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OXYGEN TARGETS: HOW GOOD ARE WE IN ACHIEVING THEM

Eduardo Bancalari MD

University of Miami Miller School of Medicine

Jackson Memorial Medical Center

CARE OF THE SICK NEWBORN 2015

Infants born at UM-JMH, GA 24-31w Years 2008-2009

Postnatal age (weeks)

Oxygen Dependency

GA wks

9.813.6

33.9

0

25

50

NONE MILD MODERATE-SEVERE

Hrs

TcP

O2

> 8

0 n

nH

g

(week

s 1

– 4

)

ROP Severity (N= 101)

Flynn J, Bancalari E, NEJM 1992

Progression to Threshold

Conventional

Sat 89-94%

Supplemental

Sat 96-99%

ALL 48% 41%

OR 0.72 (0.52 – 1.01)

Non plus

disease 46% 32%

STOP – ROP The STOP-ROP Multicenter Study Group: Pediatrics 105:295, 2000 STOP – ROP

The STOP-ROP Multicenter Study Group: Pediatrics 105:295, 2000 Conventional Supplemental

Pneumonia or Pulmonary

Deterioration

8.5%

13.2%

Hospitalized at 50 wks PMA 6.8% 12.7%

On Oxygen at 50 wks PMA 37.0% 46.8%

On Diuretics at 50 wks PMA 24.4% 35.8%

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358 infants enrolled at 32 weeks PMA

Saturation targets: 91-94 vs 95-98

OUTCOME Standard

Saturation

N=178 Bwt

918g

High

Saturation

N=180 Bwt

916g

P

BPD (O2 at 36 weeks PMA)

(%)

82 (46) 116 (64)

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Distribution pattern, time, and age dependency of

hyperoxia-induced apoptosis in infant rats

Felderhoff-Mueser, U et al. Neurobiol Disease 2004; 17(2): 273-282

Multivariate odds ratios for DCP with 95% CI and

test of significance for risk factors

From Collins, MP et al. Ped Res 2001; 50(6): 712-719

Risk factor Model 1* (N=400) Model 2* (N=400) Model 3* (N=390) Model 4* (N=336)

Cumulative hypocapnia 2.9 (1.6, 5.5)

p= 0.001

2.2 (1.1, 4.5)

p= 0.03

2.2 (1.0, 4.7)

p= 0.04

2.6 (1.1, 6.4)

p= 0.03

Cumulative hyperoxemia 2.5 (1.3, 5.1)

p= 0.01

2.4 (1.1, 5.2)

p= 0.02

2.1 (0.9, 5.0)

p= 0.10

Prolonged ventilation 2.9 (1.5, 5.6)

p= 0.002

2.3 (0.9, 5.9)

p= 0.09

3.0 (1.0, 8.9)

p= 0.04

Gestational age 0.9 (0.6, 1.5)

p=0.83

0.9 (0.7, 1.5)

p= 0.59

Odds Ratio

0.1 1 10

Term

Preterm

Apgar score 1 min 1,000g) and the most depressed infants

(1-min Apgar

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Optimal oxygenation of ELBW infants: A meta-analysis and systematic review of the oxygen saturation target studies

BPD

Saugstad OD and Aune D. Neonatology 2014; 105: 55-63.

Optimal oxygenation of ELBW infants: A meta-analysis and systematic review of the oxygen saturation target studies

NEC

Saugstad OD and Aune D. Neonatology 2014; 105: 55-63.

Optimal oxygenation of ELBW infants: A meta-analysis and systematic review of the oxygen saturation target studies

Mortality

Saugstad OD and Aune D. Neonatology 2014; 105: 55-63.

How good are we keeping

oxygen targets?

Achieved Versus Intended Pulse Oximeter

Saturation in Infants Born Less Than 28wks

The AVIOx Study

14 Centers using different saturation targets

Percent time

Below target 16 (0-47)

Within target 48 (6-75)

Above target 36 (5-90)

Hagadorn et al. Pediatrics 2006

Higher vs. Lower Arterial Oxygen Saturations in Extremely Preterm Infants

Schmidt B et al. JAMA 2013; 309: 2111-2120.

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Why are we so bad in keeping oxygen

targets?

Blood oxygen level fluctuates constantly: Require

continuous attendance and tight alarm settings

Delayed response:

Desensitization to frequent alarms

Lack of buy-in by staff, unknown

consequences of transient deviations

More concern with hypoxemia than hyperoxemia

Response not always appropriate for the mechanism of

the hypoxemia

Sp

O2

FiO

2

Claure et al. J Pediatr 2009

Nurse: patient ratio and achievement of oxygen saturation goals in premature infants

Sink DW, et al. Arch Dis Child Fetal Neonatal Ed (2010). Online First doi:10.1136/F2 of 6 adc.2009.178616

PaO2 vs. SpO2

Castillo et al,

Pediatrics 2008

Quine et al,

ADC FN Ed 2008

Develop clear unit guidelines for oxygen monitoring and targets

Set alarms on target range

Minimize factors that induce fluctuations in

oxygenation

Continuous education of medical and nursing personnel

Proper nurse patient ratio

Monitor incidence of pathologies associated with

hyperoxia

Automated systems for oxygen control

How can maintenance of oxygen

targets be improved? % time within target

Cl. loop Manual Type

Beddis, 1979

Dugdale, 1988

Bhutani, 1992

Morozoff, 1992

Morozoff, 1993

Sun, 1997

Claure, 2001

Urschitz, 2004

Morozoff, 2009

Claure, 2009

Claure, 2011

Efficacy of Automated FiO2 Control

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The University of Miami, Drs. Claure and Bancalari

have a patent on the algorithm for automated

adjustment of inspired oxygen and a licensing

agreement with Carefusion

Clio studies have been supported by Carefusion

Disclosure

*:p 93% (@O2>21%)

> 98% (@O2>21%)

< 87% < 75%

*

*

*

* *

% o

f 24 h

ou

rs

Claure et al. PAS 2009

Prolonged episodes with SpO2 below intended range

SpO2 < 85% (>120s)

*:p60s)

Standard

Automated

Workload:FiO2 adjustments

*:p

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Oxygenation Targets:

Can they be achieved?

Arterial oxygen levels fluctuate constantly in preterm infants and maintenance of targets is a tedious and

demanding task

Fluctuations can be produced by different mechanisms

that require specific interventions

While hypoxemic episodes are usually related to patient

issues, hyperoxemia is always induced by excessive

inspired oxygen

Infants are seldom hyperoxic on room air

Need to define the best targets and the short and long

term consequences of fluctuations in oxygenation

Surely can do better with

oxygen targets, but…

Avoid hyperoxemia: Keep PaO2 40mmHg

SpO2 over 88-90%

Keep higher SpO2 in infants with ROP or BPD?

Keep in mind limitations of SpO2 in predicting PaO2

What oxygen targets should we

use?