Elsevier

Resuscitation

Volume 84, Issue 8, August 2013, Pages 1108-1113
Resuscitation

Clinical paper
Observing the resuscitation of very preterm infants: Are we able to follow the oxygen saturation targets?

https://doi.org/10.1016/j.resuscitation.2013.01.025Get rights and content

Abstract

Background

Since 2010, the European Resuscitation Council (ERC) guidelines advise oxygen saturation (SpO2) targets for the first 10 min of resuscitation after birth. Unfortunately, the control of SpO2 in newborn infants is difficult.

Aim

To determine to what extent SpO2 levels match the ERC targets during the resuscitation of very preterm infants, and how well the SpO2 is kept within the high and low limits until the infants are transported to the NICU.

Methods

In a single-centre observational study, the SpO2 and fraction of inspired oxygen (FiO2) were collected during the resuscitation of very preterm infants with a gestational age (GA)  30 weeks.

Results

A total of 78 infants were included [median (IQR): GA 274/7 (26–286/7) weeks, birth weight 945 g (780–1140)]. During the initial 10 min after birth, large variations in SpO2 were observed with deviations above the target [median (IQR)] of 4.4% SpO2 (1.4–6.5), and below the target of 8.2% SpO2 (2.8–16.0). After the first 10 min, the SpO2 levels were respectively above and below the limit for 11% (0–27) and 8% (0–23) of the time.

Conclusion

During the resuscitation of very preterm infants, large deviations of the SpO2 from the ERC targets are observed. During the first minutes of resuscitation the deviations were likely caused by an inability to control the SpO2, whereas later deviations were due to weaning, pauses in respiratory support (i.e. intubation) and over exposure to oxygen. Changing the SpO2 targets to a target range that depicts the acceptable deviation might be helpful in providing better respiratory support.

Introduction

During resuscitation of preterm infants, supplemental oxygen therapy is often used to reach and maintain adequate oxygenation. Adequate oxygenation is essential in preterm infants because both hypoxia and hyperoxia can have detrimental effects on the organs, and even fluctuations in oxygenation can be damaging.1, 2, 3 The damage to the organs is caused by the formation of excessive oxygen free radicals.4 The compromised anti-oxidative capacity of preterm infants and the need for a certain level of oxidative stress to initiate the adaptation from intra to extra uterine life make the control of oxygenation a delicate balance.5

To prevent negative outcomes due to under- or overexposure to oxygen in newborn infants, the European Resuscitation Council (ERC),6 American Heart Association (AHA)7 and Australian and New Zealand Resuscitation Council (ARC NZRC)8 guidelines advise pulse oximetry oxygen saturation (SpO2) targets for the first 10 min after birth. These targets are based on observational studies of healthy term and preterm infants not needing any intervention during their resuscitation.9 To reach and maintain these SpO2 targets, the fraction of inspired oxygen (FiO2) is titrated manually according to the SpO2 measurement. Unfortunately, none of the resuscitation guidelines specify how the FiO2 should be titrated to make sure SpO2 targets are reached.

Literature shows that manual control of the SpO2 is difficult, reporting time spent outside the target range of approximately 50% in neonatal intensive care units (NICU).10, 11, 12, 13 Although the status of the infants and the tasks of the physicians in NICUs differ from that during resuscitations immediately after birth, it is likely that during DR resuscitation it is difficult for clinicians to keep SpO2 within the recommended target range. It is unknown to what extent the SpO2 targets are achieved. Therefore, the aim of this study was to determine to what extent SpO2 levels matched ERC targets during the resuscitation immediately after birth of very preterm infants.

Section snippets

Materials and methods

An observational study was performed at the Erasmus Medical Centre – Sophia Children's Hospital, Rotterdam, the Netherlands, a level-III-c NICU with 33 beds.14 The medical ethics committee of the Erasmus Medical Centre approved this study (ASM/hl/135583), and decided that informed consent was not needed because no interventions were imposed and no personal data was processed. Because of the observational nature of this study, there was no possibility to determine a sample size.

Results

Seventy-eight infants were included during an 8-month period (see Table 1 for patient characteristics). The results are presented as median (IQR) unless stated otherwise. Of the 142 eligible infants, 42 were excluded [GA 273/7 (254/7–284/7) weeks, birth weight 870 g (763–1050)] because they were included in one of two (interventional) studies that conflicted with the initial adjustment of the FiO2.21 The data of 21 patients [GA 274/7 (263/7–284/7) weeks, birth weight 955 g (828–1186)] could not

Discussion

This study determined to what extent SpO2 levels matched the ERC targets during the resuscitation of preterm infants in daily practice. While the median of the observed infants followed the ERC targets quite nicely, it did deviate below the targets during the first 5 min after birth. Overall the variation in the SpO2 was large. The average deviation from the targets was 6.6% SpO2 (4.6–9.6), whereas the deviation more than doubled in the worst cases (95th centile 19.3% SpO2) (Figs. 1A and 3).

Conclusions

In conclusion, in our institution, the SpO2 targets were not always followed accurately during the initial minutes after birth. At the start of resuscitation, deviations were most likely caused by an inability to control the SpO2, i.e., no lung aeration and/or no initial SpO2 measurement, resulting in low SpO2 values. Whereas after the infants were stabilised, the deviations were due to weaning, pauses in respiratory support (i.e., intubation), and/or overexposure to oxygen. The ERC advise

Conflict of interest statement

There are no conflicts of interest regarding this manuscript.

References (31)

  • Airway management and mask ventilation of the newborn infant. ARC and NZRC guideline 2010

    Emerg Med Australas

    (2011)
  • J.A. Dawson et al.

    Defining the reference range for oxygen saturation for infants after birth

    Pediatrics

    (2010)
  • V.K. Bhutani et al.

    Adaptive control of inspired oxygen delivery to the neonate

    Pediatr Pulmonol

    (1992)
  • J. Taube et al.

    Automatic control of neonatal fractional inspired oxygen

    IEEE

    (1991)
  • A.C. van der Eijk et al.

    An observational study to quantify manual adjustments of the inspired oxygen fraction in extremely low birth weight infants

    Acta Paediatr

    (2011)
  • Cited by (0)

    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2013.01.025.

    View full text