Amplitude-Integrated Electroencephalography Interpretation During Therapeutic Hypothermia: An Educational Program and Novel Teaching Tool Lauren Sacco, DNP, ARNP, NNP-BC, RN Continuing Nursing Education ABSTRACT (CNE) Credit Therapeutic hypothermia (TH) is now considered a standard in tertiary NICUs. Amplitude-integrated A total of 4.3 contact hours may be earned as CNE credit electroencephalography (aEEG) is an important adjunct to this therapy and is gaining acceptance for for reading the articles in this issue use on the neonatal population. It can be easily incorporated into practice with appropriate education identified as CNE and for completing and training. Current publications are lacking regarding nursing care of neonatal patients undergoing an online posttest and evaluation. To be successful the learner must TH with the use of aEEG. This article presents a broad educational program as well as novel teaching obtain a grade of at least 80% on tool for neonatal nurses caring for this population. the test. Test expires three (3) years from publication date. Disclosure: The author/planning committee Keywords: amplitude-integrated electroencephalography (aEEG); hypoxic-ischemic encephalopathy has no relevant financial interest (HIE); therapeutic hypothermia; nursing; education or affiliations with any commercial interests related to the subjects discussed within this article. No commercial support or sponsorship was provided for this educational activity. ANN/ANCC does not endorse any commercial products discussed/displayed in conjunction with this educational activity. ACH YEAR IN THE UNITED STATES, THERE infants with HIE.5–7 The use of aEEG allows The Academy of Neonatal Nursing is are an estimated four million births.1 the bedside provider to identify seizure activ- accredited as a provider of continuing E nursing education by the American Of those births, there are one to four infants ity that is not always recognized by visual Nurses Credentialing Center’s per 1,000 who will experience an insult assessment. The aEEG use and interpreta- Commission on Accreditation. at birth that results in hypoxic-ischemic tion can be incorporated into the practice Provider, Academy of Neonatal 2 Nursing, approved by the California encephalopathy (HIE). Globally, up to two- of the bedside provider with an appropriate Board of Registered Nursing, thirds of newborns who develop HIE die, education program and adequate resources. Provider #CEP 6261; and Florida Board of Nursing, Provider #FBN and approximately one-fourth of those who With appropriate training, the provider may 3218, content code 2505. survive will have severe neurodevelopmental be able to identify and treat seizure activity 3 The purpose of this article is to provide sequelae. Brain injury caused by HIE is the that could be overlooked otherwise and may nurses with evidence-based rationale top contributing cause of neurodevelopmen- minimize the neurologic damage sustained for the use of aEEG interpretation 4 8,9 during TH, including all of the tools tal disabilities, the most common being cere- during HIE. and products for the staff education. bral palsy (CP). Several tools are required in order for the provider and bedside nurse to accurately PATHOPHYSIOLOGY identify and quickly treat newborns affected OF BRAIN INJURY by HIE. One of those tools is the amplitude- HI E is caused by either placental, fetal, or integrated electroencephalogram (aEEG). maternal insult or injury that results in neo- The aEEG is an important adjunct in the pre- natal brain hypoxia. The brain injury that diction of long-term neurologic outcomes for occurs following a hypoxic-ischemic insult Accepted for publication November 2015. N EONATAL N ETWORK 78 © 2016 Springer Publishing Company MARCH/APRIL 2016, VOL. 35, NO. 2 http://dx.doi.org/10.1891/0730-0832.35.2.78 occurs in two phases. In the first phase, the neonatal brain publications regarding nursing care for these infants iden- responds by converting to anaerobic metabolism, leading to tified, the mechanics of how aEEG is used described, and depletion of adenosine triphosphate, increased lactic acid pro- models of teaching about aEEG and cooling therapy to other duction, and a disturbance in normal metabolic activity. This clinical groups reviewed. A broad educational program for response disrupts intercellular pumps in the brain and causes neonatal nurses, including innovative teaching tools, imple- a buildup of sodium, calcium, and water, which produces mentation, and systems change, will be presented. accumulation of fatty acids and oxygen-free radicals. These events, together, cause cell apoptosis. Preceding the initial injury to the neonatal brain, a second phase of injury will SIGNIFICANCE ensue if intervention is not initiated.4,10,11 T he use of the aEEG monitor by bedside providers for early T he second phase of HIE, which involves several pro- identification and detection of seizure activity is an important cesses and is not well understood, includes accumulation of aspect in the management of infants with HIE undergoing excitatory neurotransmitters and cell apoptosis. Once the TH. Because TH is offered in institutions of different levels, second phase begins, any brain injury that occurs in this aEEG monitoring by bedside providers is especially benefi- phase is irreversible.11 cial within institutions, where neurologists or neurophysicists Seizures occur in this population as a result of the brain are not readily available to assess the infant and evaluate for injury sustained during a hypoxic event. Seizures are one of seizure activity.18,21 the most common signs of neurologic dysfunction and can When abnormal background and seizure activity is iden- occur very early, even before the second phase, postnatally. tified, monitored, and treated effectively and efficiently, the If left unnoticed or untreated, frequent seizures can further associated negative outcomes are significantly reduced.5,6 increase the amount of damage to the neonatal brain. The Because of increased risk of seizure activity associated with diagnosis of neonatal seizures can be challenging because as HIE, it may be advantageous for the bedside nurse to have many as 80 percent of infants have clinical signs that are subtle the ability to assess with aEEG. The bedside nurse provides or absent. This can be especially difficult in seizures that are a ongoing care and assessment of these infants on a contin- result of brain injury from HIE because many of these infants ual basis, making him or her critical for the identification of require intubation and paralytics, further masking the clini- changes in aEEG. It is imperative that nurses are educated cal signs of seizure activity.12,13 regarding aEEG use and interpretation to correctly identify T reatment for HIE must occur rapidly to avoid further the subtle changes that can occur on the aEEG and report to damage. Therapeutic hypothermia (TH) for treatment of the provider quickly and efficiently. HIE has become the gold standard and has demonstrated It has been demonstrated that nurses who are provided positive outcomes for mild to moderate cases of HIE.4,11,14 with critical thinking education and subsequent protocols are Currently, there are two forms of cooling: selective head the most effective caregivers for the neonatal population.22–24 cooling15 and total body cooling.16 Both methods have Although there are many published articles related to the use proven effective with minimal side effects. The benefits of of aEEG for seizure identification in infants treated with TH, this intervention outweigh the side effects and, therefore, there are no published articles in which innovative tools for this intervention has been implemented in many centers after teaching interpretation of aEEG are presented. proper training has occurred.2,17,18 Specific protocols have been developed for each method of cooling, which have been easily translated to practice in both community and academic EVIDENCE APPRAISAL centers. Infants who meet HIE criteria, as defined in each T he focus of the review and appraisal of the literature is protocol, are cooled to 33.5°–35°C within six hours after on the aEEG, including its benefits for infants with HIE who birth and are maintained at that temperature for 72 hours, receive TH, interpretation, and training with the focus on following a slow rewarming process.15,16,19 neonatal data. This evidence appraisal was the basis for the I nfants are monitored closely by various methods, includ- approach and content of the development of the educational ing aEEG. The aEEG is a cerebral function monitor that program. The literature search was performed between time-compresses, rectifies, and filters the conventional elec- January 2013 and June 2014. Many searches were done troencephalogram (cEEG), which can be visualized and using PubMed, Cochrane Database of Systematic Reviews, interpreted by the bedside provider. The aEEG is easily set Academic Search Complete (EBSCO), and Cumulative up at the bedside and can be applied by the bedside nurse.8,20 Index for Nursing and Allied Health Literature databases. Although cEEG is considered the gold standard for the accu- The search terms included neonates/newborns/infants, rate detection of seizure activity in the neonate, it is tedious HIE, TH, aEEG, interpretation, nurses, and training. to apply and requires evaluation by a neurologist or neuro- Included in this evidence appraisal are one meta-analysis, five physicist specially trained in reading the neonatal cEEG. randomized controlled trials, one nonrandomized controlled In this article, the importance of aEEG for bedside seizure trial, three systematic reviews, and three retrospective chart identification in infants will be established, the lack of existing reviews. N EONATAL N ETWORK VOL. 35, NO. 2, MARCH/APRIL 2016 79 BENEFITS OF aEEG DURING to severe birth asphyxia with normal aEEG data after 24 hours THERAPEUTIC HYPOTHERMIA of life had normal outcomes at one year of life. Limitations A n aEEG, when applied prior to initiation of TH, pro- to this study are the small sample size and lack of long-term vides an assessment of baseline brain background pattern follow-up evaluation beyond one year of life.