NHS FORTH VALLEY Neonatal Oxygen Saturation Guideline

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1 NHS FORTH VALLEY Neonatal Oxygen Saturation Guideline Date of First Issue 11/07/2011 Approved 30/09/2011 Current Issue Date 07/09/2011 Review Date July 2013 Version 1 EQIA Yes 22/10/2011 Author / Contact Group Committee Final Approval Greater Glasgow Guideline Group/Linda Hannah FVRH Neonatal Forum Group 30/09/11 This document can, on request, be made available in alternative formats Version 1 7 th September 2011 Page 1 of 7

Committee Final Approval Greater Glasgow Guideline Group/Linda Hannah FVRH Neonatal Forum Group 30/09/11

2 NHS Forth Valley Consultation and Change Record Contributing Authors: Consultation Process: A Powls and C Lilley Greater Glasgow & Clyde Guideline Group Distribution: Change Record Date Author Change Version Version 1 7 th September 2011 Page 2 of 7

Glasgow & Clyde Guideline Group Distribution: Change Record

3 NHS Forth Valley Women & Children s Unit Neonatal Oxygen Saturation Guideline This guideline is applicable to all medical and nursing staff caring for neonates in FVRH. Permission for the use of this guideline in Forth Valley has been granted by the Greater Glasgow & Clyde Guideline Group Introduction Oxygen is a highly reactive molecule which, whilst essential for life, is toxic in excess. It has been shown that preterm neonates who have been exposed to an excess of oxygen are more likely to have Chronic Lung Disease (CLD) and/or Retinopathy of Prematurity (ROP). Recent trials and case controlled studies have suggested that pathologies may be reduced by lowering the saturation limits set for the most vulnerable babies and introducing strict guidelines about the use of supplementary oxygen 1-5. However, more recent evidence has shown a strong correlation with lower oxygen saturations and mortality. The Boost 2 study, comparing target oxygen saturations of 85-89% versus 91-95% for preterm infants receiving supplementary oxygen,was halted prior to full recruitment due to an interim analysis showing a significantly increased mortality in the group with a lower target oxygen saturation (mortality 19.9 vs. 16.2%,RR %CI, ; p=0.04) Longer term data is not yet available however most units are moving to higher targeted oxygen saturation limits to reflect the strong statistical significance of this finding. 6 Continuous monitoring of saturation is mandatory for all babies under 32 weeks gestation. It should always be remembered that pulse oximetry is limited in its ability to detect hyperoxia, the gold standard for which is the partial pressure of oxygen (po2) in arterial blood. Therefore, these babies should also have po2 monitored intermittently by blood gas analysis. BAPM guidelines for the management of babies with Respiratory Distress Syndrome (RDS) 7 have recommended that the partial pressure of oxygen should be maintained at 6-10 kpa, however there is a lack of high grade evidence to support this recommendation. Desaturation episodes are commonly due to apnoea or intrapulmonary shunting and are not appropriately treated by immediate increase in the FiO2. Furthermore, desaturation alarms may be due to motion or perfusion artefact. If the FiO2 is increased during such episodes there is a risk of the baby becoming hyperoxic as the episode resolves. Where there is a true deterioration in oxygenation, the more appropriate response may be to initiate, or increase ventilatory support rather than increase FiO2. Recent guidelines from the British Thoracic Society have recommended minimum saturation levels for babies with established chronic lung disease to reduce the likelihood of developing pulmonary hypertension. 8 This guidance is reflected in this document. Version 1 7 th September 2011 Page 3 of 7

4 The Target Range represents the values we are aiming for when the infant is stable and at rest. The Saturation limits to be set on the pulse oximeter are deliberately lower than the target range to limit the number of desaturation alarms and discourage frequent, and often inappropriate, increases in FiO2. For infants who are in air the upper limit can be set at 100% however must be reset to the limits documented below if maintained in oxygen. Babies at risk of ROP < 1500g or <32 weeks Babies discharged from ROP screening & All other babies Target Range 91-95% >92% Limits to be set on 89-95% 91-98% monitor * Note that this recommended range is not applicable to infants with cyanotic congenital heart disease or persistent pulmonary hypertension of the newborn. Please refer to appropriate guidelines for the care of these infants Limits should be checked at the start of each shift and documented. Response to Desaturations Whilst this new guideline has set higher oxygen saturation targets it remains important to avoid hyperoxia in infants at risk of ROP. Arguably, this issue is now more important than previously, as the very studies that have recently identified a higher mortality in the group of infants with lower set limits also report higher rates of ROP in the group with higher set limits. The following approaches to help avoid excessive oxygen use and limit over reaction to destauration events should be considered first- No Treatment. There should always be an assessment to determine whether the desaturations represents monitoring artefact. Look at the monitor to ensure there is a good pulse wave and that the heart rate correlates with the ECG. Remember to look at the baby. Many babies will recover from desaturation events spontaneously with no intervention. Gentle stimulation. If a baby is apnoeic there is no benefit to increasing the FiO2. Manual breaths/ mask ventilation. For the baby who is apnoeic and does not respond to stimulation. When performed with blended air &oxygen to provide a similar FiO2 to that which the baby is currently receiving. If an increased FiO2 is necessary When it is necessary to increase the FiO2 (if SpO2 remains low after adequate respirations have been established) this should be done in small increments of around 5%. If the FiO2 is increased by more than 5% from baseline levels the carer (doctor or Version 1 7 th September 2011 Page 4 of 7

increases in FiO2. For infants who are in air the upper limit can be set at 100% however must be reset to the limits documented below if maintained in oxygen.

5 midwife/nurse) should remain with the baby until the SpO2 recovers and the FiO2 has been returned to its original level. Alarms should not be muted unless the carer remains with the baby. If it is not possible to return the FiO2 to a level within 5% of the baseline level a review of ventilatory requirements is warranted. Making large changes in FiO2 and walking away is strongly to be discouraged. Response to high saturation alarms It is important to respond to high saturation alarms with the same degree of urgency as the response given to desaturation alarms. References 1 Lily C. Chow, Kenneth W. Wright, and Augusto Sola. Can Changes in Clinical Practice Decrease the Incidence of Severe Retinopathy of Prematurity in Very Low Birth Weight Infants? Pediatrics 2003; 111: W Tin, D W A Milligan, P Pennefather, and E Hey Pulse oximetry, severe retinopathy, and outcome at one year in babies of less than 28 weeks gestation. Arch. Dis. Child. Fetal Neonatal Ed., Mar 2001; 84: F L. M. Askie, D. J. Henderson-Smart, L. Irwig, and J. M. Simpson. Oxygen-Saturation Targets and Outcomes in Extremely Preterm Infants. New England Journal of Medicine 2003; 349; The STOP-ROP Multicenter Study Group. Supplemental therapeutic oxygen for prethreshold retinopathy of prematurity (STOP-ROP), a randomised, controlled trial. I: Primary outcomes. Pediatrics 2000;105: Askie LM, Henderson-Smart DJ, Ko H. Restricted versus liberal oxygen exposure for preventing morbidity and mortality in preterm or low birth weight infants. Cochrane Database of Systematic Reviews 2009, Issue 1. 6 Stenson et al Engl J Med 2011; 364: April 28, Management of Neonatal Respiratory Distress Syndrome. RCPCH Guidelines for Good Practice Dec 2000 Version 1 7 th September 2011 Page 5 of 7

Making large changes in FiO2 and walking away is strongly to be discouraged.

6 8 BTS guidelines for home oxygen in children Magee, R A Primhak, M P Samuels, N J Shaw, S Stevens, C Sullivan, J A I M Balfour-Lynn, D J Field, P Gringras, B Hicks, E Jardine, R C Jones, A G Taylor, C Wallis and on behalf of the Paediatric Section of the Home Oxygen Guideline Development Group of the BTS Standards of Care Committee Thorax 2009;64;ii1-ii26 Version 1 7 th September 2011 Page 6 of 7

C Wallis and on behalf of the Paediatric Section of the Home Oxygen Guideline Development Group of

7 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - fv-uhb.nhsfv-alternativeformats@nhs.net Version 1 7 th September 2011 Page 7 of 7

To request another language for a patient, please contact 01786 434784.

More detailed background information and references can be found at the end of this guideline

More detailed background information and references can be found at the end of this guideline Neonatal Intensive Care Unit Clinical Guideline Oxygen Over the past few years there have been significant changes, based on high quality research, in our understanding of how to give the right amount