLY? When to remove the sensors? Where to place the sensors? 7

8 10 20 System for EEG Electrode Placement Position of electrodes Left = Odd Right = Even F = Frontal C = Central P = Parietal O = Occipital T = Temporal A = Ears C P 10% of the head circumference 3.5cm 40% 60% Based on the international system System for EEG Electrode Placement Position of the Sensors Left = Odd Right = Even F = Frontal C = Central P = Parietal O = Occipital T = Temporal A = Ears 8

9 Seizures Patrizi et al, Brain Dev 2003 (n=71 seizures) Shellhaas et al, Pediatrics 2007 (n=851 seizures) Frontal 11.3% 5% Central 26.8% 56% Temporal 45% 25% Parietal 9.9% Occipital 7% 14% Sensor Application Mark Prep Place/Insert Connect Then: Secure sensors Assess impedance 9

10 Sensor Checks ((With Cares)) Distance between sensors Never touching Closer (lower) Wider (higher) Keep the symmetry 2007 BrainZ Instruments Limited LESSONS LEARNED aeeg activity resolved to normal after correction of the electrodes position Assess position not just impedance 10

11 LESSONS LEARNED Over Hydration = Signal Cancelled Assess position not just impedance Don t over hydrate the sensors when in humidity 11

12 LESSONS LEARNED Nurses Roles with aeeg Assess position not just impedance Don t over hydrate the sensors when in humidity Don t leave the screen on the impedance screen continuously 1. SENSORS 2. PATTERNS 3. DOCUMENTATION 4. EDUCATION Dividing up the Roles REVIEW & INTERPRETATION Who will look at the tracings (and how often) Who will interpret the tracings (and how often) 12

13 Nurses & aeeg Review 5 aeeg Patterns Focus on normal patterns (or expected for age patterns) Normal (Term) Normal (Preterm) Abnormal 1 tracing 1 tracing 3 tracings 5 EASY STEPS 1. CLASSIFY the aeeg Pattern Normal/Mature (For Term Infants) 2. COUNT the Sleep Wake Cycles 3. COMPARE the Hemispheres 4. COMB through the aeeg for seizures Upper Margin ABOVE 10 Lower Margin ABOVE 5 5. CONFIRM seizures (or artifacts) with raw EEG Bonus: COMPARE with previous tracing (hours or days) 13

14 Normal/Expected (For Premature Infants) 6 EASY STEPS 1. CLASSIFY the aeeg Pattern Upper Margin ABOVE 10 Lower Margin BELOW 5 DNV 2. COUNT the Sleep Wake Cycles 3. COMPARE the Hemispheres 4. COMB through the aeeg for seizures 5. CONFIRM seizures (or artifacts) with raw EEG 6. COMPARE with previous tracing (hours or days) Abnormal Mild Moderate Severe Meets One Criteria for Normal Meets NO Criteria for Normal 14

15 Nurses & aeeg Review aeeg Pattern Asymmetry Focus on normal patterns (or expected for age patterns) Focus on symmetry (if you have > 1 channel) aeeg Pattern Symmetry aeeg Pattern Asymmetry The Causes of asymmetry can be: Cerebral Extra Cerebral Mechanical 15

16 aeeg activity resolved to normal after correction of the electrodes position Visible on a 2-Channel aeeg tracing Transient unilateral low voltage Nurses & aeeg Review Focus on normal patterns (or expected for age patterns) Focus on symmetry (if you have > 1 channel) Suspicious patterns (aka seizures) Focus on common artifacts 16

17 3/23/

18 EMG Artifact (Muscle) Fast and Fuzzy (Seen during Crying, Shivering, Sucking) High Frequency Ventilation (Artifact) ECG artifact 18

19 Movement Artifact Nurses & aeeg Review Visual cues of Increased Impedance Focus on normal patterns (or expected for age patterns) Focus on symmetry (if you have > 1 channel) Suspicious patterns (aka seizures) Focus on common artifacts Create criteria for notification High impedance Change from base line Graphical Plot of Impedance and High limit visual alarm Color Tinting to Represent Impedance Values 19

20 Nurses Roles with aeeg 1. SENSORS 2. PATTERNS 3. DOCUMENTATION 4. EDUCATION Nurses & aeeg Review Focus on normal patterns (or expected for age patterns) Focus on symmetry (if you have > 1 channel) Dividing up the Roles DOCUMENTATION Who will document What will they document Where will they document Suspicious patterns (aka seizures) Focus on common artifacts Create criteria for notification High impedance Change from base line 20

21 Event Marking (On the Device) #17 Patting Create a list of the high priority events Customize quick pick documentation in monitor (when possible) Utilize event marking when interpreting tracings Essential Events to Mark (On Device) Medications Sedation Anti epileptic drugs Clinical observation of seizure like or suspicious movements Hands on Cares (i.e. movement) and repositioning Sensor manipulation Changes in ventilation or vital signs Conventional, CPAP, HFOV, Jet Apnea, Brady Intubation Surfactant Morphine & Midazolam Courtesy of S. Lavery VIBeS, Melbourne, Aus 21

22 Document in the EMR Mature = 1 cycle per hour Immature < 1 cycle per hour Absent = No visible cycling MATURE Nurses Roles with aeeg 1. SENSORS 2. PATTERNS 3. DOCUMENTATION 4. EDUCATION 22

23 Dividing up the Roles PARENT EDUCATION What is aeeg? Why is it being used? How long? Parent education brochures ROLES & RESPONSIBILITY Equipment and Supplies Management Patient Identification Sensor Application Sensor Maintenance Event Marking Pattern Recognition RN NNP NEO NEURO NEURO PHYS IT Policy Unit Clerk Parent Rep EEG Lab or Tech Pattern Notification Event Marking Documentation Medical Record Data Archiving and Storage Equipment Issues Parent Education Research Nurses Roles with aeeg CONCLUSIONS 1. SENSORS 2. PATTERNS Nurse buy in is essential for successful implementation of aeeg Focus on the early adopters Introduce the nurse s role in a stepwise approach Use aeeg often to increase learning 3. DOCUMENTATION 4. EDUCATION 23

24 Thank you to my mentors, Friends and Colleagues around the Globe LPCH Dr. Krisa Van Meurs Dr. Alexis Davis Dr. Courtney Wusthoff Dr. Valerie Chock Celia Sheppard Glennon, NNP Beth Ball Lori Bowlby Nancy Vierhaus Audrey Huntsberry Loma Linda Dr. Andy Hopper Dr. Raylene Phillips Dr. Terrie Inder Dr. Amit Mathur Shelly Lavery, RN Dr. Diveyn Shah Dr. Linda de Vries Dr. Lena Hellstrom Westas Dr. Marianne Thoreson Dr. Bob White Dr. Dongli Song Thank You!! Free aeeg Interpretation E Book aeeg Roles Worksheet 24