BRM Monitor

 

Reviewed by Clinical Practice Committee
September 2013
Clinical Guidelines Back Newborn Services Home Page

Indications

Application

Commence Assessment
CFM Natus Monitor

Commence Assessment
BRM3

The following policy/recommended best practice outlines practice applies to all Medical and Nursing staff working in Newborn Services.

Indications

The following infants should be considered for Brainz BRM monitoring.

Infants ≥34/40 with:

Monitoring should not be commenced unless directed by a doctor/NS-ANP.

Application

Electrodes to be applied by newborn Medical and Nursing staff who have undertaken BrainZ BRM training.

Equipment required:

There are two electrode options available, hydrogel and sub-dermal needle electrodes.

Hydrogel Electrode Placement

Step
Action
1
  • Position infant supine
  • Ensure head is clean
  • Place the wrap hat under the baby's head
2
Use the sensor positioning strip to identify location for the EEG electrodes.
  • Position the strip vertical and parallel to the baby's face. Align so the letter (A-H) at the saggital suture is the same letter at the tragus

3
Use a marker pen, mark the two sensor sites at the ends of the arrows

Note: DO NOT shave these placement marks

Marking.jpg (25681 bytes)
4
  • Using sterile water and gauze, part the hair vertically at the mark
  • Pat dry with gauze keeping hair parted

5

Clean the parted line
  • Place a very small amount of preparation gel (NuPrep®) on a cotton tip.
  • Using an up and down action clean the parted line with NuPrep®. Hold the skin taut as you clean.
  • Using gauze and water clean off the NuPrep®; work outwards from the centre to maintain the parting.
  • Pat dry the area.
6
Site electrodes in the following manner.
  • Apply the sensors directly over the cleaned spot, with the sensor wires directed to the top of the head.
  • Ensure electrodes do not touch each other. Electrodes should be 5-8mm apart and paralleled to each other.
  • Once applied, pat around edge of electrodes with a cotton wool swab
7

 

Turn infants head over and repeat procedure.

8

Site reference electrode
  • select a site with no hair on or near the shoulder
  • Note the same cleaning process is required
  • Site electrode with lead directing towards the head

9

Plug into the data acquisition unit (DAU)
  • Left anterior lead into C3
  • Right anterior lead into C4
  • Left posterior lead into P3

Right posterior into P4

10
Check electrode signal quality, once green apply wrap hat with adequate tension to support electrodes
11
Note: If electrodes lift, reapply using a drop of sterile water. If not adequate, remove electrode, repeat cleaning process and replace.
Do Not stop the machine. Continue monitoring, mark event.

Sub-dermal Needle Electrode Placement

Step
Action
1
  • Position infant supine.
  • Ensure head is clean.
  • Place the wrap hat under the baby’s head.
2
Use the sensor positioning strip to identify location for the EEG electrodes.
  • Position the strip vertical and parallel to the baby’s face. Align strip so that the letter (A-H) at the saggital suture is the same as the letter at the tragus
     

3
Using a marker pen, mark the two sensor sites at the ends of the arrows.
Note: DO NOT shave these insertion marks.
Marking.jpg (25681 bytes)
4
Using gauze and cleaning solution appropriate for gestation age clean the insertion sites.
  • This is important to help the tape to adhere.
  • It may help to create a vertical part in the hair.
5
Site electrodes in the following manner.
  • Hold skin taut
  • Insert a needle electrode subdermally at insertion sites.
  • Leads are directed to the top of the head
  • Ensure all metal is under the dermal layer
  • Secure electrode with a thin strip of hypafix tape under and over the needle (cross over method). Then place one strip across the top. Ensure tape is positioned so as not to completely obscure all the black area of the plastic sheath; this is important so that you can visualise whether the needle is becoming dislodged.

Click for larger image

6

Turn infants head over and repeat process.
7
Site reference electrode,
  • select a site with no hair on or near the shoulder
  • Clean the area with water and gauze
  • Using cotton tips clean the area with a very small amount of NuPrep®
  • Using water and gauze clean of the NuPrep®
  • Site electrode with lead directed towards the head
9
Check electrode signal quality, once green apply wrap hat with adequate tension to support electrodes.

10

To prevent needle dislodgement and minimise motion artefact
  • Loop sensor wires into two bundles and place near head of bed. (One bundle for the right electrodes and one for the left)

Click for larger image
11
  • Electrode sites must be checked with all cares for signs of infection and displacement.
  • Ensure all metal is under the dermal layer
  Note: To prevent likelihood of needle stick injury always check impedance signal before removing wrap hat or touching head.

If at any stage the impedance colour turns amber or red, the needle is likely to be dislodged. Remove wrap hat with care

NB. Needles can remain insitu for duration of monitoring but if dislodged, replace with new one.
 

Reporting

As a minimum the trace should be reviewed and reported as part of the daily ward round. This report shall be recorded in the clinical notes. Additional reviews and reporting will occur as required and be documented in the clinical record.

Documentation

Step
Action
1
Document the time monitoring was commenced on the infants observation chart
2
Document use of low impedance needles or hydrogel sensors
3
When using needle electrodes document that the site and needle position has been checked (with cares)
4
Document if needles or hydrogel sensors are replaced

Commence Assessment (CFM Natus Monitor)

Step
Action
1
Plug monitor into wall power supply.

2

Turn on the AC power switch (at back of monitor).

3

Touch the record button

4

Enter patient details, then press next

5

Select 5-electrode configuration

6

Press “Start Recording”.
7
Select the Impedance selector button to check sensors

Electrode impedance figure will be appear

The top 2 electrode correspond to the left hand electrodes, bottom 2 to the right)

  • OK (Green) = values <10 kO
  • Marginal (Amber) = 10 – 20 kO
  • Extremely poor (Red) = > 20 kO
8
Once impedance is satisfactory press EEG button to give you real time monitoring.
9
Press 2 channel aEEG seletor Icon

Mark Events

During monitoring Mark events i.e. suctioning, cares, observation of seizure-like movements, administration of anticonvulsants

Step
Action
1
Select “markers” icon (bottom of screen)
2
Press one of the predefined events or type in event, then press add
3
Press home
4
A green line will appear on the aEEG graphics. To recall the event data touch screen above red marker line

Suspend & Resume Monitoring

Step
Action
1
Press “Record” button to stop recording.
2
Press “Stop recording”
3
The session is now suspended
4
To resume monitoring press “Record” button

5

Press “Resume Recording”

Turn Monitor Off

Step
Action
1
Press “Record” button to stop recording.
2
Press “Stop recording”
3
Press “Patient/Close” overlay, and press close session
4
Press “Tools” overlay, and press system

5

Press “Shut down”

Commence Assessment (BRM3 Monitor)

Step
Action
1
Plug monitor into wall power supply.
2
Turn on the AC power switch (at back of monitor).
3
On main menu screen touch the ‘assess patient’ button to display the new patient screen.
4
Touch the white field next to display the on-screen keypad.
5
Typing the appropriate data, touch enter at the end of each entry.

6

Touch the appropriate check box to select the gender.

7

Use arrows to adjust birth weight / current weight.

8

Touch appropriate date on calendar to enter birth date.

9

Patient name, NHI, and clinicians initials must be entered before assessment can commence.
10
Once assessment has commenced you can return to this page to complete if required
  • press tools
  • patient details
  • enter any additional patient details (as above)

Check Contact Quality

Contact impedance is displayed on the ‘signal status screen’.

Step
Action
1
On main menu screen touch the ‘check signal’ button.
2
All 4 dots displayed on the graphics should be green.
3
If dots are yellow or red check the corresponding electrode.
4
Once all dots are green press the ‘OK’ button.

Mark Events

During monitoring Mark events i.e. suctioning, cares, observation of seizure-like movements, administration of anticonvulsants

Step
Action
1
Touch ‘mark events’ button.
2
Touch white description area to display the onscreen keypad.
3
Enter a brief note.
4
Touch enter, then OK.
5
A green line and number will appear on the aEEG graphics. To recall the event data touch the green line on the screen.

Suspend Monitoring

Step
Action
1
Press stop.
2
On confirmation screen, press suspend
3
Disconnect electrodes / cable from DAU (as required)
4
When ready to recommence, plug cable back into DAU and press resume assessment

Turn Monitor Off

Step
Action
1
On main menu screen touch ‘shutdown’ button.
2
On confirmation screen touch yes.
3
Once screen says shutdown complete, turn AC power off.
4
Remove sensors by dampening the gel with water.

References

1
BrainZ BRM2 Brain monitor reference manual

2

CFM Brainz Monitor guide

3

Natus educationand cinical support www.sanmedics.com.au