setting up the portable amplitude-integrated electroencephalogram (aeeg) recording system for transporting infants

Using a Portable Amplitude-Integrated Electroencephalogram for Infant Transport

Impaired oxygen delivery or blood flow to the brain around the time of birth can cause brain injury (hypoxic ischemic encephalopathy; HIE). This is a leading cause of death and disability in full-term babies1. HIE is reported to have a worldwide incidence of 2 per 1000 deliveries, which is likely to be higher in low to middle-income countries. In Western Australia, approximately 50 babies are born each year who have a clinical diagnosis of HIE (32308 live births in 2022, an incidence of approximately 1.5 per 10002).
HIE is diagnosed with criteria based on the circumstances of birth, changes in the infant&#39;s blood acid balance (from umbilical cord or baby after birth), and changes in neurological status3. The treatment for moderate or severe HIE is whole-body hypothermia of 33-34 &#176;C. The earlier this is commenced, the likely greater the benefit to the baby&#39;s neurological outcome3,4,5. Amplitude-integrated EEG (aEEG) is an essential part of assessment and monitoring, which in many regions is only available in tertiary centers. Electrodes (EEG safety DIN connector or DIN 42802 with 1.5 mm diameter pin) are inserted into the scalp to measure and record brain electrical activity. Electrodes are then connected to an amplifier, which is in turn connected to a clinical tablet computer to display and record brainwave activity. aEEG can provide information on brain wave activity and be used to assist with the diagnosis of HIE6. The combination of neurological examination and aEEG may enhance the ability to identify infants with moderate or severe HIE7,8,9.
The Newborn Emergency Transport Service of Western Australia (NETS WA) provides intensive care transport to approximately 1100 sick babies per year. Healthcare staff in local hospitals can contact NETS WA through a free phone number and are immediately connected via a conference call with a neonatal specialist doctor and nurse to request a transfer. The NETS team travels either by specialized road ambulance or fixed-wing aircraft with a purpose-built intensive care transport equipment cot. On arrival of the transport team to the referring hospital, the baby is assessed, and treatment is continued or escalated. The team then transfers the infant to a tertiary neonatal intensive care unit (NICU) in the state capital (Perth). In Western Australia, owing to the often-large distances between referring hospitals and centralized specialist services10 (a maximum distance of 1381 miles), aEEG may not applied for up to many hours after birth, leading to a delay in treatment.
Many monitoring systems have been designed for the intensive care unit but owing to their size and power requirement, they are impractical for the transport environment. Ward-based equipment is prone to movement artifacts, which may record insufficient quality data in the transport environment. Ambulatory EEG amplifier technology, designed primarily to be worn by patients at home, can connect to a computer tablet with EEG detection software and be applied to a newborn during transport11. This can be carried by the neonatal transport team to a baby with suspected HIE. The software is capable of being viewed remotely via a portable internet uplink and web-based viewer. Currently, there are no reports on the suitability or readability of aEEG in the transport environment.
Applying and monitoring aEEG in the transport of infants with HIE has not been previously reported, and there are no existing protocols for its use. There is no evidence to support feasibility or utility in the transport environment. We present a protocol for aEEG use in neonatal transport. It aims to assess whether aEEG in babies with HIE who require transport after birth is feasible and can provide readable clinical information.

Author Spotlight: Assessing the Feasibility of Using Amplitude-Integrated EEG During Neonatal Transport

Amplitude-Integrated EEG in Infants at Risk of Hypoxic-Ischemic Encephalopathy: A Feasibility Study in Road and Air Transport in Western Australia

We wanted to assess the feasibility of using an amplitude-integrated electroencephalogram during neonatal transport. Using clinical criteria, we determined whether the trace acquired during the transport was readable. This helps the clinician in the diagnosis and prognosis of babies requiring transportation following possible birth asphyxia or hypoxic ischemic encephalopathy.Remote monitoring automated devices and innovative transport systems to improve outcomes in sick and premature newborns. Performing any research during transport has its difficulties but is essential in improving care. Getting appropriate consent is challenging in a time of acute stress.The clinical team is required to perform research as well as clinical tasks, adding to the complexity of the transport process. We have established the necessity of undertaking research in neonatal transport and are seeking ways to improve the outcomes in babies who need to be transported after birth. We are working on means of improving thermal regulation in neonatal transport.We would like to see whether amplitude-integrated EEG enables an earlier and more accurate diagnosis of hypoxic ischemic encephalopathy. We would also like to explore if machine learning can be used to augment diagnostic decisions. Finally, we wish to assess whether this has an impact on important outcomes such as mortality and neurodevelopmental outcomes.

Setting up the Portable Amplitude-Integrated Electroencephalogram (aEEG) Recording System for Transporting Infants

To begin assembling the amplitude-integrated electroencephalogram or aEEG recording system, first, insert the aEEG electrode pins into the infant's scalp per standard guidelines. Next, measure and locate the two anatomical landmarks, sagittal suture and ear tragus. Align the electrode measuring tape vertically on the head and parallel to the face.Match the letters or symbols on the positioning aid until the same letter or symbol appears in both locations. Mark the positions with a surgical pen on each side of the tape. Let the hair part naturally or part it vertically away from the marked position using sterile water and swab sticks.Dry the area with gauze. Then clean the skin with swabs containing 1%chlorhexidine and 70%alcohol, and let it dry. Hold the skin tight and insert the needle at a 30=degree angle with the sensor wire upwards.If the scalp is very hairy, use skin preparation swabs around the needle insertion site. Secure the subdermal needle electrode in place using Steri-Strips and the Chevron method. Use two small pieces of Tegaderm on opposite sides of the needle to sandwich the needle.Point the needles and wires in the same direction. Place the reference electrode on the chest anteriorly or posteriorly, the back of the shoulder, or the nape area of the neck. Connect the electrodes to the aEEG amplifier using the C3-C4 and P3-P4 configurations.Connect the amplifier to the tablet computer using an ethernet cable. Turn on the tablet and log in. Enter the Acquire Pro application, which will automatically apply the default neonatal configuration.Change the default settings of impedance from five kiloohms to 10 kiloohms. Press Record Now to automatically create a patient ID.Press the EEG tab to observe the live trace. Finally, secure the clinical tablet to the cot used to transport the infant, which is either a Mansell Neocot or a Voyager Transport Incubator.The location of the tablet on the cot depends on which cot is taken on the transport.

setting-up-portable-amplitude-integrated-electroencephalogram-aeeg

Research

JoVE Journal

Medicine

Infants at risk of HIE require early identification and initiation of therapeutic hypothermia (TH). Earlier treatment with TH is associated with better outcomes. aEEG is frequently used when making the decision whether to commence TH. As this is often limited to tertiary centers, TH may be delayed if the infant requires transport to a center that provides it. We aimed to provide a method for the application of amplitude-integrated electroencephalogram (aEEG) and to determine the feasibility of acquiring clinically meaningful information during transport. All infants &#8805;35 weeks, at risk of HIE at referral, were eligible for inclusion. Scalp electrodes were placed in the C3-C4; P3-P4 position on the infant&#39;s scalp and connected to the aEEG amplifier. The aEEG amplifier was, in turn, connected to a clinical tablet computer with EEG software to collect and analyze aEEG information. Recordings were reviewed by the chief principal investigator and two independent reviewers (blinded) for background trace and artifact. Predefined criteria for data quality were set to movement artifacts and software impedance notifications. Surveys were completed by healthcare staff and parents for acceptability and ease of use.

Here, we present a feasibility study to assess a portable amplitude-integrated electroencephalogram (aEEG) recording system during the transport of infants with suspected hypoxic ischemic encephalopathy (HIE).

Infants at risk of HIE require early identification and initiation of therapeutic hypothermia (TH). Earlier treatment with TH is associated with better ...

Monitoring the Portable Amplitude-Integrated Electroencephalogram (aEEG) System During Transport of Infants

Proceed to transport the infant after setting up the portable amplitude integrated electroencephalogram or AEEG recording system. During the transport, note any movements that may contribute to artifact, clinical change, or seizure on the tablet software. Use buttons on the tablet to label important events including seizure, patient care, loading or unloading, takeoff, and landing.For non-continuous events, press the button only once for a timestamp. For continuous clinical events such as seizures, observe the label added for the event duration. When one continuous event finishes, press the button a second time.On arrival at the receiving hospital, transfer the baby to the intensive care bed. Disconnect scalp electrodes from the study amplifier, and transfer them onto the Neonatal Intensive Care Unit AEEG monitor to continue the recording per unit protocol.