Achieving targeted pulse oximetry values in preterm infants in the delivery room

Enhanced Neonatal Pulse Oximetry Sounds for the First Minutes of Life: A Laboratory Trial

OBJECTIVE

Auditory enhancements to the pulse oximetry tone may help clinicians detect deviations from target ranges for oxygen saturation (SpO2) and heart rate (HR).

BACKGROUND

Clinical guidelines recommend target ranges for SpO2 and HR during neonatal resuscitation in the first 10 minutes after birth. The pulse oximeter currently maps HR to tone rate, and SpO2 to tone pitch. However, deviations from target ranges for SpO2 and HR are not easy to detect.

METHOD

Forty-one participants were presented with 30-second simulated scenarios of an infant's SpO2 and HR levels in the first minutes after birth. Tremolo marked distinct HR ranges and formants marked distinct SpO2 ranges. Participants were randomly allocated to conditions: (a) No Enhancement control, (b) Enhanced HR Only, (c) Enhanced SpO2 Only, and (d) Enhanced Both.

RESULTS

Participants in the Enhanced HR Only and Enhanced SpO2 Only conditions identified HR and SpO2 ranges, respectively, more accurately than participants in the No Enhancement condition, ps < 0.001. In the Enhanced Both condition, the tremolo enhancement of HR did not affect participants' ability to identify SpO2 range, but the formants enhancement of SpO2 may have attenuated participants' ability to identify tremolo-enhanced HR range.

CONCLUSION

Tremolo and formant enhancements improve range identification for HR and SpO2, respectively, and could improve clinicians' ability to identify SpO2 and HR ranges in the first minutes after birth.

APPLICATION

Enhancements to the pulse oximeter tone to indicate clinically important ranges could improve the management of oxygen delivery to the neonate during resuscitation in the first 10 minutes after birth.

Respiratory function monitoring during early resuscitation and prediction of outcomes in prematurely born infants

OBJECTIVES

Over the last decade, there has been increased use of end-tidal carbon dioxide (ETCO2) and oxygen saturation (SpO2) monitoring during resuscitation of prematurely born infants in the delivery suite. Our objectives were to test the hypotheses that low end-tidal carbon dioxide (ETCO2) levels, low oxygen saturations (SpO2) and high expiratory tidal volumes (VTE) during the early stages of resuscitation would be associated with adverse outcomes in preterm infants.

METHODS

Respiratory recordings made in the first 10 min of resuscitation in the delivery suite of 60 infants, median GA 27 (interquartile range 25-29) weeks were analysed. The results were compared of infants who did or did not die or did or did not develop intracerebral haemorrhage (ICH) or bronchopulmonary dysplasia (BPD).

RESULTS

Twenty-five infants (42%) developed an ICH and 23 (47%) BPD; 11 (18%) died. ETCO2 at approximately 5 min after birth was lower in infants who developed an ICH, this remained significant after adjusting for gestational age, coagulopathy and chorioamnionitis (p=0.03). ETCO2 levels were lower in infants who developed ICH or died compared to those that survived without ICH, which remained significant after adjustment for gestational age, Apgar score at 10 min, chorioamnionitis and coagulopathy (p=0.004). SpO2 at approximately 5 min was lower in the infants who died compared to those who survived which remained significant after adjusting for the 5-min Apgar score and chorioamnionitis (p=0.021).

CONCLUSIONS

ETCO2 and SpO2 levels during early resuscitation in the delivery suite were associated with adverse outcomes.

Evaluating enhanced pulse oximetry auditory displays for neonatal oxygen targeting: A randomized laboratory trial with clinicians and non-clinicians

Standard pulse oximeter auditory tones do not clearly indicate departures from the target range of oxygen saturation (SpO₂) of 90%-95% in preterm neonates. We tested whether acoustically enhanced tones would improve participants' ability to identify SpO₂ range. Twenty-one clinicians and 23 non-clinicians used (1) standard pulse oximetry variable-pitch tones plus alarms; (2) beacon-enhanced tones without alarms in which reference tones were inserted before standard pulse tones when SpO₂ was outside target range; and (3) tremolo-enhanced tones without alarms in which pulse tones were modified with tremolo when SpO₂ was outside target range. For clinicians, range identification accuracies (mean (SD)) in the standard, beacon, and tremolo conditions were 52% (16%), 73% (14%) and 76% (13%) respectively, and for non-clinicians 49% (16%), 76% (13%) and 72% (14%) respectively, with enhanced conditions always significantly more accurate than standard. Acoustic enhancements to pulse oximetry clearly indicate departures from preterm neonates' target SpO₂ range.

Preliminary study of automated oxygen titration at birth for preterm infants

OBJECTIVE

To study the feasibility of automated titration of oxygen therapy in the delivery room for preterm infants.

DESIGN

Prospective non-randomised study of oxygenation in sequential preterm cohorts in which FiO₂ was adjusted manually or by an automated control algorithm during the first 10 min of life.

SETTING

Delivery rooms of a tertiary level hospital.

PARTICIPANTS

Preterm infants <32 weeks gestation (n=20 per group).

INTERVENTION

Automated oxygen control using a purpose-built device, with SpO₂ readings input to a proportional-integral-derivative algorithm, and FiO₂ alterations actuated by a motorised blender. The algorithm was developed via in silico simulation using abstracted oxygenation data from the manual control group. For both groups, the SpO₂ target was the 25th-75th centile of the Dawson nomogram.

MAIN OUTCOME MEASURES

Proportion of time in the SpO₂ target range (25th-75th centile, or above if in room air) and other SpO₂ ranges; FiO₂ adjustment frequency; oxygen exposure.

RESULTS

Time in the SpO₂ target range was similar between groups (manual control: median 60% (IQR 48%-72%); automated control: 70 (60-84)%; p=0.31), whereas time with SpO₂ >75th centile when receiving oxygen differed (manual: 17 (7.6-26)%; automated: 10 (4.4-13)%; p=0.048). Algorithm-directed FiO₂ adjustments were frequent during automated control, but no manual adjustments were required in any infant once valid SpO₂ values were available. Oxygen exposure was greater during automated control, but final FiO₂ was equivalent.

CONCLUSION

Automated oxygen titration using a purpose-built algorithm is feasible for delivery room management of preterm infants, and warrants further evaluation.

Oxygen saturation (SpO2) targeting for newborn infants at delivery: Are we reaching for an impossible unknown?

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.

Oxygen in the First Minutes of Life in Very Preterm Infants

Even a few minutes of exposure to oxygen in the delivery room in very preterm and immature infants may have detrimental effects. The initial oxygenation in the delivery room should therefore be optimized, but knowledge gaps, including initial fraction of oxygen (FiO2) and how FiO2 should be changed to reach an optimal oxygen saturation measured by pulse oximetry (SpO2) target within the first 5-10 min of life, remain. In order to answer this question, we therefore reviewed relevant literature. For newly born infants with gestational age (GA) <32 weeks in need of positive pressure ventilation (PPV) immediately after birth, we identified 2 fundamental issues: (1) the optimal initial FiO2 and (2) the target SpO2 within the first 5-10 min of life. For newly born infants between 29 and 31 weeks of GA, an initial FiO2 of 0.3 hit the target defined by the International Liaison Committee on Resuscitation (ILCOR) best. Newborn infants with GA <29 weeks in need of PPV and supplementary oxygen, we suggest starting with FiO2 0.3 and adjusting the FiO2 to reach SpO2 of 80% within 5 min of life for best outcomes. Prolonged bradycardia (heart rate <100 bpm for >2 min) is associated with increased risk of adverse outcomes, including death. The combination of strict control of development of SpO2 in the first 10 min of life and a heart rate >100 bpm represents the best tool today to achieve the most optimal outcome in the delivery room of very preterm and immature newborn infants.

Oxygen Therapy for Neonatal Resuscitation in the Delivery Room

Oxygen is commonly used in the delivery room during neonatal resuscitation. The transition from intrauterine to extrauterine life is a challenge to newborns, and exposure to too much oxygen can cause an increase in oxidative stress. The goal of resuscitation is to achieve normal oxygen levels as quickly as possible while avoiding excessive oxygen exposure and preventing inadequate oxygen supplementation. Although it has been shown that room air resuscitation is as effective as using 100% oxygen, often preterm infants need some degree of oxygen supplementation. The ideal concentration of oxygen with which to initiate resuscitation is yet to be determined. Current delivery room resuscitation guidelines recommend the use of room air for term newborns and preterm newborns of greater than or equal to 35 weeks' gestation and the use of a fraction of inspired oxygen of 0.21 to 0.3 for preterm infants of less than 35 weeks' gestation. Further recommendations include titrating oxygen supplementation as needed to obtain goal saturations. However, there is no current consensus on an intermediate oxygen concentration to start resuscitation or goal range saturations for preterm and asphyxiated term infants.

Defining information needs in neonatal resuscitation with work domain analysis

OBJECTIVE

To gain a deeper understanding of the information requirements of clinicians conducting neonatal resuscitation in the first 10 min after birth.

BACKGROUND

During the resuscitation of a newborn infant in the first minutes after birth, clinicians must monitor crucial physiological adjustments that are relatively unobservable, unpredictable, and highly variable. Clinicians' access to information regarding the physiological status of the infant is also crucial to determining which interventions are most appropriate. To design displays to support clinicians during newborn resuscitation, we must first carefully consider the information requirements.

METHODS

We conducted a work domain analysis (WDA) for the neonatal transition in the first 10 min after birth. We split the work domain into two 'subdomains'; the physiology of the neonatal transition, and the clinical resources supporting the neonatal transition. A WDA can reveal information requirements that are not yet supported by resources.

RESULTS

The physiological WDA acted as a conceptual tool to model the exact processes and functions that clinicians must monitor and potentially support during the neonatal transition. Importantly, the clinical resources WDA revealed several capabilities and limitations of the physical objects in the work domain-ultimately revealing which physiological functions currently have no existing sensor to provide clinicians with information regarding their status.

CONCLUSION

We propose two potential approaches to improving the clinician's information environment: (1) developing new sensors for the information we lack, and (2) employing principles of ecological interface design to present currently available information to the clinician in a more effective way.

Resuscitation outcomes of infants that do not achieve a 5 min target SpO2 saturation

OBJECTIVE

To determine differences in the duration and level of resuscitation between infants that achieve a peripheral oxygen saturation (SpO₂) of 80% by 5 min compared with those who remain below 80% saturation.

STUDY DESIGN

Infants < 32 weeks GA were analyzed. Pulse rate, SpO₂, airway pressure, and fraction of inspired oxygen were collected during the first 10 min of life.

RESULTS

Two hundred and eighty-four infants were analyzed of which 100 had SpO₂ < 80% at 5 min of life. Composite outcome of death and any IVH was greater in the <80% at 5 min group. These infants had lower heart rates and lower SpO₂ despite increased mean airway pressure and higher FiO₂ (p < 0.001).

CONCLUSION

Infants <32 weeks GA that do not achieve a peripheral arterial saturation of 80% by 5 min of life experience more death or severe IVH. This association is amongst the strongest seen of any predictor of morbidity in the delivery room.

Ergonomic Challenges Inherent in Neonatal Resuscitation

Neonatal resuscitation demands that healthcare professionals perform cognitive and technical tasks while working under time pressure as a team in order to provide efficient and effective care. Neonatal resuscitation teams simultaneously process and act upon multiple data streams, perform ergonomically challenging technical procedures, and coordinate their actions within a small physical space. An understanding and application of human factors and ergonomics science broadens the areas of need in resuscitation research, and will lead to enhanced technologies, systems, and work environments that support human limitations and maximize human performance during neonatal resuscitation.

A Novel Auditory Display for Neonatal Resuscitation: Laboratory Studies Simulating Pulse Oximetry in the First 10 Minutes After Birth

OBJECTIVE

We tested whether enhanced sonifications would improve participants' ability to judge the oxygen saturation levels (SpO₂) of simulated neonates in the first 10 min after birth.

BACKGROUND

During the resuscitation of a newborn infant, clinicians must keep the neonate's SpO₂ levels within the target range, however the boundaries for the target range change each minute during the first 10 min after birth. Resuscitation places significant demand on the clinician's visual attention, and the pulse oximeter's sonification could provide eyes-free monitoring. However, clinicians have difficulty judging SpO₂ levels using the current sonification.

METHOD

In two experiments, nonclinicians' ability to detect SpO₂ range and direction-while performing continuous arithmetic problems-was tested with enhanced versus conventional sonifications. In Experiment 1, tremolo signaled when SpO₂ had deviated below or above the target range. In Experiment 2, tremolo plus brightness signaled when SpO₂ was above target range, and tremolo alone when SpO₂ was below target range.

RESULTS

The tremolo sonification improved range identification accuracy over the conventional display (81% vs. 63%, p < .001). The tremolo plus brightness sonification further improved range identification accuracy over the conventional display (92% vs. 62%, p <.001). In both experiments, there was no difference across conditions in arithmetic task accuracy ( p >.05).

CONCLUSION

Using the enhanced sonifications, participants identified SpO₂ range more accurately despite a continuous distractor task.

APPLICATION

An enhanced pulse oximetry sonification could help clinicians multitask more effectively during neonatal resuscitations.

Optimal human and system performance during neonatal resuscitation

Performance in the delivery of care to sick neonates in need of resuscitation has long been defined primarily in terms of the extent of the knowledge possessed and hands-on skill demonstrated by physicians and other healthcare professionals. This definition of performance in neonatal resuscitation is limited by its focus solely on the human beings delivering care and a perceived set of the requisite skills to do so. This manuscript will expand the definition of performance to include all of the skill sets that humans must use to resuscitate newborns as well as the often complex systems in which those humans operate while delivering that care. It will also highlight how the principles of human factors and ergonomics can be used to enhance human and system performance during patient care. Finally, it will describe the role of simulation and debriefing in the assessment of human and system performance.

Oxygen Therapy in the Delivery Room: What Is the Right Dose?

Oxygen is the most commonly used medicine used during neonatal resuscitation in the delivery room. Oxygen therapy in delivery room should be used judiciously to avoid oxygen toxicity while delivering sufficient oxygen to prevent hypoxia. Measurement of appropriate oxygenation relies on pulse oximetry, but adequate ventilation and perfusion are equally important for oxygen delivery. In this article, we review oxygenation while transitioning from fetal to neonatal life, the importance of appropriate oxygen therapy, its measurement in the delivery room, and current recommendations for oxygen therapy and its limitations.

Lower versus higher oxygen concentrations titrated to target oxygen saturations during resuscitation of preterm infants at birth

BACKGROUND

Initial resuscitation with air is well tolerated by most infants born at term. However, the optimal fractional inspired oxygen concentration (FiO₂ - proportion of the breathed air that is oxygen) targeted to oxygen saturation (SpO₂ - an estimate of the amount of oxygen in the blood) for infants born preterm is unclear.

OBJECTIVES

To determine whether lower or higher initial oxygen concentrations, when titrated according to oxygen saturation targets during the resuscitation of preterm infants at birth, lead to improved short- and long-term mortality and morbidity.

SEARCH METHODS

We conducted electronic searches of the Cochrane Central Register of Controlled Trials (13 October 2017), Ovid MEDLINE (1946 to 13 October 2017), Embase (1974 to 13 October 2017) and CINAHL (1982 to 13 October 2017); we also searched previous reviews (including cross-references), contacted expert informants, and handsearched journals.

SELECTION CRITERIA

We included randomised controlled trials (including cluster- and quasi-randomised trials) which enrolled preterm infants requiring resuscitation following birth and allocated them to receive either lower (FiO₂ < 0.4) or higher (FiO₂ ≥ 0.4) initial oxygen concentrations titrated to target oxygen saturation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies for inclusion, extracted data and assessed methodological quality. Primary outcomes included mortality near term or at discharge (latest reported) and neurodevelopmental disability. We conducted meta-analysis using a fixed-effect model. We assessed the quality of the evidence using GRADE.

MAIN RESULTS

The search identified 10 eligible trials. Meta-analysis of the 10 included studies (914 infants) showed no difference in mortality to discharge between lower (FiO₂ < 0.4) and higher (FiO₂ ≥ 0.4) initial oxygen concentrations targeted to oxygen saturation (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.68 to 1.63). We identified no heterogeneity in this analysis. We graded the quality of the evidence as low due to risk of bias and imprecision. There were no significant subgroup effects according to inspired oxygen concentration strata (FiO₂ 0.21 versus ≥ 0.4 to < 0.6; FiO₂ 0.21 versus ≥ 0.6 to 1.0; and FiO₂ ≥ 0.3 to < 0.4 versus ≥ 0.6 to 1.0). Subgroup analysis identified a single trial that reported increased mortality from use of lower (FiO₂ 0.21) versus higher (FiO₂ 1.0) initial oxygen concentration targeted to a lowest SpO₂ of less than 85%, whereas meta-analysis of nine trials targeting a lowest SpO₂ of 85% to 90% found no difference in mortality.Meta-analysis of two trials (208 infants) showed no difference in neurodevelopmental disability at 24 months between infants receiving lower (FiO₂ < 0.4) versus higher (FiO₂ > 0.4) initial oxygen concentrations targeted to oxygen saturation. Other outcomes were incompletely reported by studies. Overall, we found no difference in use of intermittent positive pressure ventilation or intubation in the delivery room; retinopathy (damage to the retina of the eyes, measured as any retinopathy and severe retinopathy); intraventricular haemorrhage (any and severe); periventricular leukomalacia (a type of white-matter brain injury); necrotising enterocolitis (a condition where a portion of the bowel dies); chronic lung disease at 36 weeks' gestation; mortality to follow up; postnatal growth failure; and patent ductus arteriosus. We graded the quality of the evidence for these outcomes as low or very low.

AUTHORS' CONCLUSIONS

There is uncertainty as to whether initiating post birth resuscitation in preterm infants using lower (FiO₂ < 0.4) or higher (FiO₂ ≥ 0.4) oxygen concentrations, targeted to oxygen saturations in the first 10 minutes, has an important effect on mortality or major morbidity, intubation during post birth resuscitation, other resuscitation outcomes, and long-term outcomes including neurodevelopmental disability. We assessed the quality of the evidence for all outcomes as low to very low. Further large, well designed trials are needed to assess the effect of using different initial oxygen concentrations and the effect of targeting different oxygen saturations.

Continuous noninvasive monitoring in the neonatal ICU

PURPOSE OF REVIEW

Standard hemodynamic monitoring such as heart rate and systemic blood pressure may only provide a crude estimation of organ perfusion during neonatal intensive care. Pulse oximetry monitoring allows for continuous noninvasive monitoring of hemoglobin oxygenation and thus provides estimation of end-organ oxygenation. This review aims to provide an overview of pulse oximetry and discuss its current and potential clinical use during neonatal intensive care.

RECENT FINDINGS

Technological advances in continuous assessment of dynamic changes in systemic oxygenation with pulse oximetry during transition to extrauterine life and beyond provide additional details about physiological interactions among the key hemodynamic factors regulating systemic blood flow distribution along with the subtle changes that are frequently transient and undetectable with standard monitoring.

SUMMARY

Noninvasive real-time continuous systemic oxygen monitoring has the potential to serve as biomarkers for early-organ dysfunction, to predict adverse short-term and long-term outcomes in critically ill neonates, and to optimize outcomes. Further studies are needed to establish values predicting adverse outcomes and to validate targeted interventions to normalize abnormal values to improve outcomes.

Cerebral Oxygen Saturation to Guide Oxygen Delivery in Preterm Neonates for the Immediate Transition after Birth: A 2-Center Randomized Controlled Pilot Feasibility Trial

OBJECTIVE

To assess if monitoring of cerebral regional tissue oxygen saturation (crSO2) using near-infrared spectroscopy (NIRS) to guide respiratory and supplemental oxygen support reduces burden of cerebral hypoxia and hyperoxia in preterm neonates during resuscitation after birth.

STUDY DESIGN

Preterm neonates <34(+0) weeks of gestation were included in a prospective randomized controlled pilot feasibility study at 2 tertiary level neonatal intensive care units. In a NIRS-visible group, crSO2 monitoring in addition to pulse oximetry was used to guide respiratory and supplemental oxygen support during the first 15 minutes after birth. In a NIRS-not-visible group, only pulse oximetry was used. The primary outcomes were burden of cerebral hypoxia (<10th percentile) or hyperoxia (>90th percentile) measured in %minutes crSO2 during the first 15 minutes after birth. Secondary outcomes were all cause of mortality and/or cerebral injury and neurologic outcome at term age. Allocation sequence was 1:1 with block-randomization of 30 preterm neonates at each site.

RESULTS

In the NIRS-visible group burden of cerebral hypoxia in %minutes, crSO2 was halved, and the relative reduction was 55.4% (95% CI 37.6-73.2%; P = .028). Cerebral hyperoxia was observed in NIRS-visible group in 3 neonates with supplemental oxygen and in NIRS-not-visible group in 2. Cerebral injury rate and neurologic outcome at term age was similar in both groups. Two neonates died in the NIRS-not-visible group and none in the NIRS-visible group. No severe adverse reactions were observed.

CONCLUSIONS

Reduction of burden of cerebral hypoxia during immediate transition and resuscitation after birth is feasible by crSO2 monitoring to guide respiratory and supplemental oxygen support.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02017691.

Novel Pulse Oximetry Sonifications for Neonatal Oxygen Saturation Monitoring: A Laboratory Study

OBJECTIVE

We aimed to test whether the use of novel pulse oximetry sounds (sonifications) better informs listeners when a neonate's oxygen saturation (SpO2) deviates from the recommended range.

BACKGROUND

Variable-pitch pulse oximeters do not accurately inform clinicians via sound alone when SpO2 is outside the target range of 90% to 95% for neonates on supplemental oxygen. Risk of blindness, organ damage, and death increase if SpO2 remains outside the target range. A more informative sonification may improve clinicians' ability to maintain the target range.

METHOD

In two desktop experiments, nonclinicians' ability to detect SpO2 range and direction of change was tested with novel versus conventional sonifications of simulated patient data. In Experiment 1, a "shoulder" sonification used larger pitch differences between adjacent saturation percentages for SpO2 values outside the target range. In Experiment 2, a "beacon" sonification used equal-appearing pitch differences, but when SpO2 was outside the target range, a fixed-pitch reference tone from the center of the target SpO2 range preceded every fourth pulse tone.

RESULTS

The beacon sonification improved range identification accuracy over the control display (85% vs. 60%; p < .001), but the shoulder sonification did not (55% vs. 52%).

CONCLUSION

The beacon provided a distinct auditory alert and reference that significantly improved nonclinical participants' ability to identify SpO2 range.

APPLICATION

Adding a beacon to the variable-pitch pulse oximeter sound may help clinicians identify when, and by how much, a neonate's SpO2 deviates from the target range, particularly during patient transport situations when auditory information becomes essential.

Lung Disease, Oxidative Stress, and Oxygen Requirements in Preterm Infants

BACKGROUND

The role of oxidative stress remains unclear in the multifactorial pathophysiologic mechanism of lung disease in preterm infants.

AIMS

The aim of this study was to examine the associations among chronic lung disease (CLD), oxidative stress, and oxygen requirements in preterm infants.

DESIGN

Prospective, longitudinal, and correlational design.

SUBJECTS

Preterm infants born at <32 weeks' gestation (N = 31), median gestation of 29.0 weeks (range 24.9-31.7).

MEASUREMENTS

The diagnosis of CLD was obtained from the medical record. Oxidative stress was measured using 8-hydroxydeoxyguanosine (8-OHdG) in the cord blood at birth and urine on Days 1 and 7. Oxygen requirements were measured using fraction of inspired oxygen (FIO2) recorded in the first hour after birth/admission and the average FIO2 during the first 12 hr and 7 days after birth. Descriptive statistics are presented. Comparison analyses were performed using Kruskal-Wallis and Fisher's exact tests.

RESULTS

Infants with CLD (n = 12) had lower gestational age (p = .04) and weight (p = .04) at birth, more days on the ventilator (p = .004), and longer neonatal intensive care unit stay (p = .04) compared to infants without CLD (n = 19). CLD was associated with lower oxidative stress levels (p = .03) and higher oxygen requirements during the first 12 hr (p = .025) and on Day 7 (p = .001). Lower oxidative stress levels on Day 7 were associated with higher oxygen requirements in the first 12 hr (p = .01) and on Day 7 (p = .03).

CONCLUSION

Our results linking CLD and higher oxygen requirements with low oxidative stress contradict previous reports. Findings identify a gap in knowledge for postresuscitation oxygen therapy in preterm infants and expose the role of oxidative stress from inflammation and intermittent hypoxia in the etiology of CLD.

Delivery room management of extremely low birth weight infants in Italy: comparison between academic and non-academic birth centres

OBJECTIVE

International Guidelines provide a standardised approach to newborn resuscitation in the DR and, in their most recent versions, recommendations dedicated to management of ELBWI were progressively increased. It is expected that introduction in clinical practice and dissemination of the most recent evidence should be more consistent in academic than in non-academic hospitals. The aim of the study was to compare adherence to the International Guidelines and consistency of practice in delivery room management of extremely low birth weight infants between academic and non-academic institutions.

METHODS

A questionnaire was sent to the directors of all Italian level III centres between April and August 2012.

RESULTS

There was a 92% (n = 98/107) response rate. Apart from polyethylene wrapping to optimise thermal control, perinatal management approach was comparable between academic and non-academic centres.

CONCLUSIONS

There were minor differences in management of extremely low birth weight infants between Italian academic and non-academic institutions, apart from thermal management. Although there was a good, overall adherence to the International Guidelines for Neonatal Resuscitation, temperature management was not in accordance with official recommendations and every effort has to be done to improve this aspect.

Principles of pulse oximetry and its clinical application in neonatal medicine

Pulse oximetry is one of the most commonly used monitoring devices in clinical medicine. It was first introduced to neonatal medicine in the mid-1980s to monitor oxygenation and guide therapy, and it is now used widely in the delivery room during resuscitation. More recently, it is utilized to screen for congenital heart disease. Pulse oximetry is based on the variation in the ratio of the light absorbances of tissues during systole and diastole. It has become the mainstay of non-invasive continuous oxygen monitoring but with a wide variation in clinical practices and without good research evidence. This article provides a brief historical overview of pulse oximetry development, its principles, advantages and limitations, and the clinical applications in neonatal medicine.

Ventilation onset prior to umbilical cord clamping (physiological-based cord clamping) improves systemic and cerebral oxygenation in preterm lambs

Background

As measurement of arterial oxygen saturation (SpO₂) is common in the delivery room, target SpO₂ ranges allow clinicians to titrate oxygen therapy for preterm infants in order to achieve saturation levels similar to those seen in normal term infants in the first minutes of life. However, the influence of the onset of ventilation and the timing of cord clamping on systemic and cerebral oxygenation is not known.

Aim

We investigated whether the initiation of ventilation, prior to, or after umbilical cord clamping, altered systemic and cerebral oxygenation in preterm lambs.

Methods

Systemic and cerebral blood-flows, pressures and peripheral SpO₂ and regional cerebral tissue oxygenation (SctO₂) were measured continuously in apnoeic preterm lambs (126±1 day gestation). Positive pressure ventilation was initiated either 1) prior to umbilical cord clamping, or 2) after umbilical cord clamping. Lambs were monitored intensively prior to intervention, and for 10 minutes following umbilical cord clamping.

Results

Clamping the umbilical cord prior to ventilation resulted in a rapid decrease in SpO₂ and SctO₂, and an increase in arterial pressure, cerebral blood flow and cerebral oxygen extraction. Ventilation restored oxygenation and haemodynamics by 5–6 minutes. No such disturbances in peripheral or cerebral oxygenation and haemodynamics were observed when ventilation was initiated prior to cord clamping.

Conclusion

The establishment of ventilation prior to umbilical cord clamping facilitated a smooth transition to systemic and cerebral oxygenation following birth. SpO₂ nomograms may need to be re-evaluated to reflect physiological management of preterm infants in the delivery room.

Pulse oximetry in very low birth weight infants

Pulse oximetry has become ubiquitous and is used routinely during neonatal care. Emerging evidence highlights the continued uncertainty regarding definition of the optimal range to target pulse oximetry oxygen saturation levels in very low birth weight infants. Furthermore, maintaining optimal oxygen saturation targets is a demanding and tedious task because of the frequency with which oxygenation changes, especially in these small infants receiving prolonged respiratory support. This article addresses the historical perspective, basic physiologic principles behind pulse oximetry operation, and the use of pulse oximetry in targeting different oxygen ranges at various time-points throughout the neonatal period.

Safe oxygen saturation targeting and monitoring in preterm infants: can we avoid hypoxia and hyperoxia?

Oxygen is a neonatal health hazard that should be avoided in clinical practice. In this review, an international team of neonatologists and nurses assessed oxygen saturation (SpO₂) targeting in preterm infants and evaluated the potential weaknesses of randomised clinical trials.

Pedi-cap color change precedes a significant increase in heart rate during neonatal resuscitation

INTRODUCTION

Heart rate is the most important indicator of infant well-being during neonatal resuscitation. The Nellcor Pedi-Cap turns gold when exposed to exhaled gas with CO₂>15 mmHg. The aim of this study was to determine if Pedi-Cap gold color change during neonatal resuscitation precedes an increase in heart rate in babies with bradycardia receiving mask ventilation.

METHODS

This was a single-center retrospective review of video recordings and physiologic data of newborns with bradycardia receiving mask positive pressure ventilation during neonatal resuscitation. Subjects were included if the baby's HR<100 BPM within the first 90 s of resuscitation. The primary outcome was the change in HR prior to Pedi-Cap gold color change compared to the HR after Pedi-Cap gold color change.

RESULTS

Forty-one newborns during the study period had HR<100 BPM and received mask positive pressure ventilation with a Pedi-Cap. The median heart rate 10s prior to Pedi-Cap gold color change was 75 BPM (IQR 62-85) and increased to 136 BPM (IQR 113-158) 30 s after gold color change (p<0.001). SpO₂ increased from 45 ± 17% prior to Pedi-Cap gold color change to 52 ± 17% 30s after gold color change (p=0.001).

CONCLUSIONS

Colorimetric CO₂ detection during mask positive pressure ventilation in neonatal resuscitation precedes a significant increase in heart rate and SpO₂. The Pedi-Cap can be easily applied during resuscitation, requires no electricity, provides immediate feedback and may be a useful, simple tool early in resuscitation and may be especially useful in resource limited settings.

Delivery room management of extremely low birthweight infants shows marked geographical variations in Italy

AIM

To evaluate any geographical variations in practice and adherence to international guidelines for early delivery room management of extremely low birthweight (ELBW) infants in the North, Centre and South of Italy.

METHODS

A questionnaire was sent to all 107 directors of Italian level III centres between April and August 2012.

RESULTS

There was a 92% (n = 98) response rate. A polyethylene bag/wrap was used by 54 centres (55.1%), with the highest rate in Northern Italy (77.5%) and the lowest rate in Southern (37.7%) areas. In Northern regions, one centre (2.5%) said it used oxygen concentrations >40% to initiate positive pressure ventilation in ELBW infants. These proportions were higher in the Central (14.3%) and Southern (16.2%) areas. A T-piece device for positive pressure ventilation was more frequently available in the Northern (95%) units than in those in the Central (66.7%) and Southern (69.4%) regions. A median of 13% (IQR: 5%-30%) of ELBW infants received chest compressions at birth in Italy: 5%, 18% and 22% in Northern, Central and Southern units, respectively.

CONCLUSION

In Italy, delivery room management of ELBW infants showed marked geographical variations. Implementation of national training programmes could increase adherence to the guidelines and reduce such discordance.

Umbilical cord milking improves transition in premature infants at birth

Background

Umbilical cord milking (UCM) improves blood pressure and urine output, and decreases the need for transfusions in comparison to immediate cord clamping (ICC). The immediate effect of UCM in the first few minutes of life and the impact on neonatal resuscitation has not been described.

Methods

Women admitted to a tertiary care center and delivering before 32 weeks gestation were randomized to receive UCM or ICC. A blinded analysis of physiologic data collected on the newborns in the delivery room was performed using a data acquisition system. Heart rate (HR), SpO₂, mean airway pressure (MAP), and FiO₂ in the delivery room were compared between infants receiving UCM and infants with ICC.

Results

41 of 60 neonates who were enrolled and randomized had data from analog tracings at birth. 20 of these infants received UCM and 21 had ICC. Infants receiving UCM had higher heart rates and higher SpO₂ over the first 5 minutes of life, were exposed to less FiO₂ over the first 10 minutes of life than infants with ICC.

Conclusions

UCM when compared to ICC had decreased need for support immediately following delivery, and in situations where resuscitation interventions were needed immediately, UCM has the advantage of being completed in a very short time to improve stability following delivery.

Trial Registration

ClinicalTrials.gov NCT01434732

Resuscitation of preterm neonates with limited versus high oxygen strategy

OBJECTIVE

To determine whether a limited oxygen strategy (LOX) versus a high oxygen strategy (HOX) during delivery room resuscitation decreases oxidative stress in preterm neonates.

METHODS

A randomized trial of neonates of 24 to 34 weeks' gestational age (GA) who received resuscitation was performed. LOX neonates received room air as the initial resuscitation gas, and fraction of inspired oxygen (Fio2) was adjusted by 10% every 30 seconds to achieve target preductal oxygen saturations (Spo2) as described by the 2010 Neonatal Resuscitation Program guidelines. HOX neonates received 100% O2 as initial resuscitation gas, and Fio2 was adjusted by 10% to keep preductal Spo2 at 85% to 94%. Total hydroperoxide (TH), biological antioxidant potential (BAP), and the oxidative balance ratio (BAP/TH) were analyzed in cord blood and the first hour of life. Secondary outcomes included delivery room interventions, respiratory support on NICU admission, and short-term morbidities.

RESULTS

Forty-four LOX (GA: 30 ± 3 weeks; birth weight: 1678 ± 634 g) and 44 HOX (GA: 30 ± 3 weeks; birth weight: 1463 ± 606 g) neonates were included. LOX decreased integrated excess oxygen (∑Fio2 × time [min]) in the delivery room compared with HOX (401 ± 151 vs 662 ± 249; P < .01). At 1 hour of life, BAP/TH was 60% higher for LOX versus HOX neonates (13 [9-16] vs 8 [6-9]) µM/U.CARR, P < .01). LOX decreased ventilator days (3 [0-64] vs 8 [0-96]; P < .05) and reduced the incidence of bronchopulmonary dysplasia (7% vs 25%; P < .05).

CONCLUSIONS

LOX is feasible and results in less oxygen exposure, lower oxidative stress, and decreased respiratory morbidities and thus is a reasonable alternative for resuscitation of preterm neonates in the delivery room.

Oxygen therapy and oximetry in the delivery room

Pulse oximetry is increasingly being used in the delivery room. Expert recommendations state that oxygen therapy during newborn resuscitation should be guided by pulse oximetry. Obtaining accurate and stable oxygen saturation and heart rate information from a pulse oximeter in the delivery room can be challenging. Understanding the properties of this device is important in overcoming these challenges. This article describes several aspects of pulse oximetry use in the delivery room ranging from technical issues with the device itself to clinical applications of the technology.