Canberra Hospital and Health Services

Canberra Hospital and Health Services

ClinicalProcedure

Neonatal Neurology

Contents

Contents

Purpose

Scope

Section 1: Bedside aEEG monitoring

Section 2: Cooling for HIE

Section 4: Neurovascular Assessment & Observation

Section 5: Seizure Management

Section 6: Lumbar Puncture

Related Policies, Procedures, Guidelines and Legislation

References

Search Terms

Purpose

This procedure outlines themanagement of infants with neurological problems in the Department of Neonatology.

Scope

This document pertains to infants nursed in the Department of Neonatology at the Centenary Hospital for Women & Children.

This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice:

• Medical Officers
• Registered Nurses and Midwives
• Student Nurses and Midwives working under supervision

Section 1: Bedside aEEG monitoring

Background

Bedside aEEG monitoring provides a continuous record of electrocortical acitivity of the brain.

Bedside aEEG monitoring allows for early detection and treatment of pathological events, surveillance of interventions, and their effects and a more selective use of formal EEG in the Department of Neonatology.

The criteria for bedside aEEG monitoring includes:

• Definite or questionable seizures
• Perinatal asphyxia (pH <7 and encephalopathy 2-3)
• Apnoea in term or near- term infants
• Muscle relaxed infants (If muscle relaxation for days and hypoxia/ischaemia likely)

All abnormal aEEG recordings should be confirmed by multi-channel EEG from the Neurology Department. However, treatment of seizures should not be delayed waiting for a multi-channel EEG.

aEEG findings are to be recorded every 8 hours in the clinical notes, detailing:

• background activity
• presence and duration of seizures

How to record aEEG

Equipment

• Bedside EEG monitoring
• Neonatal sensor set (electrodes)
• Positioning aid (measuring tape provided)
• Skin marker
• Skin preparation treatment
• Sterile water
• Cotton applicator
• Gauze pads

Procedure

1. Position the infant supine
2. Use supplied measuring tape and measure from the sagittal suture to the ear tragus and note the letter (A, B etc) mark the site for electrode placement making sure the picture of the infant’s face on the tape measure is facing the same way as the infant

1. Reverse the tape measure and mark the site on the other side of the head
2. Clean the marked areas with sterile water and gauze, parting the hair in a line towards the top of the head
3. Gently pat dry with gauze maintaining the part in the hair
4. Clean the area with skin prep using a small swab stick
5. Remove the skin prep with gauze swab and water continuing to maintain the part in the hair
6. Pat the area dry with the gauze swab maintaining the part in the hair
7. Site the electrodes as follows:
8. black electrode at the back and direct leads toward the top of the head
9. white electrode in front of the black lead ensuring only a 5 mm distance between the 2 electrodes, direct the leads toward the top of the head
10. gently turn the infant’s head over and repeat the process
11. reference electrode may be placed on either side of the infant, behind the ear or on the shoulder away from the hair after preparing the skin as above

For Insertion of Needle Electrodes

1. Cleanse area that needle electrodes are inserted
2. Hold skin taut and insert needle electrodes at a <30o angle(sub-dermal) just under the skin parallel to each other

1. When using needle electrodes the reference electrode should be hydrogel
2. Place reference electrode as for standard hydrogel electrodes

1. Secure the sub-dermal needle electrode in place with steri-strip as below

1. On the CFM open the screen using the following:
2. user name = NICU
3. password = NICU
4. Push assess patient box on the screen to record the data for a new patient
5. If electrodes lift, reapply using a drop of sterile water and apply warmth with warm cloth. Do not stop the machine if electrodes lift
6. Mark events on the recording, i.e. suction, cares, xray etc: to ensure that any changes are interpreted correctly
7. If readout demonstrates:
8. impulses outside normal limits contact Medical Officer
9. contact impedance as displayed by red or yellow alert reapply electrode as above
10. green light indicates effective electrode function

To change date/time

1.Go to ‘Home’

2.Touch ‘Tools’

3.Touch ‘System’ and then ‘Exit to maintenance’

4.Touch ‘Date/time’ button then choose either ‘Date’ or ‘Time’ and adjust using arrows

5.Touch ‘Accept’ button and return to monitor

Any abnormalities should be discussed with the Neonatal Registrar. The neonatal Registrars are to be informed of seizures immediately.

The type of trace must be recorded on the Neonatal Encephalopathy Chart by the medical staff the trace must be discussed at each ward round

Any significant change must be reported to the Neonatologist by the registrar or nursing staff.

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Section 2: Cooling for HIE

Background

Hypoxic ischemic encephalopathy (HIE) is the brain injury caused by hypoxia and ischaemia during the perinatal period. Whole body cooling for infants with moderate-severe encephalopathy has been shown to reduce long-term brain injury. Infants diagnosed with HIE who fulfil the criteria as below, will be whole body cooled within 6 hours of birth to a rectal temperature of 33.0-34.0oC for 72 hours.

The infants that will be cooled must meet the following four criteria:

1. More than or equal to 35 weeks gestational age
2. Less than 6 hours of age
3. Evidence of asphyxia as defined by the presence of at least two of the following-

a)Apgar less than 6 at 10 minutes or continued need for resuscitation with positive pressure ventilation +/- chest compressions at 10 minutes

b)Any acute perinatal event that may result in HIE (ie. Abruption placentae, cord prolapsed, severe FHR abnormality etc.)

c)Cord pH less than 7.0 or base excess of -12mmol/L or less

d)If cord pH is not available, arterial pH less than 7.0 or BE less than -12mmol/L within 60 minutes of birth.

1. The presence of moderate/severe HIE: defined as seizures OR presence of signs in at least three of the six categories given below:

Exclusion Criteria (based on little expected benefit or high empirical treatment risk)

• Cooling cannot be started within 6 hours of birth.
• Birth weight less than 2.0 kg
• Major congenital abnormalities including:

• Suspected neuromuscular disorders
• Suspected significant chromosomal abnormalities

• Life threatening abnormalities of the cardiovascular or respiratory systems
• Uncontrolled severe clinical coagulopathy (low platelet count or clinical evidence of abnormal clotting and/or clotting studies which has not responded to appropriate therapy)
• Infants requiring inspired oxygen concentration over 80%
• Infant in extremis i.e. very low blood pressure or severe acidosis unresponsive to treatment

Equipment

• Cool packs (from refrigerator, NOT freezer) if Blanketrol unavailable
• Cooling blanket
• Rectal thermometer
• Open care centre
• ECG monitoring
• Saturation monitor and leads
• Blood pressure monitoring equipment
• aEEG monitoring and equipment

Procedure

1. Employ universal precautions when handling the infant as per Infection Control Manual Section 3.
2. Parents are provided with the “Cooling Treatment for Perinatal Asphyxia” leaflet.
3. Infants will be admitted to an open care centre, with the heating turned OFF.
4. For constant temperature monitoring, insert thermistor into the rectum (using lubrication) to a distance of 5cm and tape to thigh.
5. Commence continuous monitoring of ECG, respirations, saturations and blood pressure.
6. Observations must be recorded hourly throughout the entire cooling and rewarming process.
7. Attach infant to the aEEG machine as per Neonatal Practice Guidelines and monitor for at least 72 hours, ideally for 24 hours after normothermia has been achieved and aEEG is normal.
8. Strict fluid balance must be monitored, particular attention must be payed to urine output.
9. Document encephalopathy score, therapy and aEEG findings and investigations on the Neonatal Encephalopathy chart
10. Use the Blanketrol cooling blanket to cool the infant-see operating guide for use
11. If cooling blanket is not available, cool the infant by turning the radiant warmer to the OFF position and by exposing the infant to ambient temperature. If this does not result in a decrease in temperature by 1oC within 2 hours, cool packs (from fridge, NOT freezer) may be applied to the back of the neck, head and across the torso.
12. Active cooling will be reduced when the rectal temperature falls below 34.5OC.
13. Active cooling is stopped when the temperature falls below 34OC.
14. If the temperature falls below 33.5OC the heater output on the radiant warmer will be manually adjusted to maintain a rectal temperature of approximately 33.5OC.

The following blood tests should be done at least daily:

14.1.Electrolytes

14.2.Urea, creatinine

14.3.Liver function test

14.4.Full blood count including platelets

14.5.Coagulation profile

1. Monitor Arterial Blood Gases, glucose levels and lactate daily or more frequently if clinically indicated.

Alert

If the inspired oxygen increases by more than 20% then active cooling should be reduced (i.e. remove the cool packs or turn the cooling blanket off)

Infants treated with anticonvulsants may become hypothermic as a result of the anticonvulsant therapy; therefore ACTIVE cooling may not be necessary.

Cooling may be stopped if there is:

• Persistent hypoxaemia in 100% oxygen
• Life threatening coagulopathy
• Arrythmia requiring medical treatment (not sinus bradycardia)

1. After 72 hours rewarming will occur at a rate not exceeding 0.5OC every two hours using the rewarming facility on the blanketrol
2. Infants will take up to 12 hours to be rewarmed to a target rectal temperature of 37oC.
3. Rewarming is a risk for seizures to occur/recur – aEEG monitoring must be continued duing this time
4. To prevent rebound hypothermia the rectal probe measurements should be continued for six hours after the infant has been rewarmed to a normal body temperaturetemperature.
5. Accurate documentation of the cooling and rewarming process must be kept.
6. MRI of the brain should be done ideally 7-10 days after birth

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Section 4: Neurovascular Assessment & Observation

Background

Monitoring and recording of neurovascular observations is essential in all infants with the following conditions:

• Limbs splinted or in plaster
• The limbs are damaged by birth trauma
• Those with a peripheral arterial line in-situ
• Swelling from extravasations of IV lines or peripheral arterial lines

Procedure

1. Attend hand hygiene before touching the patient by either hand washing or using ABHR
2. Attend observations hourly for 4 hours following the plaster/splint application and then 4-6 hourly as directed by the Neonatologist
3. Observe the affected limb or area to be assessed for vascular status
4. Observe the colour of the limb/area in comparison with the unaffected limb/area and document in terms of pink, normal colour or dusky
5. Feel the temperature of the affected limb/area and compare to the unaffected limb and document in terms of warm or cold
6. Assess movement by touching fingers or toes - note response
7. To assess sensation, apply firm pressure to the fingers or toes – note the infant’s response
8. Observe capillary refill by applying finger pressure to the affected limb/area and estimate the time taken for return of blood supply
9. Locate the pulse on the affected limb/area and document strength and presence in comparison with the unaffected limb/area
10. Observe for any swelling
11. Assess the infant for signs of pain - irritability, restlessness or increased bouts of crying
12. Compare observations with previous assessment and report any changes to the team leader
13. Document observations on flow chart and any abnormal findings in the infant’s progress notes
14. Settle the infant in a position of comfort with limbs in natural alignment

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Section 5: Seizure Management

Neonatal seizures are the most common neurological adverse event during the neonatal period and are a sign of an underlying disease process. Treatment is aimed at the underlying cause first, and then at controlling seizures.

Investigations:

Detailed neurologic examination should be performed, paying attention to level of consciousness, tone, reflexes and head circumference. Please record on the encephalopathy measurement /monitoring chart

Seizures are frequently under-diagnosed, can be brief or mimic normal behaviour.

If aninfant is suspected of having seizures, an aEEG or EEG should be recorded as soon as possible to confirm seizure activity (see Section 1)

Differential diagnosis

• Accurate seizure diagnosis remains a challenge. Any unusual or stereotypical movement may represent a seizure. (refer to Clinical seizure activity table)
• Some normal behaviour of preterm and term infants may increase suspicion of seizures. Normal behaviours include:
• Stretching, non-specific random movements that can be sudden (particularly in preterm infants), random sucking, coughing or gagging
• Physiological myoclonus known as benign neonatal myoclonus which occurs during active sleep (rapid eye movement (REM)) and quiet or non-REM sleep
• Jitteriness occurs primarily in response to minor stimulation. It is important to distinguish seizures from jitteriness

Differentiation between jitteriness and seizures

Clinical seizure activity

Neonatal seizures can present in several ways and several types may be seen in the same infant over several hours. Seizure activity is classified according to clinical presentation. (refer to table below)

Immediate management

Equipment

• Resuscitation equipment at the cot side
• Monitoring equipment
• Cannulation equipment
• Pathology tubes for investigations as requested by the medical staff
• aEEG monitoring
• Emergency trolley
• Seizure observation chart.

1. Observe seizure activity, noting time of commencement and completion, description of motor movements, eye deviations and respiratory status including vital signs and level of consciousness.
2. Notify medical staff
3. Assess ventilation: If compromised initiate immediate respiratory support noting airway, breathing, circulation and temperature
4. Obtain assistance from other staff members if necessary. Do not leave infant unattended to do this.

Ongoing management

1. If necessary assist with cannulation and intubation as required

1. Assist with fluid and electrolyte administration
2. Apply aEEG
3. Inform parents of event and explain planned management

Accurately document the event in patient’s notes and seizure observation chart.

Investigations:

If seizures are confirmed clinically, by aEEG or EEG, investigations include:

1. Blood test

1. glucose, electrolytes (include magnesium, ionised calcium),
2. full blood count
3. CRP
4. blood culture
5. blood gas (lactate, pH)

1. Urine

1. culture
2. urine analysis (pH, ketones, leucocytes)

1. Neuro-imaging:

1. Head US (bleed, anatomical abnormality, stroke)
2. Consider MRI (diffusion weighted images)

1. Other

1. Consider metabolic screen

Maternal history:

1. GBS status, other risk factors for sepsis
2. Overseas travel, viral history including herpes simplex
3. Antenatal US results
4. Medications
5. Family history of neonatal seizures
6. Details of delivery (forceps, vacuum, Apgar scores, cord pH)

Treatment:

All clinical seizures lasting greater than 3 minutes, brief but serial seizures (>3 per hour), and all electrical (subclinical) seizures (even in the absence of clinically apparent seizures) should be treated with antiepileptic medication

All suspected clinical neonatal seizures need EEG or aEEG confirmation.

Medication

For detailed information regarding medications refer to the medication manual.

The consensus order for escalating medications is listed below. Each medication should be given to a recommended maximum dose before adding another anti-epileptic drug as the apoptotic effects are increased with increasing number of medications.

1. First line: Intravenous (IV)Phenobarbitone,
2. Second line: IV Lignocaine
3. Third line: Levetiracetam
4. Consider a trial of Pyridoxine
5. Fourth line: Midazolam iv

There may be some individual variation in treatment prescribed by the neonatologist dependant on the nature of theseizures, response to treatment and aetiology.