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Oxygen therapy and monitoring in neonates

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Overview

Supplemental oxygen must always be monitored. There are risks of too little or too much oxygen.

  • Preterm infants are at risk of ROP with high levels. 
  • Term infants are at risk of pulmonary hypertension if hypoxaemic. 
  • Babies with chronic lung disease are at risk of pulmonary vascular disease if hypoxic.

Monitoring

Pulse Oximetry (SpO2)

  • Any baby receiving oxygen therapy (except chronic babies prior to discharge) should have continuous pulse oximeter monitoring. These are very useful and easy to use. 
  • Accuracy is about ± 2%. The therapeutic range is small. Remember the oxygen dissociation curve in interpreting the result.
Moves to the Left  Moves to the Right
Fetal Hb  (SpO2 higher for given PaO2)
Alkalosis
Low temperature
Low PaCO2
Low 2-3 DPG
Adult Hb  (SaO2 lower for a given PaO2)
Acidosis
High temperature
High PaCO2
Low 2-3 DPG

 Umbilical Artery Catheter

Use in preference to peripheral in VLBW or babies likely to have prolonged or difficult course. Use size 3.5 FG <1000 gms, 5 FG >1000 gms.

Preferably, use a high catheter position (T6-T10) rather than the low position (L3-L4).

Peripheral Artery (Radial, Ulnar or Posterior Tibial)

For Radial/Ulnar, check patency of other artery by transillumination. (Allen test is unreliable.)

Do not use if other artery is not patent.

Arterial Stabs

These are seldom necessary as oxygenation can be determined by SpO2 and CO2 is often inaccurate with a stab on an unsettled baby.

Transcutaneous Monitor (TcPO2 and TcPCO2)

These may be useful in complementing SpO2 monitoring, but are less reliable and more difficult to use.

Capillary Blood Gas

  • This gives an indication of pH and PCO2 only and is not accurate. 
  • They are NOT useful for PO2 assessment. 
  • Interpret results with caution. 
  • Check with an arterial blood gas if necessary. 
  • Interpret in the whole clinical context (i.e. look at the baby). 
  • The result tells you that the true pH and PCO2 are probably no worse (well not much) than the capillary result. 
  • Do not repeat an imprecise and not very useful test too often!

Tissue Oxygenation

This is dependent on the tissues need (utilisation or uptake) and oxygen delivery. O2 delivery varies with blood flow and O2 content, in turn a product of haemoglobin and saturation.

Oxygen saturation targets

Infants PaO2 (kPa) Saturation range Alarm limits
Preterm <36 weeks     6.5 - 9.0 90-94%  89-95%
Term(≥ 36 weeks) or post-term   8.0 - 12.0 90-99% 
In the first 24 hours,
95-99%
 90-99%
In the first 24 hours,
95-99%
CLD AND 36 weeks PMA  8.0 - 10.0 90-95% 88-96% 

Standing orders for nursing staff

Oxygenation and oxygen therapy must be closely monitored. Appropriate use is life saving but inappropriate use has dangers: i.e. high levels contributing to retinopathy of prematurity and low levels to pulmonary hypertension.

In unwell infants, oxygen needs are continually changing and the nurse should vary the inspired oxygen concentration within these guidelines.

  1. A cyanosed baby or one with a low saturation (SpO2) should be given enough oxygen to become pink or saturated. It may be necessary to initiate other resuscitative procedures. Call medical staff for urgent assistance. 
  2. Babies receiving supplemental oxygen, or those likely to need it should be monitored by continuous pulse oximetry, (with the exception of babies close to being discharged on oxygen). If an arterial line is in situ, regular blood gases should be done. The frequency of these varies with the clinical situation (discuss this with medical staff or NS-ANPs). 
  3. For recommended values see saturation targets above. Any different range for an individual baby should be noted and signed on the nursing chart by Dr/NS-ANP.
  4. The nurse should alter the inspired oxygen to maintain the appropriate SpO2/PaO2. Remember that babies having apnoeas need to breath to oxygenate: it may be more appropriate to stimulate, bag or change ventilation settings rather than increase FiO2
  5. If there is a sustained change in FiO2 of more than 0.1 (10%), inform medical staff. 
  6. Be careful to decrease FiO2 after a desaturation and avoid overshooting to high SpO2 levels
  7. With Persistent Pulmonary Hypertension of the Newborn, FiO2 is not to be decreased except on (signed) medical orders. 
  8. In some babies with complex cardiac conditions, a low saturation is desirable to help prevent ductus closure and excessive pulmonary blood flow. In these babies, the medical staff will determine the desired saturation range.

Nursing responsibilities

  1. Baby has a clear airway and is suctioned as per protocol.
  2. Oxygen is administered to maintain SpO2 as per standing orders. Alarm limits are set accordingly.
  3. SpO2 lead position should be changed every four hours.
  4. Oxygen level is checked and documented (including amount of supplemental oxygen and SpO2 levels):
    - at nursing handover (beginning of each shift)
    - hourly if baby on CPAP or ventilated
    - 2 - 3 hourly if baby receiving LF O2 / incubator O2
    NB: on infants where O2 levels require frequent alteration, check more frequently (e.g. on returning from meal break) 
  5. Medical staff are notified if a baby's oxygen requirement increases consistently by 10% or more.
  6. An oxygen analyser, calibrated at the beginning of each shift, is used when oxygen is administered via:
    - CPAP
    - Ventilator
    - Incubator
  7. Oxygen analyser is calibrated to:
    - air if baby receiving <60% O2
    - 100% O2 if baby receiving >60% O2
  8. Humidification appropriate to oxygen delivery is provided at all times

Equipment changes

  1. Change CPAP and ventilator circuits weekly and document on Care Map.
  2. Change litre bag of H2O appropriately to ensure humidifier water level maintained.
  3. Nasal prongs are changed once a week or in between if blocked with nasal secretions.
  4. Oxygen masks / cones / portable oxygen analysers and SPO2 probes are changed when baby discharged.

References

  • Askie LM, Henderson-Smart DJ, Irwig L, Simpson JM. Oxygen-saturation targets and outcomes in extremely preterm infants. N Engl J Med 2003;349:959-67

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Document Control

  • Date last published: 28 February 2013
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years