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Definition of Terms
Oxygen therapy is one of the most common therapies used in the neonates, especially in the preterm population. Supplemental oxygen has been shown to improve survival and neurodevelopmental outcomes.
However, exposure to higher oxygen saturation for prolonged periods is associated with an increased incidence of retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), cerebral palsy, periventricular leukomalacia and necrotizing enterocolitis (NEC).
Continuous pulse oximetry allows the clinician to monitor oxygen saturation and titrate oxygen therapy to target levels within a defined range.
Evidence for oxygen saturation target ranges in the term neonates is limited. Although term neonates (>1.5kg) are not at risk of ROP, hyperoxia may have harmful effects on cerebral perfusion and exacerbate oxidative stress in the event of hypoxic ischemic injury.
Oxygen saturations should be targeted within the range of 91-95%, when receiving oxygen therapy, in both preterm and term neonates.
Fi02 is one of several determinants of arterial oxygenation provided by supplemental oxygen therapy. Additional factors including but not limited to positive end expiratory pressure and mean airway pressure are specific to the mode of oxygen therapy used. This document should be used in conjunction with the appropriate policy regarding the specific oxygen mode of delivery provided to the neonate.
To provide medical and nursing staff at the Royal Children’s Hospital with clear parameters within which SpO2 levels should be maintained, in the neonate when they are receiving oxygen.
Nursing Assessment Guideline.
1. Alarm limits
2. Oxygen titration in response to saturation monitoring
Preterm neonates commonly experience fleeting desaturations which normally self-correct without interference.
Accuracy of continuous pulse oximetry is limited as it is based on time-averages over several heartbeats, to reduce the occurrence of false alarms due to erratic movements. This may result in less sensitivity to brief desaturations
<30 seconds or marked <70%. Assessment of the patient’s oxygen requirement should be a combination of continuous pulse oximetry with patient assessment.
Acute severe or prolonged desaturations should be treated as an emergency- assessing the patient using DRSABC.
For any neonate with a Sp02 persistently outside the target range, oxygen therapy should be titrated by nursing or medical staff to maintain Sp02 within the target range.
A significant increase in inspired fraction of oxygen (>10%) required to maintain target saturations should be reviewed by a medical team member.
Desaturations should be documented in the patient’s EMR observation flow sheet. Information should include if the event was apnoeic or not, the lowest recorded heart rate and desaturation, colour change, activity and position prior to event and intervention required.
Sp02 alone is an inadequate indicator of end-organ perfusion and should be considered in conjunction with patient assessment.
Consider underlying pathology and additional factors causing an increase in oxygen requirement. Optimise patient position and comfort, consider analgesic requirement and benefits of kangaroo care.
In the following circumstances, the above oxygen saturation target ranges may not apply:
Bronchiolitis: Oxygen saturation target of equal to or greater than 90% with supplemental oxygen therapy.
Cyanotic heart disease and duct dependant cardiac lesions: A target range of 75- 85% is typically recommended for neonates with mixed circulation, patient specific parameters must be determined by the treating cardiology or primary medical team.
*Limited evidence is available for a standardised oxygen saturation target range for neonates with cyanotic heart disease. Maintaining saturations >85% may be unachievable in these neonates without causing significant hyperoxia due to cardiac shunting.
Hyperoxia should be avoided in neonates with duct dependant cardiac lesions to avoid pulmonary over circulation, systemic hypo perfusion and sequelae.
Establish persistent pulmonary hypertension of the newborn (PPHN) or *risk of PPHN: Hypoxia should be avoided to reduce pulmonary vasoconstriction and subsequent increased pulmonary vascular resistance, worsening PPHN crisis.
If pulmonary artery pressure is greater than aortic pressure (systemic blood pressure), post-ductal saturations will decrease due to right-to-left shunting.
Oxygen saturation target ranges in these neonates may be altered by the treating medical team. Any deviation from the above guideline should be documented in the neonate’s medical notes and a medical order placed in the EMR
*Risk factors for PPHN include respiratory distress syndrome (RDS), meconium aspiration syndrome (MAS), sepsis, asphyxia, congenital diaphragmatic hernia (CDH), alveolar capillary dysplasia (ACD) and total anomalous pulmonary venous drainage (TAPVD).
Evidence table for this guideline can be viewed here.
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read the disclaimer.
The development of this nursing guideline was coordinated by Alice Benbow, RN, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated May 2020.