PCEP Book III Neonatal Care: Part 1

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Time-efficient, cost-effective perinatal education and training PCEP PCEP PCEP III BOOK Perinatal Continuing Education Program, 3rd Edition, Book III Perinatal Continuing Education Program, 3rd Edition Perinatal Continuing Education Program 3RD EDITION EDITOR IN CHIEF, NEONATOLOGY Robert A. Sinkin, MD, MPH, FAAP EDITOR IN CHIEF, OBSTETRICS PCEP Workbook Contents EARN UP TO MATERNAL AND FETAL EVALUATION AND IMMEDIATE Christian A. Chisholm, MD, FACOG 54 CRED CME NEWBORN CARE (BOOK I) Neonatal Care IT For more than 35 years, the Perinatal CONT S OR • Is the Mother Sick? Is the Fetus Sick? A Continuing Education Program (PCEP) HOUR CT • Fetal Age, Growth, and Maturity S! • Fetal Well-being has enhanced the knowledge and skills of • Is the Baby Sick? physicians, nurses, nurse midwives and • Resuscitating the Newborn practitioners, respiratory therapists, and other • Gestational Age and Size and Associated Risk Factors providers of care for pregnant women and newborns. • Thermal Environment • Hypoglycemia The third edition PCEP workbooks have been brought up-to-date MATERNAL AND FETAL CARE (BOOK II) with leading-edge procedures and techniques. These information-rich • Hypertensive Disorders of Pregnancy volumes are filled with concise information, step-by-step instructions, • Obstetric Hemorrhage and practice-focused exercises. They offer time-saving, low-cost • Perinatal Infections solutions for self-paced learning or as adjuncts to instructor-led • Other High-risk Conditions skills teaching. • Abnormal Glucose Tolerance PCEP IS A PROVEN EDUCATIONAL TOOL FOR • Premature Rupture or Infection of the Amniotic • Improving perinatal care know-how, policies, practices, and Membranes procedures. • Preterm Labor • Inducing and Augmenting Labor • Teaching both practical skills and cognitive knowledge. • Abnormal Labor Progress and Difficult Deliveries • Saving time—self-paced self-study approach streamlines the • Imminent Delivery and Preparation for Maternal/ learning process. Fetal Transport • Saving money—provide top-notch education at low NEONATAL CARE (BOOK III) per-participant costs. • Oxygen • Encouraging cooperation and communication among diverse • Respiratory Distress specialties and staffing levels. • Umbilical Catheters • Simplifying education planning and budgeting. • Low Blood Pressure • Intravenous Therapy CONVENIENT, HASSLE-FREE CME OR CONTACT HOURS • Feeding Earn • Hyperbilirubinemia AMA PRA Category 1 Credit(s)™ or ANCC contact hours • Infections CME credits are available from the University of Virginia. Visit www.cmevillage.com for more information. • Review: Is the Baby Sick? Identifying and Caring for Sick and At-Risk Babies or contact The University of Virginia School of Medicine is accredited by • Preparation for Neonatal Transport the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of Virginia School of Nursing is accredited as SPECIALIZED NEWBORN CARE (BOOK IV) • Direct Blood Pressure Measurement hours! a provider of continuing nursing education by the American • Exchange, Reduction, and Direct Transfusions Nurses Credentialing Center’s Commission on Accreditation. • Continuous Positive Airway Pressure • Assisted Ventilation With Mechanical Ventilators • Surfactant Therapy THE PCEP WORKBOOKS AND RELATED PRODUCTS CAN BE PURCHASED DIRECTLY • Continuing Care for At-Risk Babies FROM THE AMERICAN ACADEMY OF PEDIATRICS AT SHOP.AAP.ORG. AAP
PCEP Perinatal Continuing Education Program Neonatal Care Book III 00_FM_BKIII_PCEP_i-viii.indd 1 9/6/16 10:02 AM
American Academy of Pediatrics Publishing Staff The original version of these self-instructional Mark Grimes, Director, Department of Publishing books was developed in 1978 at the Eileen Glasstetter, MS, Manager, Product Development University of Virginia under contract Theresa Wiener, Manager, Publishing and Production (#N09-HR-2926) from the National Heart, Services Lung, and Blood Institute. Subsequent Jason Crase, Manager, Editorial Services versions have been developed independently Amanda Helmholz, Editorial Specialist by the authors and, for the current edition, an Peg Mulcahy, Manager, Graphic Design and Production editorial board. Mary Lou White, Director, Department of Marketing and Original PCEP Authors Sales John Kattwinkel, MD, FAAP Linda Smessaert, MSIMC, Marketing Manager, Professional Lynn J. Cook, RNC, MPH Publications Hallam Hurt, MD, FAAP George A. Nowacek, PhD Published by the American Academy of Pediatrics Jerry G. Short, PhD 141 Northwest Point Blvd Elk Grove Village, IL 60007-1019 Original Primary Authors for the Obstetric Telephone: 847/434-4000 Content Facsimile: 847/434-8000 Warren Crosby, MD www.aap.org Lynn J. Cook, RNC, MPH Information about obtaining continuing medical education and continuing education credit for book study may be obtained by visiting www.cmevillage.com. Several different approaches to specific perinatal problems may be acceptable. The PCEP books have been written to present specific recommendations rather than to include all currently acceptable options. The recommendations in these books should not be considered the only accepted standard of care. We encourage development of local standards in consultation with your regional perinatal center staff. Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics. Every effort has been made to ensure that the drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at time of publication. It is the responsibility of the health care professional to check the package insert of each drug for any change in indications and dosage and for added warnings and precautions. Products and Web sites are mentioned for informational purposes only and do not imply an endorsement by the American Academy of Pediatrics. Web site addresses are as current as possible but may change at any time. Brand names are furnished for identification purposes only. No endorsement of the manufacturers or products mentioned is implied. No commercial involvement of any kind has been solicited or accepted in development of the content of this publication. The publishers have made every effort to trace the copyright holders for borrowed materials. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. Special discounts are available for bulk purchases of this publication. E-mail our Special Sales Department at aapsales@aap.org for more information. © 2017 University of Virginia Patent Foundation All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior permission from the publisher (locate title at http://ebooks.aappublications.org and click on © Get Permissions; you may also fax the permissions editor at 847/434-8780 or e-mail permissions@aap.org). First American Academy of Pediatrics edition published 2007; second, 2012. Original edition © 1978 University of Virginia. Printed in the United States of America 5-280/1016 1 2 3 4 5 6 7 8 9 10 PC0021 ISBN: 978-1-61002-056-5 eBook: 978-1-61002-057-2 Library of Congress Control Number: 2016932959 00_FM_BKIII_PCEP_i-viii.indd 2 9/6/16 10:02 AM
Perinatal Continuing Education Program (PCEP), 3rd Edition Textbook Editorial Board Editors Editor in Chief, Neonatology Editor in Chief, Obstetrics Robert A. Sinkin, MD, MPH, FAAP Christian A. Chisholm, MD, FACOG Charles Fuller Professor of Neonatology Associate Professor of Obstetrics and Gynecology Division Head, Neonatology Vice Chair for Education Medical Director for Newborn Services Medical Director, Labor and Delivery Department of Pediatrics University of Virginia Medical Center University of Virginia Children’s Hospital Charlottesville, VA Charlottesville, VA PCEP Editorial Board Members Lorie Banker, BSN, RNC Barbara O’Brien, RN, MS Care Coordinator Program Director Golisano Children’s Hospital Office of Perinatal Quality Improvement Rochester, NY The University of Oklahoma Health Sciences Center Melissa F. Carmen, MD, FAAP Oklahoma City, OK Assistant Professor of Pediatrics Division of Neonatology Chad Michael Smith, MD University of Rochester Medical Center Associate Professor of Obstetrics & Gynecology Rochester, NY Medical Director, Labor & Delivery Medical Director, Perinatal Patient Safety Susan B. Clarke, MS, RNC-NIC, RN-BC, CNS University of Oklahoma Health Sciences Center Professional Development Specialist Medical Director, Oklahoma Perinatal Quality Continuing Education and Outreach Improvement Collaborative Primary Nurse Planner Oklahoma City, OK Children’s Hospital Colorado Aurora, CO Jonathan R. Swanson, MD, MSc, FAAP Associate Professor of Pediatrics Ann Kellams, MD, FAAP, IBCLC, FABM Division of Neonatology Associate Professor, Department of Pediatrics Chief Quality Officer for Children’s Services Director, Well Newborn and Breastfeeding Medical Director, Neonatal Intensive Care Unit Medicine Services University of Virginia Children’s Hospital University of Virginia Children’s Hospital Charlottesville, VA Charlottesville, VA Sharon Veith, MSN, RN Sally Ann Miller, CNM, NP Assistant Professor Advanced Practice Registered Nurse University of Virginia School of Nursing Women’s Services Charlottesville, VA University of Virginia Health System Charlottesville, VA Sarah M. Wilson, RN, MSN, NNP-BC Neonatal Intensive Care Unit Susan Niermeyer, MD, MPH, FAAP University of Virginia Children’s Hospital Professor of Pediatrics Charlottesville, VA Section of Neonatology University of Colorado School of Medicine Aurora, CO iii 00_FM_BKIII_PCEP_i-viii.indd 3 9/6/16 10:02 AM
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Continuing Education Credit AMA PRA Category 1 Credit(s)™, ANCC contact hours or hours of participation are avail- able to all perinatal health care professionals: physicians, nurses, respiratory therapists, nurse practitioners, nurse midwives, and all others who care for pregnant women or newborns based on their accreditation bodies. The American Medical Association’s AMA PRA Category 1 Credit(s)™ (CME credits) are available to physicians. ANCC contact hours are available to nurses, nurse practitioners, and nurse midwives. Hours of participation are available to respiratory therapists and any other healthcare professionals who provide care to pregnant women or newborn babies for submis- sion to their professional organizations to satisfy their continuing education. Accreditation and Designation Statements The University of Virginia School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for physicians. The University of Virginia School of Medicine designates this enduring material for a maxi- mum of 54 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit com- mensurate with the extent of their participation in the activity. The University of Virginia School of Medicine awards 54 hours of participation (equivalent to AMA PRA Category 1 Credit(s)™ to each non-physician participant who successfully com- pletes this educational activity. The University of Virginia School of Medicine maintains a record of participation for six (6) years. The University of Virginia School of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The University of Virginia SONCE awards 54 contact hours for nurses who participate in this educational activity and complete the post-activity evaluation. Disclosure of Financial Relationships All the authors and editorial board members listed on the previous pages have disclosed that they have no relevant financial relationships with any commercial interest. AMA PRA Category 1 Credit(s)™, ANCC Contact Hours or Hours of Participation Credit is awarded upon passing the book exams, not individual educational unit posttests. Possible credits: Book I, 14.5; Book II, 15.5; Book III, 16.5; Book IV, 7.5. To obtain either AMA PRA Category 1 Credit(s)™, ANCC contact hours or hours of partici- pation register online at www.cmevillage.com (navigate to the PCEP pages) and pass the book exams. v 00_FM_BKIII_PCEP_i-viii.indd 5 9/6/16 10:02 AM
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III BOOK Neonatal Care Unit 1: Oxygen.......................................................................... 1 Skill Units: Administering Oxygen Measuring Oxygen Concentration Blending Oxygen and Compressed Air Heating and Humidifying an Oxygen/Air Mixture Monitoring Oxygen Peripheral Arterial Blood Gas Sampling Unit 2: Respiratory Distress..................................................... 49 Part 1: Respiratory Distress Part 2: Apnea Part 3: Pneumothorax Skill Units: Detecting a Pneumothorax Transillumination Chest Radiograph Treating a Pneumothorax Needle Aspiration Chest Tube Insertion APPENDIX Unit 3: Umbilical Catheters................................................... 121 Skill Unit: Inserting and Managing Umbilical Catheters Unit 4: Low Blood Pressure................................................... 165 Skill Unit: Measuring Blood Pressure Unit 5: Intravenous Therapy.................................................. 191 Skill Units: Peripheral Intravenous Infusions Inserting and Managing Peripheral Intravenous Infusions Unit 6: Feeding…................................................................... 217 Part 1: Feeding Principles Part 2: Tube Feeding Skill Unit: Nasogastric Tube Feedings Unit 7: Hyperbilirubinemia.................................................... 253 Appendix: Identification and Treatment of Jaundice During the First Week After Birth Unit 8: Infections................................................................... 285 Unit 9: Review: Is the Baby Sick? Identifying and Caring for Sick and At-Risk Babies.................................... 325 Subsections: Vital Signs and Observations Tests and Results Unit 10: Preparation for Neonatal Transport........................... 355 Subsection: Caring for Parents of Transported Babies Pretest Answer Key............................................................. 377 Index....................................................................................... 381 vii 00_FM_BKIII_PCEP_i-viii.indd 7 9/6/16 10:02 AM
For more information, see the other books in the Perinatal Continuing Education Program (PCEP) series. Book I: Maternal and Fetal Evaluation and Immediate Newborn Care Introduction: What You Need to Know Unit 6: Gestational Age and Size and Associated Risk Factors Unit 1: Is the Mother Sick? Is the Fetus Sick? Skill Unit: Estimating Gestational Age by Examination Skill Unit: Determining Fetal Presentation With Leopold of a Newborn Maneuvers Unit 7: Thermal Environment Unit 2: Fetal Age, Growth, and Maturity Skill Units: Radiant Warmers Unit 3: Fetal Well-being Incubators and Neutral Thermal Environment Skill Unit: Electronic Fetal Monitoring Unit 8: Hypoglycemia Unit 4: Is the Baby Sick? Skill Unit: Blood Glucose Screenings Skill Units: Electronic Cardiorespiratory Monitoring Pretest Answer Key Pulse Oximetry Glossary Unit 5: Resuscitating the Newborn Index Skill Units: Suctioning Management of Oxygen in the Delivery Setting Free-Flow Oxygen and Positive-Pressure Ventilation Endotracheal Intubation Chest Compressions Emergency Medications Apgar Score Book II: Maternal and Fetal Care Unit 1: Hypertensive Disorders of Pregnancy Unit 7: Preterm Labor Unit 2: Obstetric Hemorrhage Unit 8: Inducing and Augmenting Labor Unit 3: Perinatal Infections Unit 9: Abnormal Labor Progress and Difficult Deliveries Unit 4: Other High-risk Conditions Unit 10: Imminent Delivery and Preparation for Maternal/Fetal Unit 5: Abnormal Glucose Tolerance Transport Unit 6: Premature Rupture or Infection of the Amniotic Pretest Answer Key Membranes Index Skill Units: Sterile Speculum Examination Tests With Suspected or Proven Rupture of Membranes Book IV: Specialized Newborn Care Unit 1: Direct Blood Pressure Measurement Unit 4: Assisted Ventilation With Mechanical Ventilators Skill Unit: Transducer Blood Pressure Monitoring Skill Unit: Endotracheal Tubes Unit 2: Exchange, Reduction, and Direct Transfusions Unit 5: Surfactant Therapy Skill Unit: Exchange Transfusions Skill Unit: Surfactant Administration Unit 3: Continuous Positive Airway Pressure Unit 6: Continuing Care for At-Risk Babies Skill Unit: Delivery of Continuous Positive Airway Subsection: Babies With Special Problems Pressure Pretest Answer Key Index viii 00_FM_BKIII_PCEP_i-viii.indd 8 9/6/16 10:02 AM
Unit 1: Oxygen Objectives................................................................................................................................ 2 1. How much oxygen does a baby need?.......................................................................... 5 2. How is the amount of oxygen measured?.................................................................... 5 3. How does oxyhemoglobin saturation (Spo2) compare to arterial blood oxygen (Pao2)?................................................................................................................. 7 4. What is the best way to monitor a baby’s oxygenation?............................................ 8 5. When does a baby need supplemental oxygen?.......................................................... 8 6. How much oxygen do you administer to a baby?........................................................ 9 7. When does a baby not need supplemental oxygen?..................................................10 8. How should oxygen be given?......................................................................................10 Unit 1: oxygen/contents 9. How can you use a pulse oximeter to adjust inspired oxygen?................................ 13 10. When do you obtain an arterial blood gas measurement?....................................... 14 11. What are the problems related to oxygen therapy?................................................... 14 12. What are reference arterial blood gas values and how are capillary and venous blood gas values used?............................................................. 15 Tables and Figures Table 1.1. Approximate Relationship of Spo2 and Pao2................................................... 7 Figure 1.1. Equipment Needed for Administering Oxygen, Measuring Delivered Oxygen, and Measuring Baby’s Blood Oxygen.............................................................. 6 Figure 1.2. Relationship of Pao2 and Spo2........................................................................ 8 Figure 1.3. Pre-ductal Oxygenation Saturation Changes Following Birth (Median and Interquartile Range)................................................................... 9 Figure 1.4. Components Required for Administering and Measuring Oxygen..................11 Recommended Routines.................................................................................................... 19 Skill Units Administering Oxygen..................................................................................................... 25 Measuring Oxygen Concentration................................................................. 27 Blending Oxygen and Compressed Air.......................................................... 29 Heating and Humidifying an Oxygen/Air Mixture....................................... 32 Monitoring Oxygen......................................................................................................... 37 Peripheral Arterial Blood Gas Sampling........................................................ 38 1 01-Unit1_BKIII_PCEP_001-048.indd 1 9/6/16 10:06 AM
Unit 1: oxygen Objectives In this unit you will learn to A. Identify babies who require supplemental oxygen. B. Administer oxygen as a drug while understanding its benefits and hazards. C. Operate the appropriate equipment for the controlled delivery of oxygen. D. Monitor a baby’s oxygenation. 2 01-Unit1_BKIII_PCEP_001-048.indd 2 9/6/16 10:06 AM
Unit 1: oxygen Unit 1 Pretest Before reading the unit, please answer the following questions. Select the one best answer to each question (unless otherwise instructed). Record your answers on the test and check them against the answers at the end of the book. 1. Which of the following procedures is the best way to measure the concentration of arterial oxygen? A. With an oxygen analyzer B. From an arterial blood gas sample C. Check the liter-per-minute flow of oxygen D. From a warmed capillary blood sample 2. A baby with respiratory distress is breathing 45% oxygen and has an arterial blood oxygen tension of 96 mm Hg. What adjustments in oxygen should be made for this baby? A. Change the inspired oxygen to room air. B. Change the inspired oxygen to 40%. C. Change the inspired oxygen to 50%. D. No changes in oxygen therapy for this baby 3. A baby’s eyes may be damaged from periods of too much A. Bilirubin in the blood B. Carbon dioxide in the air C. Oxygen in the blood D. Oxygen in the air 4. Which of the following procedures is the best way to gauge the amount of oxygen a baby needs? A. Arterial blood gas measurements B. Cyanosis of the trunk and mucous membranes C. Degree of respiratory distress D. Venous blood gas measurements 5. Which of the following babies is least likely to require supplemental oxygen? A. A preterm baby with respiratory distress and heart rate of 80 beats per minute B. A 5-day-old who appears dusky all over C. An extremely preterm baby in the delivery room with a 5-minute Apgar score of 2 D. A preterm baby with an arterial blood oxygen tension (or Pao2) of 60 mm Hg 6. Which of the following techniques is the best way to regulate the amount of oxygen a baby receives? A. Administer oxygen alone and regulate the liter-per-minute flow. B. Control the time the baby receives supplemental oxygen. C. Hold the oxygen source closer or farther away from the baby’s face. D. Use an oxygen blender. 7. True False A baby found in mother’s room with bluish-colored tongue and lips requires immediate oxygen therapy. 8. True False Arterial blood gas samples are not needed if continuous pulse oximetry is used. 3 01-Unit1_BKIII_PCEP_001-048.indd 3 9/6/16 10:06 AM
Unit 1: oxygen 9. True False Lung damage is a possible consequence of high inspired oxygen concentration over time. 10. True False Capillary blood gas measurements are a reliable way to determine a baby’s blood oxygen level. 11. True False Oxygen from a tank that has been in a warm room for more than 24 hours does not need to be heated or humidified. 12. True False A pulse oximeter uses light to estimate the degree to which hemo- globin is saturated with oxygen. 13. True False Pulse oximetry is most sensitive in detecting low blood oxygen. 4 01-Unit1_BKIII_PCEP_001-048.indd 4 9/6/16 10:06 AM
Unit 1: oxygen Both too little and too much oxygen can be harmful. • Too little oxygen in the blood can cause damage to the brain and other vital organs. • Too much oxygen in the blood can cause damage to the eyes and other organs. • Too much inspired oxygen can cause damage to the lungs. 1. How much oxygen does a baby need? Oxygen is essential for our survival, but oxygen can also be toxic in excess. Tissues require oxygen to metabolize normally. However, during metabolism involving oxygen, chemical reac- tions release toxic substances (oxygen free radicals) that can cause tissue injury. Free radicals are even more injurious to tissues that have already experienced a period of oxygen deprivation from asphyxia or hypoperfusion, such as that which may occur during a complicated preg- nancy and delivery. Air-breathing mammals normally produce enzymes and other molecules that scavenge oxygen free radicals before they can produce significant injury. The fetus, how- ever, develops in a very low oxygen environment and has not yet fully developed free radical scavengers until born at term. Therefore, a baby who is preterm, has acquired a serious infec- tion, has experienced an asphyxial event, has respiratory disease, or is otherwise compromised has particularly high risk from exposure to too little or too much oxygen. When a healthy fetus is born and undergoes transition from receiving oxygen via the placenta to using the lungs to extract oxygen from the air, the amount of oxygen dissolved in the plasma and bound to hemoglobin in arterial blood increases dramatically over a period of approxi- mately 10 minutes following birth. This increase occurs because the amount of oxygen avail- able in the room air being breathed by the baby is substantially greater than the amount of oxygen transferred across the placenta from the mother’s circulation. If the baby’s lungs are compromised, normal increase in blood oxygenation may not occur and the baby may become oxygen deprived unless the concentration of oxygen that the baby breathes is increased from the 21% contained in room air to some greater percentage. Conversely, if the concentration being breathed by the baby is excessive, arterial blood oxygenation can easily become too high. Hypoxemia (low blood oxygen) or hyperoxemia (high blood oxygen) can be harmful, so it is very important that a sick baby’s arterial blood oxygen be maintained in the range normally found in a healthy baby who is breathing room air. 2. How is the amount of oxygen measured? Oxygen concentration should be measured in the baby’s inspired air and in the baby’s blood (Figure 1.1). A. Inspired oxygen concentration Inspired oxygen concentration is frequently abbreviated as Fio2 (fraction of inspired oxygen) and is the amount of oxygen a baby breathes. The Fio2 is measured by an oxy- gen analyzer, which is a sensing device placed near the baby’s nose (Figure 1.1) or in-line with a device for delivering positive pressure. Most analyzers provide a constant readout of the oxygen concentration. Fraction of inspired oxygen (Fio2) is the fraction or percentage of oxygen in the space being measured. Natural, “room” air includes 21% oxygen, which is equivalent to Fio2 of 0.21. Oxygen-enriched air has a higher Fio2 than 0.21, up to 1.00, which means 100% oxygen. In this unit, percentages are used. 5 01-Unit1_BKIII_PCEP_001-048.indd 5 9/6/16 10:06 AM
Unit 1: oxygen Blender Flowmeter Pulse oximeter Heated humidifier 90 Oxygen hood Umbilical catheter Pulse oximeter sensor Oxygen sensor 40 Oxygen analyzer Figure 1.1. Equipment Needed for Administering Oxygen (blender, flowmeter, heated humidifier, oxygen hood), Measuring Delivered Oxygen (oxygen analyzer), and Measuring Baby’s Blood Oxygen (umbilical catheter, pulse oximeter) B. Arterial blood oxygen levels Oxygen is carried in blood attached to hemoglobin in red blood cells and dissolved in plasma. The amount bound to hemoglobin (oxyhemoglobin) is expressed as Spo2, mea- sured in percentage of saturation, and concentration in plasma is expressed as Pao2, measured in mm Hg. Arterial blood must be used for Pao2 determinations. Venous and capillary blood do not give accurate estimates of oxygenation. 1. Oxyhemoglobin saturation When there is no oxygen bound to hemoglobin, it is “0% saturated”; when the hemo- globin is carrying as much oxygen as possible, it is “100% saturated.” Hemoglobin changes color from blue to red as it becomes increasingly saturated with oxygen. A pulse oximeter detects the color of the blood and gives a reading expressed as percentage of saturation. It does this by shining a tiny light through the skin, reg- istering the color of the light coming from the skin (which is determined by the color of blood in the arteries), and thus estimating oxygen saturation, without requiring a blood sample to be drawn. The desired level of oxyhemoglobin saturation in a baby is generally 85% to 95%. Many neonatologists will advise using 88% to 92% saturation as a target but will set oximeters to alarm below 85% and above 95%. 6 01-Unit1_BKIII_PCEP_001-048.indd 6 9/6/16 10:06 AM
Unit 1: oxygen 2. Arterial blood oxygen dissolved in plasma Arterial blood oxygen levels are shown as the Pao2 value from arterial blood gas measurements. The blood to be analyzed is usually drawn from an umbilical artery catheter (see Unit 3, Umbilical Catheters, in this book), a peripheral arterial catheter, or a peripheral arterial stick (see Skill Unit: Monitoring Oxygen, Peripheral Arterial Blood Gas Sampling, in this book). If an arterial catheter cannot be inserted, monitor oxygenation with continuous pulse oximetry until transport to a higher level of care can be arranged. The desired level of Pao2 in any baby (sick, well, preterm, post-term) is generally 45 to 65 mm Hg. Babies with varying degrees of lung disease will require different levels of Fio2 to main- tain desired arterial blood oxygen level. For example, a baby with severe respiratory distress syndrome may require Fio2 ranging up to 100% to maintain a Pao2 between 45 and 65 mm Hg, while a baby with mild respiratory distress syndrome may require only 30% oxygen to maintain a Pao2 between 45 and 65 mm Hg. Note: There is disagreement among experts as to the appropriate range of Pao2 and oxyhemoglobin saturation. Know the acceptable range for your hospital. Also, the target range will be different immediately following birth. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.) 3. How does oxyhemoglobin saturation (Spo2) compare to arterial blood oxygen (Pao2)? Oxygen tension (or partial pressure) in a blood sample (Pao2) can range from 0 to approxi- mately 500 mm Hg; oxyhemoglobin saturation (Spo2) can range from 0% to 100%. When Spo2 is greater than 95%, the hemoglobin is almost fully saturated with oxygen, and a small increase in saturation can correspond to a large increase in Pao2. If Spo2 saturation is greater than approximately 95%, Pao2 could be acceptable (45–65 mm Hg) or undesirably high (greater than 65 mm Hg) (Table 1.1). Table 1.1. Approximate Relationship of Spo2 and Pao2 Oxyhemoglobin Saturation (Spo2) Pao2 0%–85% 0–45 mm Hg 85%–95% 45–65 mm Hg 95%–100% 65–500 mm Hg Oxyhemoglobin saturation as measured by a pulse oximeter is most valuable for detecting low blood oxygen. Percentage of saturation is not a sensitive measure when Pao2 is high. The approximate relationship of Pao2 and oxyhemoglobin saturation is shown in Table 1.1 and Figure 1.2. The shaded area of Figure 1.2 shows the approximate relationship between 85% to 95% oxy- hemoglobin saturation and 45 to 65 mm Hg arterial blood oxygen level for a slightly preterm baby during the first few days following birth. 7 01-Unit1_BKIII_PCEP_001-048.indd 7 9/6/16 10:06 AM
Unit 1: oxygen Figure 1.2. Relationship of Pao2 and Spo2 For some babies, simultaneous measurements of Pao2 and Spo2 may give results quite differ- ent than those predicted by the graph. The precise relationship of oxygen saturation and Pao2 is affected by several factors, such as age since birth, the presence of acidosis, characteristics of hemoglobin (eg, methemoglobin, hemoglobin S), and whether the baby has had a blood transfusion. 4. What is the best way to monitor a baby’s oxygenation? A baby’s blood oxygen level will frequently fluctuate from minute to minute, particularly if the baby is distressed or undergoing any sort of procedure. A pulse oximeter can be used to moni- tor these changes so you will know quickly when the baby’s oxygenation is persistently out of the desirable range and requires attention. However, because pulse oximeters only report Spo2, which has a variable relationship to Pao2, the baby’s Pao2 should be measured intermittently with a sample of arterial blood. Watch for oximeter readings to stabilize to know the best time to obtain an arterial blood sample that reflects the baby’s resting state (not changes that may occur with, eg, crying, stress during procedures). The best way to monitor a baby’s blood oxygen is to • Follow trends or changes in Spo2 with a pulse oximeter. and • Measure Pao2 intermittently from samples of arterial blood. 5. When does a baby need supplemental oxygen? Babies require oxygen therapy when the concentration of oxygen in arterial blood is low and the oxygen needs of a sick baby vary over time. Therefore, the only sure way to determine if a baby is receiving the correct amount of oxygen is to measure Spo2 continuously by pulse oxim- etry and periodically measure Pao2 by arterial blood gas sample. In emergency situations, a baby may need oxygen immediately. First, give oxygen; then mea- sure the Spo2 or Pao2 as soon as possible. The following signs show that a baby needs oxygen: A. Central cyanosis Generally, a baby’s body will look blue. This overall color change may be dramatic or much less obvious. The best clinical sign of central cyanosis is a bluish appearance of 8 01-Unit1_BKIII_PCEP_001-048.indd 8 9/6/16 10:06 AM
Unit 1: oxygen the lips, inside of the mouth, and conjunctival surface of the eyelids. Central cyanosis indicates the baby needs immediate oxygen therapy. However, studies have shown that clinical assessment of cyanosis is very inconsistent; therefore, if a baby receives oxygen therapy for more than a brief period, the baby’s Spo2 or Pao2 must be measured. B. Need for resuscitation When a baby’s respiratory rate and heart rate are very slow or have stopped, ventilation must be improved immediately to help restore the baby’s vital signs. Oxygen concentra- tions required during assisted ventilation may range from 21% (room air) to as high as 100% as guided by pulse oximetry. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.) C. Respiratory distress Some babies have difficulty breathing and will require extra oxygen for long periods. (See Unit 2, Respiratory Distress, in this book.) For these babies, it is extremely important to ensure adequate ventilation, use continuous oximetry, and measure arterial blood oxygen levels (Pao2) frequently to avoid the hazards of too much or too little oxygen. 6. How much oxygen do you administer to a baby? A. Resuscitation The priority during resuscitation should be to establish ventilation and a normal heart rate. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.) Guidelines recommend starting the resuscitation of a term newborn with no supplemental oxygen (ie, room air) and beginning resuscitation of preterm babies (,35 weeks) with a low concentration of supplemental oxygen (eg, Fio2 of 21%–30%). In either case, Fio2 should be adjusted to match reference arterial satura- tion values as guided by oximetry (Spo2). Reference values for the few minutes following birth will be quite low, so the oximetry goal will also begin low and gradually increase to the 88% to 92% range (Figure 1.3). Some degree of cyanosis may also be normal during the first few minutes after birth. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.) B. Cyanosis 1. Immediate treatment For cyanosis that appears in the nurs- ery, decide on an initial oxygen con- centration depending on the degree of cyanosis. For example, if a baby In utero SpO2 is deeply blue all over, choose 100%. If the mucous membranes are only slightly dusky, choose approximately 30%. Increasing degrees of cyanosis between these extremes will require Figure 1.3. Pre-ductal Oxygen Saturation Changes increasing concentrations of oxygen. Following Birth (Median and Interquartile Range) Reprinted from Mariani G, Dik PB, Ezquer A, et al. J Pediatr. 2007;150(4):418–421, with permission from Elsevier. 9 01-Unit1_BKIII_PCEP_001-048.indd 9 9/6/16 10:06 AM
Unit 1: oxygen Degree of slightly dusky ⎯→ increasing ⎯→ deeply blue Cyanosis mucous membranes cyanosis all over Oxygen 30% ⎯⎯⎯⎯⎯→ increasing ⎯→ 100% Concentration oxygen oxygen oxygen 2. Adjust according to baby’s response and Spo2 Place the baby in the chosen concentration and observe for the disappearance of central cyanosis. Attach a pulse oximeter as soon as possible. Adjust oxygen con- centration up or down to achieve desired saturation. Obtain an arterial blood gas measurement. C. Respiratory distress Babies with respiratory distress need to be given oxygen only if they are cyanotic or have a low arterial blood oxygen concentration. The amount of oxygen required depends on the degree of cyanosis and how low Pao2 or Spo2 values are. It is possible for a baby to be in respiratory distress, not be cyanotic, and still have a low arterial blood oxygen value. These babies should have continuous pulse oximetry moni- toring and monitoring of arterial blood gas measurements and be given sufficient oxygen to keep arterial oxygenation within reference range. Use of a pulse oximeter should not replace periodic arterial blood gas measurements, which also measure blood pH and carbon dioxide (CO2) concentration, in addition to blood oxygen concentration. A pulse oximeter, appropriately applied with results checked against arterial blood gas, is helpful in providing continuous estimates of arterial blood oxygen levels and should reduce the number of arterial blood measurements that are needed. 7. When does a baby not need supplemental oxygen? A. Acrocyanosis (only hands and feet blue) Acrocyanosis without central cyanosis is not an indication for oxygen to be administered. This condition may be caused by reasons other than lack of oxygen (eg, cold stress, poor peripheral blood flow). B. Prematurity without respiratory distress or cyanosis Preterm babies should not be given supplemental oxygen unless they are cyanotic or have a low arterial blood oxygen level. C. Babies with cyanotic congenital heart disease During the first week or so after birth, some babies with certain types of congenital heart malformations will worsen if given high concentrations of supplemental oxygen. Use of supplemental oxygen and saturation targets for such babies should be determined by a pediatric cardiologist. 8. How should oxygen be given? (Figure 1.4) The concentration of oxygen in room air is 21%. To deliver supplemental oxygen (22%–100%) • Deliver oxygen blended with air, using equipment that will prevent fluctuations in oxygen concentration. 10 01-Unit1_BKIII_PCEP_001-048.indd 10 9/6/16 10:06 AM
Unit 1: oxygen Delivery System Air Mixing Apparatus Warmer and Oxygen for Oxygen and Air Humidifier Analyzer Oxygen Measurement of Oxygen Saturation With a Pulse Oximeter Measurement of Arterial Blood Oxygen Figure 1.4. Components Required for Administering and Measuring Oxygen • Heat and humidify the oxygen/air mixture to the baby’s neutral thermal environment tem- perature. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 7, Thermal Environment.) • Measure the concentration of inspired oxygen (Fio2) precisely and continuously. • Monitor oxyhemoglobin saturation (Spo2) continuously. • Measure the concentration of oxygen in the baby’s blood (Pao2) intermittently. A. Blend oxygen and air Oxygen from a wall outlet or tank is 100% oxygen, regardless of the liter-per-minute flow rate. The only way to get less than 100% oxygen is to mix the oxygen with air. Air for blending with oxygen is obtained from a wall outlet, compressed air tank, or electri- cal air compressor. An oxygen blender automatically regulates this blending of oxygen and compressed air to provide a specified and adjustable oxygen concentration. Blenders, however, are not always precise. An oxygen analyzer should be used to check the exact concentration of oxygen being delivered to a baby. The flow rate of oxygen does not determine the concentration of oxygen inspired by a baby. The amount of oxygen and compressed air blended together determine inspired oxygen concentration (Fio2). B. Heat and humidify oxygen and air Oxygen and air directly from wall outlets or tanks are cold and dry, even if a tank itself is warm. Oxygen and air must be warmed to avoid chilling the baby. Regulation of the tem- perature of the oxygen/air mixture is just as important as strict regulation of the baby’s environmental temperature (neutral thermal environment). Oxygen and air must also be humidified to avoid drying the baby’s mucous membranes and airways. 11 01-Unit1_BKIII_PCEP_001-048.indd 11 9/6/16 10:06 AM