The document discusses guidelines for using amplitude integrated EEG (aEEG) or cerebral function monitoring (CFM) to assess brain activity in newborns experiencing hypoxic-ischemic encephalopathy (HIE) or other neurological conditions. CFM can help predict outcomes from HIE by identifying abnormal brain activity in the first 6 hours after birth and detecting neonatal seizures. The document provides guidance on proper electrode placement and interpreting CFM readings to distinguish normal and abnormal brain activity patterns while avoiding common artifacts.

2.  HIE in term and late preterm infant is a significant
cause of mortality and neurodisability.
 Its incidence in UK is 1—1.5 per 1000 live birth and it
account for up to 30% of cerebral palsy.

3.  -evidence of anti partum asphyxia.
 -respiratory depression at birth
 Encephalopathy in immediate post natal
period

4. APGAR score of<5 at 10 min
acidosis with in 60 min of birth(umbilical cord –
capillary-or arterial ph<7.0)
base deficit >16mmol/L in 60 min of birth
The presence of these objective parameter in
addition to background of cerebral function
monitoring(CFM) is require in case selection for
management and intervention

5. CFM))cerebral function monitoring

6. For CFM in nicuProtocol
The CFM provides information on global cerebral activity.
An abnormal CFM trace in the first 6hours of life, after an
asphyxia insults, is a predictive of abnormalities on acute
neurological testing and long term neurodevolopmental
outcome.CFM also provide information information on
duration ,intensity and frequency of neonatal seizures that
may be helpful in diagnosis and treatment. Aim of this
protocol provide guidance on operation and interpretation
of CFM

7. :The Guidance
An amplitude integrated EEG (CFM) is a device of a
minimally invasive tool used to measure background
electrocortical activity in the brain. it has 2 electrode place
on either side of baby head and a third electrode act as
ground placed anteriorly to anterior fontanel.CFM
technology was initially developed in 1960 for adult
suffering neurological depression or under goes surgery,
however due to technical constrains it didn’t gain wide
acceptance. Then it was reintroduce in1980 by
neonatologist. research show it could be of sensitive tool for
predicting HIE if applied in first 6-12hours following
prenatal asphyxia .

9. Indication:
HIE
Seizures or clinical scenario mimicking seizure
disorder(apnea ,hypertension ,tachycardia).
Significant neurological disorder(eg, brain malformation,
vascular lesion).
Post cardiac arrest
In born error of metabolism(eg, urea cycle disorder
,hypoglycemia, hypocalcaemia).
Neonatal abstinence syndrome(eg, alcohol/opiate
withdrawal).

10. Application guidance
The main screen divided into 2main graphic strips, the top
measure electrical brain activity, and the bottom strips
measure the impedance of lead and evaluate the connection
of the lead to patient scalp.

11. The wave analysis:
 Normal tracing :the amplitude assessed by measuring the upper margin
which should be above 10microvolt and lower margin which should be
greater than 5 microvolt.

12. Moderately abnormal tracing, the upper margin>10mv and lower
margin <5mv.

13. Severely abnormal tracing :upper margin less than
5 and lower margin less than 10.

14.  Seizure, rising and narrowing in CFM,and gape of
rising and narrowing(lower margin become suddenly
raised for several min)with repetitive pattern

15. During integrating aEEG there are most common artefact you
should encounter when using aEEG:
 Shift/drift of baseline artefact: sometime during the suppression phase the
electrode will still record so the actual line of 0mv now lie in 3mv

16. Movement artefact: some time movement can cause sudden shift
in aEEG and can be misinterpreted as seizure if the raw of aEEG not
reviewed.

17. Respiratory artefact :respiration can similarly be a process which create a lot of
movement, this generate constant interference which not only lifts the lower
margin but also can make the entire recording useless.
Here its helpful to determine the frequency of the artefact and compare it with respiration
parameter.
The amplitude height can be very variable and is ,for example, often low during high frequency
respiration.

18. Muscle artefact :proximity to the usual electrode position there is many strong
muscle ,e.g. ,musculus temporalis, in particular needle which placed directly to
the muscle result in recording electrogram rather than aEEG.
Muscle artefact are characterized by high frequency and there for easy to identify
one could practically say the EEG looks like muscle tremor.

19. ECG artefact: occasionally, the EEG drives heart activity and thus an
ECG ,this result in baseline drift.

20. Sensor contact or “short circuit” artefact: this occur if the lead come into
direct contact, ,the confusing aspect is that a very good impedance is measured and there
for ,the user doesn’t think that any thing wrong with the electrode, ,this tend to occur when
using needle electrode if placed facing each other or too close to each other.

21. Edema or hematoma:
Fixing electrode over larger edema or hematoma result in
an artefact.the EEG signal is weakened and generally
produce electrical shunting, where by its possible to give
the appearance of absent brain activity.

22. conclusion
Artefacts are found on average in approx.12% of recording
period. of theses 45% are caused by movement and
remaining 55% by electrical interference
By implementing the raw EEG in the recording it
becomes significantly easier to identify artefacts
reliably.

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