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Duport O, Rolle VL, Guerrero G, Beuchée A, Hernández AI. Parametric analysis of an integrated cardio-respiratory model in preterm newborns during apnea. Comput Biol Med 2024; 173:108343. [PMID: 38513388 DOI: 10.1016/j.compbiomed.2024.108343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/16/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Abstract
The analysis of the complex interactions involved in the acute physiological response to apnea-bradycardia events in preterm newborns remains a challenging task. This paper presents a novel integrated model of cardio-respiratory interactions, adapted to preterm newborns. A sensitivity analysis, based Morris' screening method, was applied to study the effects of physiological parameters on heart rate and desaturation, during the simulation of a 15-seconds apnea-bradycardia episode. The most sensitive parameters are associated with fundamental, integrative physiological mechanisms involving: (i) respiratory mechanics (intermediate airways and lung compliance), (ii) fraction of inspired oxygen, (iii) metabolic rates (oxygen consumption rate), (iv) heart rate regulation and (v) chemoreflex (gain). Results highlight the relevant influence of physiological variables, involved in preterm apnea-bradycardia events.
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Affiliation(s)
- Orlane Duport
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Virginie Le Rolle
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France.
| | - Gustavo Guerrero
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Alain Beuchée
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
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Care Bundle to Improve Oxygen Maintenance and Events. Pediatr Qual Saf 2023; 8:e639. [PMID: 36926217 PMCID: PMC10013622 DOI: 10.1097/pq9.0000000000000639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/14/2023] [Indexed: 03/15/2023] Open
Abstract
Prolonged periods spent outside the target range of oxygen saturation (SpO2) in preterm infants, along with frequent desaturation events, predispose them to retinopathy of prematurity (ROP) and long-term neurodevelopmental impairment. The primary aim of this study was to increase the mean time spent within the target SpO2 range (WTR) by 10% and to reduce the frequency of desaturation events by 5 events per patient day, respectively, within 18 months of implementing a care bundle. Methods This study was completed in a 46-bed neonatal intensive care unit (NICU), involving 246 staff members and led by a quality improvement team. The change interventions included implementing new practice guidelines, reviewing daily summaries of SpO2 maintenance, daily infant wellness assessment, standardizing workflow, and responding to SpO2 alarms. In addition, we collected staff satisfaction and compliance with change interventions, resource use, and morbidity and mortality data at discharge. Results The mean time spent WTR increased from 65.3% to 75.3%, and the frequency of desaturation events decreased from 25.1 to 16.5 events per patient day, respectively, with a higher magnitude of benefit in infants on days with supplemental oxygen. Postimplementation, the duration of high-frequency ventilation and supplemental oxygen were lower, but morbidity and mortality rates were similar. Staff satisfaction with training workshops, coaching, use of the infant wellness assessment tool, and SpO2 alarm management algorithms were 74%, 82%, 80%, and 74%, respectively. Conclusion Implementing a care bundle to improve oxygen maintenance and reduce desaturation events increased the time spent WTR and reduced the frequency of desaturation events.
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Sandal O, Ceylan G, Topal S, Hepduman P, Colak M, Novotni D, Soydan E, Karaarslan U, Atakul G, Schultz MJ, Ağın H. Closed–loop oxygen control improves oxygenation in pediatric patients under high–flow nasal oxygen—A randomized crossover study. Front Med (Lausanne) 2022; 9:1046902. [DOI: 10.3389/fmed.2022.1046902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022] Open
Abstract
BackgroundWe assessed the effect of a closed–loop oxygen control system in pediatric patients receiving high–flow nasal oxygen therapy (HFNO).MethodsA multicentre, single–blinded, randomized, and cross–over study. Patients aged between 1 month and 18 years of age receiving HFNO for acute hypoxemic respiratory failure (AHRF) were randomly assigned to start with a 2–h period of closed–loop oxygen control or a 2–h period of manual oxygen titrations, after which the patient switched to the alternative therapy. The endpoints were the percentage of time spent in predefined SpO2 ranges (primary), FiO2, SpO2/FiO2, and the number of manual adjustments.FindingsWe included 23 patients, aged a median of 18 (3–26) months. Patients spent more time in a predefined optimal SpO2 range when the closed–loop oxygen controller was activated compared to manual oxygen titrations [91⋅3% (IQR 78⋅4–95⋅1%) vs. 63⋅0% (IQR 44⋅4–70⋅7%)], mean difference [28⋅2% (95%–CI 20⋅6–37⋅8%); P < 0.001]. Median FiO2 was lower [33⋅3% (IQR 26⋅6–44⋅6%) vs. 42⋅6% (IQR 33⋅6–49⋅9%); P = 0.07], but median SpO2/FiO2 was higher [289 (IQR 207–348) vs. 194 (IQR 98–317); P = 0.023] with closed–loop oxygen control. The median number of manual adjustments was lower with closed–loop oxygen control [0⋅0 (IQR 0⋅0–0⋅0) vs. 0⋅5 (IQR 0⋅0–1⋅0); P < 0.001].ConclusionClosed-loop oxygen control improves oxygenation therapy in pediatric patients receiving HFNO for AHRF and potentially leads to more efficient oxygen use. It reduces the number of manual adjustments, which may translate into decreased workloads of healthcare providers.Clinical trial registration[www.ClinicalTrials.gov], identifier [NCT 05032365].
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Bancalari E, Claure N. Importance and Challenges Associated with Oxygen Control in Premature Infants. J Pediatr 2022; 247:8-9. [PMID: 35640674 DOI: 10.1016/j.jpeds.2022.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 05/25/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida.
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
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Dijkman KP, Mohns T, Dieleman JP, van Pul C, Goos TG, Reiss IK, Andriessen P, Niemarkt HJ. Predictive Intelligent Control of Oxygenation (PRICO) in preterm infants on high flow nasal cannula support: a randomised cross-over study. Arch Dis Child Fetal Neonatal Ed 2021; 106:621-626. [PMID: 33972265 DOI: 10.1136/archdischild-2020-320728] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/24/2021] [Accepted: 04/08/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To investigate the efficacy of automated control of inspired oxygen (FiO2) by Predictive Intelligent Control of Oxygenation (PRICO) on the Fabian ventilator in maintaining oxygen saturation (SpO2) in preterm infants on high flow nasal cannula (HFNC) support. DESIGN Single-centre randomised two-period crossover study. SETTING Tertiary neonatal intensive care unit. PATIENTS 27 preterm infants (gestational age (GA) <30 weeks) on HFNC support with FiO2 >0.25. INTERVENTION A 24-hour period on automated FiO2-control with PRICO compared with a 24-hour period on routine manual control (RMC) to maintain a SpO2 level within target range of 88%-95% measured at 30 s intervals. MAIN OUTCOME MEASURES Primary outcome: time spent within target range (88%-95%). SECONDARY OUTCOMES time spent above and below target range, in severe hypoxia (SpO2 <80%) and hyperoxia (SpO2 >98%), mean SpO2 and FiO2 and manual FiO2 adjustments. RESULTS 15 patients received PRICO-RMC and 12 RMC-PRICO. The mean time within the target range increased with PRICO: 10.8% (95% CI 7.6 to 13.9). There was a decrease in time below target range: 7.6% (95% CI 4.2 to 11.0), above target range: 3.1% (95% CI 2.9 to 6.2) and in severe hypoxia: 0.9% (95% CI 1.5 to 0.2). We found no difference in time spent in severe hyperoxia. Mean FiO2 was higher during PRICO: 0.019 (95% CI 0.006 to 0.030). With PRICO there was a reduction of manual adjustments: 9/24 hours (95% CI 6 to 12). CONCLUSION In preterm infants on HFNC support, automated FiO2-control by PRICO is superior to RMC in maintaining SpO2 within target range. Further validation studies with a higher sample frequency and different ventilation modes are needed.
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Affiliation(s)
- Koen P Dijkman
- Neonatology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Thilo Mohns
- Neonatology, Maxima Medical Centre, Veldhoven, The Netherlands
| | | | - Carola van Pul
- Clinical Physics, Maxima Medical Centre, Veldhoven, The Netherlands.,Applied Physics, University of Technology Eindhoven, Eindhoven, The Netherlands
| | - Tom G Goos
- Neonatology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Peter Andriessen
- Neonatology, Maxima Medical Centre, Veldhoven, The Netherlands.,Applied Physics, University of Technology Eindhoven, Eindhoven, The Netherlands
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Grottenberg BG, Korseth KM, Follestad T, Stensvold HJ, Støen R, Austeng D. Stable incidence but regional differences in retinopathy of prematurity in Norway from 2009 to 2017. Acta Ophthalmol 2021; 99:299-305. [PMID: 32914576 DOI: 10.1111/aos.14593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To explore the changes over time and regional differences in the incidence of retinopathy of prematurity (ROP) in a national cohort of infants born <28 weeks' gestational age (GA). METHODS A population-based study of infants with GA <28 weeks in Norway from 2009 to 2017. Prospectively collected data on clinical variables and outcomes were obtained from the Norwegian Neonatal Network. RESULTS Of 1499 live-born infants transferred to a neonatal intensive care unit, 1156 were discharged alive. Four-hundred and fifty-eight infants (39.6%) had ROP, 152 (13.1%) had severe ROP, and 110 (9.5%) were treated for ROP. Eleven hundred infants (95.2%) had complete data sets. In a model comprising region of primary care, GA [odds ratios (OR): 0.65; 95% CI: 0.55-0.77], growth velocity (OR: 1.10; 95% CI: 1.00-2.00), medically treated patent ductus arteriosus (OR: 1.80; 95% CI: 1.19-2.72), weeks of supplemental oxygen (OR: 1.07; 95% CI: 1.03 to 1.11) and region of primary care (OR: 4.95; 95% CI: 3.05-8.04 for the pair of regions with the highest estimated OR) were significantly associated with severe ROP. Additionally, institutional differences for severe ROP were found, with ORs from 0.41 (95% CI: 0.05-3.23) to 5.36 (95% CI: 3.05-9.43) using the largest institution as reference. Incidences were stable over time after adjusting for GA. A larger proportion was treated with anti-vascular endothelial growth factor after 2011. CONCLUSIONS The incidence of severe ROP was stable between 2009 and 2017 in Norway. Regional and institutional differences need to be explored in future studies.
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Affiliation(s)
- Beanca Gjølberg Grottenberg
- Department of Clinical and Molecular Medicine Norwegian University of Science and Technology Trondheim Norway
- Department of Internal Medicine Stavanger University Hospital Stavanger Norway
| | - Katinka Madtzog Korseth
- Department of Clinical and Molecular Medicine Norwegian University of Science and Technology Trondheim Norway
- Department of Neurology St. Olavs Hospital Trondheim University Hospital Trondheim Norway
| | - Turid Follestad
- Department of Public Health and Nursing Norwegian University of Science and Technology Trondheim Norway
| | - Hans Jørgen Stensvold
- Norwegian Neonatal Network Oslo University Hospital Oslo Norway
- Neonatal Department Division of Paediatric and Adolescent Medicine Oslo University Hospital Rikshospitalet Oslo Norway
| | - Ragnhild Støen
- Department of Clinical and Molecular Medicine Norwegian University of Science and Technology Trondheim Norway
- Department of Neonatology St. Olavs Hospital Trondheim University Hospital Trondheim Norway
| | - Dordi Austeng
- Department of Neuromedicine and Movement Science Norwegian University of Science and Technology Trondheim Norway
- Department of Ophthalmology St. Olavs Hospital Trondheim University Hospital Trondheim Norway
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Gottimukkala SB, Sotiropoulos JX, Lorente-Pozo S, Monti Sharma A, Vento M, Saugstad OD, Oei JL. Oxygen saturation (SpO2) targeting for newborn infants at delivery: Are we reaching for an impossible unknown? Semin Fetal Neonatal Med 2021; 26:101220. [PMID: 33674253 DOI: 10.1016/j.siny.2021.101220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
For more than 200 years, pure oxygen was given ad libitum to newborn infants requiring resuscitation. Due to oxidative stress and injury concerns, a paradigm shift towards using "less" oxygen, including air (21% oxygen) instead of pure (100%) oxygen, occurred about twenty years ago. A decade later, clinicians were advised to adjust fractional inspired oxygen (FiO2) to target oxygen saturations (SpO2) that were derived from spontaneously breathing, healthy, mature infants. Whether these recommendations are achievable, beneficial, harmful or redundant is uncertain. The underlying pathology leading to resuscitation varies between infants and may considerably alter an infant's response to supplemental oxygen. In this review, we summarize available evidence for the use of SpO2 monitoring at delivery for newborn infants, elucidate existing knowledge and service gaps, and suggest future research recommendations that will lead to the safest clinical strategies for this standard and important practice.
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Affiliation(s)
- Sasi Bhushan Gottimukkala
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia; Department of Newborn Care, The Royal Hospital for Women, Randwick, NSW, Australia
| | | | | | | | | | | | - Ju Lee Oei
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia; Department of Newborn Care, The Royal Hospital for Women, Randwick, NSW, Australia.
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Abstract
PURPOSE OF REVIEW Over the past two decades, numerous algorithms for automated control of the fraction of inspired oxygen (FiO2) have been developed and incorporated into contemporary neonatal ventilators and high-flow devices in an attempt to optimize supplemental oxygen therapy in preterm infants. This review explores whether current evidence is sufficient to recommend widespread adoption of automated oxygen control in neonatal care. RECENT FINDINGS To date, 15 studies have compared automated versus manual control of FiO2 in preterm infants on respiratory support. This includes four new randomized cross-over trials published in the last 2 years. Available evidence consistently demonstrates a significant improvement in time spent within the target saturation range with automated FiO2 control. There are fewer episodes of severe hypoxemia and fewer manual FiO2 adjustments with automated oxygen control. Nursing workload may be reduced. However, no currently completed studies report on clinical outcomes, such as chronic lung disease or retinopathy of prematurity. SUMMARY Automated oxygen control appears to be a reasonable option for FiO2 titration in preterm infants on respiratory support, if resources are available, and might substantially reduce nursing workload. Further randomized clinical trials to explore its effects on clinical outcomes are required.
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Affiliation(s)
- Souvik Mitra
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Dalhousie University and IWK Health
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Douglas McMillan
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Dalhousie University and IWK Health
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Gentle S, El-Ferzli G, Winter L, Salas AA, Philips Iii JB. Oxygen saturation histogram monitoring to reduce death or retinopathy of prematurity: a quality improvement initiative. J Perinatol 2020; 40:163-169. [PMID: 31506527 DOI: 10.1038/s41372-019-0486-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/15/2019] [Accepted: 07/20/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Maintaining preterm infants within a goal oxygen saturation range challenges care providers. Through periodic assessment of saturation trends on infants' bedside histogram reports, our initiative aimed to (1) increase time spent at goal saturations and (2) reduce death or severe retinopathy of prematurity. STUDY DESIGN The initiative integrated histogram monitoring into provider, respiratory, and nursing care. Achieved oxygen saturations, chart audits, and bedside histogram monitoring flowsheets provided process measures with the outcome measure of death or severe retinopathy of prematurity. RESULTS In infants <29 weeks' gestation (n = 518), the rate of death or severe retinopathy of prematurity prior to hospital discharge decreased from 32.1% to 18.0%. Time at goal saturations (90-95%) increased from 48.7% to 57.6%. CONCLUSION In infants born at <29 weeks' gestation, periodic, multidisciplinary oxygen saturation histogram monitoring improved time at goal saturations and was associated with a reduction in death or severe retinopathy of prematurity.
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Affiliation(s)
- Samuel Gentle
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - Lindy Winter
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ariel A Salas
- University of Alabama at Birmingham, Birmingham, AL, USA
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10
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Huizing MJ, Villamor-Martínez E, Meus S, de Jonge FM, Villamor E. Dutch Neonatal Intensive Care Nurses' Perceptions of Pulse Oximeter Saturation Target Limits for Preterm Infants. J Pediatr Nurs 2019; 49:e36-e41. [PMID: 31439356 DOI: 10.1016/j.pedn.2019.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/07/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To conduct a national survey to assess practice, knowledge, barriers, and perceptions regarding oxygen saturation (SpO2) target limits among Dutch neonatal intensive care unit (NICU) nurses. DESIGN AND METHODS Cross-sectional, web-based survey among 667 nurses from 9 level 3 Dutch NICUs. Part of the questions were based on a clinical scenario (28-weeks preterm infant, treated with CPAP, FiO2 0.4). RESULTS 328 (53.6%) nurses responded to the survey. Of these, 281 (85.7%) reported to know the local policy of SpO2 target limits, and 261 (79.6%) and 244 (74.4%) rightly identified the lower and upper limit, respectively. Six NICUs recently increased their lower SpO2 limit and for 62.0% of their nurses this led to a significant alarm increase. For the majority of the respondents, the baby from the clinical scenario would spend <10% of the time outside the lower or upper SpO2 limits. Automated oxygen control systems were considered a good idea by 59.2% of the respondents, but 53.9% considered allowing parents to participate in FiO2 titration a bad or very bad idea. CONCLUSIONS: The majority of the respondents identified their unit's policy-specified SpO2 target limits and reported that the increase in SpO2 target limits may have led to more alarms. Titration of FiO2 is a part of care that respondents were reluctant to share with parents. PRACTICE IMPLICATIONS A potential increase in the number of SpO2 alarms may lead to alarm fatigue. Although family-centered care philosophy is widely accepted across Dutch NICUs, there are still barriers to overcome.
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Affiliation(s)
- Maurice J Huizing
- Department of Pediatrics, Neonatal Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Eduardo Villamor-Martínez
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, the Netherlands
| | - Stefanie Meus
- Department of Pediatrics, Neonatal Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Fred M de Jonge
- Department of Pediatrics, Neonatal Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Eduardo Villamor
- Department of Pediatrics, Neonatal Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands; School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, the Netherlands.
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Oei JL, Vento M. Is There a "Right" Amount of Oxygen for Preterm Infant Stabilization at Birth? Front Pediatr 2019; 7:354. [PMID: 31555622 PMCID: PMC6742695 DOI: 10.3389/fped.2019.00354] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/09/2019] [Indexed: 11/16/2022] Open
Abstract
The amount of oxygen given to preterm infants within the first few minutes of birth is one of the most contentious issues in modern neonatology. Just two decades ago, pure oxygen (FiO2 1.0) was standard of care and oximetry monitoring was not routine. Due to concerns about oxidative stress and injury, clinicians rapidly adopted the practice of using less oxygen for the respiratory support of all infants, regardless of gestational maturity and pulmonary function. There is now evidence that initial starting fractional inspired oxygen may not be the only factor involved in providing optimum oxygenation and that the amount of oxygen given to babies within the first 10 min of life is a crucial factor in determining outcomes, including death and neurodevelopmental injury. In addition, evolving practice, such as non-invasive respiratory support and delayed cord clamping, need to be taken into consideration when considering oxygen delivery to preterm infants. This review will discuss evidence to date and address the major knowledge gaps that need to be answered in this pivotal aspect of neonatal practice.
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Affiliation(s)
- Ju Lee Oei
- Department of Newborn Care, The Royal Hospital for Women, Randwick, NSW, Australia
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
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12
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Klevebro S, Hammar U, Holmström G, Bottai M, Hellström A, Hallberg B. Adherence to oxygen saturation targets increased in preterm infants when a higher target range and tighter alarm limits were introduced. Acta Paediatr 2019; 108:1584-1589. [PMID: 30951230 DOI: 10.1111/apa.14808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/04/2019] [Accepted: 04/01/2019] [Indexed: 01/22/2023]
Abstract
AIM European consensus guidelines published in May 2013 recommended a target peripheral capillary oxygen saturation (SpO2 ) range of 90-95% for preterm infants. These were incorporated into guidelines at the Karolinska University Hospital, Sweden, in November 2013. This study compared clinical practice before and after those local guidelines. METHODS We included infants who were born between 23 + 0 and 30 + 6 weeks from January 1, 2013 to December, 31 2015 and received intensive care in two Karolinska units. The lower saturation target of 88-92% and alarm limits of 85-95% used before November 2013 were compared to the new higher saturation target of 90-95% and alarm limits of 89-96%. RESULTS Data from 399 infants were analysed. The mean SpO2 was 92.4% with the higher target (n = 301) and 91.1% with the lower target (n = 98). Using the higher instead of lower target meant that the SpO2 was within the prescribed target range more frequently (51% versus 30%) and the proportion of time with SpO2 >95% was increased by 9% (95% confidence interval 7-11%, p < 0.001). CONCLUSION The higher saturation target and tighter alarm limits led to higher mean oxygen saturation, increased adherence to the target and increased time with hyperoxaemia.
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Affiliation(s)
- S Klevebro
- Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
- Sachs’ Children and Youth Hospital South General Hospital Stockholm Sweden
| | - U Hammar
- Unit of Biostatistics Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - G Holmström
- Department of Neuroscience, Ophthalmology Uppsala University Uppsala Sweden
| | - M Bottai
- Unit of Biostatistics Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - A Hellström
- Department of Ophthalmology Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - B Hallberg
- Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
- Department of Neonatal Medicine Karolinska University Hospital Stockholm Sweden
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Tubbs-Cooley HL, Mara CA, Carle AC, Mark BA, Pickler RH. Association of Nurse Workload With Missed Nursing Care in the Neonatal Intensive Care Unit. JAMA Pediatr 2019; 173:44-51. [PMID: 30419138 PMCID: PMC6583427 DOI: 10.1001/jamapediatrics.2018.3619] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in clinical and safety outcomes in neonatal intensive care units (NICUs); when core care is missed, outcomes can worsen. OBJECTIVE To evaluate the association of NICU nurse workload with missed nursing care. DESIGN, SETTING, AND PARTICIPANTS A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assigned infants from March 1, 2013, through January 31, 2014, at a 52-bed level IV NICU in a Midwestern academic medical center. A convenience sample of registered nurses who provided direct patient care and completed unit orientation were enrolled. Nurses reported care during each shift for individual infants whose clinical data were extracted from the electronic health record. Data were analyzed from January 1, 2015, through August 13, 2018. EXPOSURES Workload was assessed each shift with objective measures (infant-to-nurse staffing ratio and infant acuity scores) and a subjective measure (the National Aeronautics and Space Administration Task Load Index [NASA-TLX]). MAIN OUTCOMES AND MEASURES Missed nursing care was measured by self-report of omission of 11 essential care practices. Cross-classified, multilevel logistic regression models were used to estimate associations of workload with missed care. RESULTS A total of 136 nurses provided reports of shift-level workload and missed nursing care for 418 infants during 332 shifts of 12 hours each. When workload variables were modeled independently, 7 of 12 models demonstrated a significant worsening association of increased infant-to-nurse ratio with odds of missed care (eg, nurses caring for ≥3 infants were 2.51 times more likely to report missing any care during the shift [95% credible interval, 1.81-3.47]), and all 12 models demonstrated a significant worsening association of increased NASA-TLX subjective workload ratings with odds of missed care (eg, each 5-point increase in a nurse's NASA-TLX rating during a shift was associated with a 34% increase in the likelihood of missing a nursing assessment for his or her assigned infant[s] during the same shift [95% credible interval, 1.30-1.39]). When modeling all workload variables jointly, only 4 of 12 models demonstrated significant association of staffing ratios with odds of missed care, whereas the association with NASA-TLX ratings remained significant in all models. Few associations of acuity scores were observed across modeling strategies. CONCLUSIONS AND RELEVANCE The workload of NICU nurses is significantly associated with missed nursing care, and subjective workload ratings are particularly important. Subjective workload represents an important aspect of nurse workload that remains largely unmeasured despite high potential for intervention.
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Affiliation(s)
- Heather L. Tubbs-Cooley
- Center for Women, Children, and Youth, The Ohio State University College of Nursing, Columbus,Department of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Constance A. Mara
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Adam C. Carle
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio,James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Barbara A. Mark
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill
| | - Rita H. Pickler
- Martha S. Pitzer Center for Women, Children, and Youth, The Ohio State University College of Nursing, Columbus, Ohio
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