Oxygen Saturation Targets Research Articles

Strategies to Prevent Severe Retinopathy of Prematurity: A 2020 Update and Meta-analysis.

The incidence of retinopathy of prematurity (ROP) is showing an increasing trend in the United States. This may be because of increasing survival rates among extremely preterm infants (<25 weeks' gestation) and targeting higher oxygen saturation. Five randomized clinical trials of low versus high oxygen saturation target ranges found increased mortality in the low oxygen saturation target group and an increased incidence of ROP in the high oxygen saturation target group. The American Academy of Pediatrics recommends using an oxygen saturation target range of 90% to 95% in extremely low-birthweight infants. The change of practice to target this higher oxygen saturation range, from admission until discharge, may be contributing to the increasing incidence of ROP in extremely preterm infants. To decrease the incidence of ROP without increasing mortality, 2 new cohort trials suggest gradually increasing oxygen saturation targets as preterm infants mature. There is evidence that human milk, vitamin A, and omega-3 fatty acids can help, in addition to continuous oxygen saturation monitoring, to decrease the risk of ROP. We review this literature and provide a meta-analysis to evaluate the evidence.

Accuracy of pulse oximetry in preterm and term infants is insufficient to determine arterial oxygen saturation and tension.

Oxygen saturation is frequently monitored with pulse oximetry to assess vital signs in critically ill patients. Optimally, pulse oximetry closely tracks arterial oxygen tension (PaO2 ), which provides guidance in oxygen titration. We investigated whether monitoring peripheral oxygen saturation (SpO2 ) could accurately guide oxygen titration in newborn infants. Twenty seven thousand two hundred thirty seven SpO2 readings were retrospectively paired with arterial oxygen saturation (SaO2 ) and PaO2 results from blood gas analyses performed in infants with arterial catheters in place. SpO2 overestimated SaO2 readings by 2.9±5.8%. When pulse oximetry readings were within the defined oxygen saturation target range, 7809 (20.9%) SaO2 values were below and 2830 (7.6%) exceeded the target range. In 57% of patients, PaO2 levels<6kPa was diagnosed while SpO2 readings were>90%. PaO2 >11kPa was recorded in 19% of cases, when SpO2 readings were<95%. Infants treated with supplemental oxygen showed a threefold increased risk of hypoxaemia compared to infants breathing room air. Sensitivity and specificity for detecting upper and lower target range limits were fair to good. For SpO2 values below 91%, ISO quality criteria were no longer fulfilled. Based on arterial blood gas analyses as reference, pulse oximetry readings did not fulfil the performance requirements for titrating oxygen in neonatal patients.

The feature of brain oxygenation in the sleep cycle of healthy newborn babies

Noninvasive monitoring brain oxygenation with near-infrared spectroscopy (NIRS) is becoming a widely used in neonatology for determine the optimal target oxygen saturation during resuscitation of newborns, but its use in clinical practice for diagnostics and prognosis perinatal pathology is limited because intra and especially interpatient variability are too large for this aim. This study aimed to determine cerebral oximetry values during the sleep cycle and wakefulness in healthy full term newborns. 38 newborns (gestational age 38 weeks were included in this study (22 after normal birth I group and 16 after cesarean section). Near-infrared spectroscopy (CrSO2) from left fronto-parietal region was recorded in synchrony with polysomnography. Continuous cerebral CrSO2 were measured using near-infrared spectroscopy (Somanetic INVOS 5100C, USA). Fraction tissue oxygen extraction (FTOE) was calculated using SaO2 (pulse oximeter Radical Masimo) and CrSO2 (FTOE = (SаO2 CrSO2)/SаO2). CrSO2 and SаO2 were analyzed during 15 minutes polysomnography-defined quiet, active sleep and wakefulness (defined according to standard guidelines). The results: cerebral oxygen saturation varies with sleep-wake states: during active sleep (74,18 0,75%) was similar to the value in wakefulness (75,6 1,0%) and smaller than in quiet sleep (81,93 1,74%, р 0,001), but FTOE during active sleep was significantly higher (0,221 0,008% and 0,129 0,005%, p 0,001). There were no differences of rates between groups. The high oxygen consumption during REM sleep supports its role during postnatal brain functional development. The use of NIRS taking into account sleep structure will be new method for diagnostic and prognosis perinatal pathology CNS.

Neonatal oxygen saturations and blood pressure at school-age in children born extremely preterm: a cohort study.

Objective:To explore the relationship between neonatal oxygen saturation and BP at age 6-7 years in a cohort of infants born extremely preterm.Study Design:Infants <28 weeks gestation were assigned to a higher or lower oxygen saturation target. Oximeter data were monitored throughout the neonatal period. A subset of survivors was seen at age 6. BP was measured and compared by group assignment, achieved saturations, and time spent in hypoxemia (saturations < 80%).Results:There was no difference in systolic or diastolic BP between assigned groups. Median achieved weekly oxygen saturation was not associated with BP. Longer duration of hypoxemia during the first week of age was associated with higher systolic BP.Conclusion:Neither target nor actual median oxygen saturations in this study was associated with BP at school age. Increased duration of hypoxemia in the first postnatal week was associated with higher systolic BP at 6-7 years of age.

Status of Oxygen Monitoring in Four Selected Special Care Newborn Units in India

To investigate the status of oxygen monitoring in Special Newborn Care Units. Observations were made and records reviewed of infants on oxygen in all four Special Newborn Care Units of a state delivering a model program for retinopathy of prematurity. Multiple choice questions were administered to nurses, semi-structured interviews conducted with pediatricians, ophthalmologists and senior nurses. All units had more than 100% occupancy. The number of functioning pulse oximeters was 73% of that recommended. None of the units had air-oxygen blenders. The upper oxygen saturation alarm was set accurately only for 1 out of 18 babies receiving oxygen and none of the infants had continuous saturation monitoring. 84% of nurses did not know optimal oxygen saturation targets. Most interviewees attributed suboptimal care to overcrowding. Compressed air, air-oxygen blenders, sufficient functioning pulse oximeters, rational admission policies and training of nurses are needed to improve oxygen related practices.

2019 American Heart Association Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2019 focused update to the American Heart Association neonatal resuscitation guidelines is based on 2 evidence reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. The International Liaison Committee on Resuscitation Expert Systematic Reviewer and content experts performed comprehensive reviews of the scientific literature on the appropriate initial oxygen concentration for use during neonatal resuscitation in 2 groups: term and late-preterm newborns (≥35 weeks of gestation) and preterm newborns (<35 weeks of gestation). This article summarizes those evidence reviews and presents recommendations. The recommendations for neonatal resuscitation are as follows: In term and late-preterm newborns (≥35 weeks of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. One hundred percent oxygen should not be used to initiate resuscitation because it is associated with excess mortality. In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen and to base subsequent oxygen titration on oxygen saturation targets. These guidelines require no change in the Neonatal Resuscitation Algorithm-2015 Update.

Rational supplemental oxygen therapy in COVID-19

Background: Hypoxemia often occurs in Coronavirus disease 2019 (COVID-19) patients. This condition requires adequate oxygen therapy to achieve oxygen saturation target. Objective: This review aims to explain the rational oxygen therapy in COVID-19. Materials and Methods: A literature search for studies on COVID-19 was performed using PubMed and Science Direct database. About 46 articles were identified. Twenty-five articles were considered suitable for review. The bibliographies of included studies were also searched for additional references. Results: Oxygen therapy involves conventional devices such as nasal cannulas, simple masks, reservoir masks, and venturi to advanced devices such as high-flow nasal cannulas. Initial therapy is given based on holistic assessment of the patient, followed by close monitoring. In emergency situations, airway management is required, and resuscitation is carried out with a saturation target of ≥94% while in stable patients, the SpO2 target is >90% in nonpregnant and ≥92%–95% in pregnant patients. Oxygen escalation might be needed during therapy without delaying intubation. Besides its intricate management algorithm, the rational management of oxygen therapy in COVID-19 also requires caution on the issue of each aerosol-generating device and transmission risk, especially for health-care workers. Conclusions: Rational management of oxygen therapy includes the provision of initial therapy, followed by proper monitoring and escalation without delaying intubation and also the considerations of the health-care workers' protection and the risk of transmission.

Implementing target range oxygen in critical care: A quality improvement pilot study.

Iatrogenic hyperoxaemia is common on critical care units and has been associated with increased mortality. We commenced a quality improvement pilot study to analyse the views and practice of critical care staff regarding oxygen therapy and to change practice to ensure that all patients have a prescribed target oxygen saturation range. A baseline measurement of oxygen target range prescribing was undertaken alongside a survey of staff attitudes. We then commenced a programme of change, widely promoting an agreed oxygen target range prescribing policy. The analyses of target range prescribing and staff survey were repeated four to five months later. Thirty-three staff members completed the baseline survey, compared to 29 in the follow-up survey. There was no discernible change in staff attitudes towards oxygen target range prescribing. Fifty-four patients were included in the baseline survey and 124 patients were assessed post implementation of changes. The proportion of patients with an oxygen prescription with a target range improved from 85% to 95% (χ2 = 5.17, p = 0.02) and the proportion of patients with an appropriate prescribed target saturation range increased from 85% to 91% (χ2 = 1.4, p = 0.24). The improvement in target range prescribing was maintained at 96% 12 months later. The introduction and promotion of a structured protocol for oxygen prescribing were associated with a sustained increase in the proportion of patients with a prescribed oxygen target range on this unit.

Closed loop automated oxygen control in neonates-A review.

Neonates frequently require supplementary oxygen but may develop complications if the oxygen saturation is outside the target range. This review aimed to determine whether the algorithms used in closed loop automated oxygen control systems influenced their efficacy and whether use of the systems reduced relevant, long-term neonatal complications. A literature search was conducted using PubMed and Google Scholar. The search terms were 'closed loop' or 'automat*', 'oxygen' and 'neonat*'. Eighteen studies were identified: sixteen comparison clinical studies, an observational study and an animal study. Overall, closed loop automated oxygen control was associated with an increased percentage of time spent within the target oxygen saturation range and there were fewer manual adjustments to the inspired oxygen concentration when compared with manual oxygen control. The systems were effective in infants on non-invasive respiratory support or mechanically ventilated, but no study included term-born infants. No long-term data were available to determine if complications of oxygen toxicity were reduced. Closed loop automated oxygen control has been shown in short term trials including preterm and low birth weight infants to improve target saturation achievement. Whether long-term outcomes will be improved with their use requires investigation.

2019 American Heart Association Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

This 2019 focused update to the American Heart Association neonatal resuscitation guidelines is based on 2 evidence reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. The International Liaison Committee on Resuscitation Expert Systematic Reviewer and content experts performed comprehensive reviews of the scientific literature on the appropriate initial oxygen concentration for use during neonatal resuscitation in 2 groups: term and late-preterm newborns (≥35 weeks of gestation) and preterm newborns (<35 weeks of gestation). This article summarizes those evidence reviews and presents recommendations. The recommendations for neonatal resuscitation are as follows: In term and late-preterm newborns (≥35 weeks of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. One hundred percent oxygen should not be used to initiate resuscitation because it is associated with excess mortality. In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen and to base subsequent oxygen titration on oxygen saturation targets. These guidelines require no change in the Neonatal Resuscitation Algorithm-2015 Update.

Evaluation of hyperoxia-induced hypercapnia in obese patients after cardiac surgery: a randomized crossover comparison of conservative and liberal oxygen administration.

Recent studies on patients with stable obesity-hypoventilation syndrome have raised concerns about hyperoxia-induced hypercapnia in this population. This study aimed to evaluate whether a higher oxygen saturation target would increase arterial partial pressure of carbon dioxide (PaCO2) in obese patients after coronary artery bypass grafting surgery (CABG). Obese patients having CABG were recruited. With a randomized crossover design, we compared two oxygenation strategies for 30 min each, immediately after extubation:aperipheral oxygen saturation (SpO2)target of ≥ 95% achieved with manual oxygen titration (liberal) and a SpO2target of 90% achieved with FreeO2, an automated oxygen titration device (conservative). The main outcome was end-of-periodarterial PaCO2. Thirty patients were included. Mean (standard deviation [SD]) body mass index (BMI) was 34 (3) kg·m-2 and mean (SD) baseline partial pressure of carbon dioxide (PCO2) was 40.7 (3.1) mmHg. Mean (SD) end-of-period PaCO2 was 42.0 (5.4) mmHg in the conservative period, compared with 42.6 (4.6) mmHg in the liberal period [mean difference - 0.6 (95% confidence interval - 2.2 to 0.9) mmHg; P = 0.4]. Adjusted analysis for age, BMI, narcotics, and preoperative PaCO2 did not substantively change the results. Fourteen patients were retainers, showing an elevation in mean (SD) PaCO2 in the liberal period of 3.3 (4.1) mmHg. Eleven patients had the opposite response, with a mean (SD) end-of-period PaCO2 decrease of 1.8 (2.2) mmHg in the liberal period. Five patients had a neutral response. This study did not show a clinically important increase in PaCO2 associated with higher SpO2 values in this specific population of obese patients after CABG. Partial pressure of carbon dioxide increased with liberal oxygen administration in almost half of the patients, but no predictive factor was identified. www.clinicaltrials.gov (NCT02917668); registered 25 September, 2016.

Influence of FreeO2 on Percentage of Time Within Oxygen Saturation Target Using Noninvasive Ventilation (NIV) and Continuous Positive Airway Pressure (CPAP) for Patients Admitted for AECOPD or Bariatric Surgery

Influence of FreeO2 on Percentage of Time Within Oxygen Saturation Target Using Noninvasive Ventilation (NIV) and Continuous Positive Airway Pressure (CPAP) for Patients Admitted for AECOPD or Bariatric Surgery

Effects of closed-loop automatic control of the inspiratory fraction of oxygen (FiO2-C) on outcome of extremely preterm infants \u2013 study protocol of a randomized controlled parallel group multicenter trial for safety and efficacy

BackgroundMost extremely low gestational age neonates (ELGANS, postmenstrual age at birth (PMA) < 28 completed weeks) require supplemental oxygen and experience frequent intermittent hypoxemic and hyperoxemic episodes. Hypoxemic episodes and exposure to inadequately high concentrations of oxygen are associated with an increased risk of retinopathy of prematurity (ROP), chronic lung disease of prematurity (BPD), necrotizing enterocolitis (NEC), neurodevelopmental impairment (NDI), and death beyond 36 weeks PMA.Closed-loop automated control of the inspiratory fraction of oxygen (FiO2-C) reduces time outside the hemoglobin oxygen saturation (SpO2) target range, number and duration of hypo- and hyperoxemic episodes and caregivers’ workload. Effects on clinically important outcomes in ELGANs such as ROP, BPD, NEC, NDI and mortality have not yet been studied.MethodsAn outcome-assessor-blinded, randomized controlled, parallel-group trial was designed and powered to study the effect of FiO2-C (in addition to routine manual control (RMC) of FiO2), compared to RMC only, on death and severe complications related to hypoxemia and/or hyperoxemia. 2340 ELGANS with a GA of 23 + 0/7 to 27 + 6/7 weeks will be recruited in approximately 75 European tertiary care neonatal centers. Study participants are randomly assigned to RMC (control-group) or FiO2-C in addition to RMC (intervention-group). Central randomization is stratified for center, gender and PMA at birth (< 26 weeks and ≥ 26 weeks).FiO2-C is provided by commercially available and CE-marked ventilators with an FiO2-C algorithm intended for use in newborn infants. The primary outcome variable (composite of death, severe ROP, BPD or NEC) is assessed at 36 weeks PMA (or, in case of ROP, until complete vascularization of the retina, respectively). The co-primary outcome variable (composite outcome of death, language/cognitive delay, motor impairment, severe visual impairment or hearing impairment) is assessed at 24 months corrected age.DiscussionShort-term studies on FiO2-C showed improved time ELGANs spent within their assigned SpO2 target range, but effects of FiO2-C on clinical outcomes are yet unknown and will be addressed in the FiO2-C trial. This will ensure an appropriate assessment of safety and efficacy before FiO2-C may be implemented as standard therapy.Trial registrationThe study is registered at www.ClinicalTrials.gov: NCT03168516, May 30, 2017.

Respiratory outcomes after neonatal prone versus supine positioning following scheduled cesarean delivery: a randomized trial

Background Prone positioning is a common practice after vaginal birth promoting skin to skin contact and has been associated with improved oxygenation in mechanically ventilated neonates in the recent analysis. Neonates of women not in labor delivered via C-section are at increased risk of respiratory distress; it is unclear whether vigorous neonates without a need of resuscitation would benefit from prone positioning immediately after birth. Objective To determine whether prone positioning of vigorous term neonates for the first 5 min after scheduled cesarean delivery will decrease the incidence of respiratory distress and therapeutic interventions, characterized by the frequency and duration of respiratory support (RS). Design/methods In a single center, randomized parallel clinical trial, vigorous term neonates delivered via scheduled cesarean delivery were positioned prone or supine and their heart rate, oxygen saturation and signs of respiratory distress were recorded at 1-min intervals for the first 5 min. Infants not reaching target oxygen saturations suggested by the neonatal resuscitation guidelines received RS via Neopuff in supine position; respiratory support was discontinued once oxygen saturation targets were met and infant was free of respiratory symptoms. Primary outcomes measured were frequency and duration of RS, secondary outcomes were admission to the NICU for respiratory distress, length of stay, heart rate and oxygen saturation during the initial 5 min of life. Results Two hundred twenty-five neonates in prone and 231 in supine position completed the study out of 500 randomized subjects. Frequency of RS (31 versus 30%, p = .93), mean RS duration (4.08 versus 4.39 min; p = .71), frequency of admission to the NICU (5% in both groups; p = .95) and mean length of stay (0.14 versus 0.28 days; p = .42) were similar between the prone and supine groups. The supine cohort had higher initial oxygen saturation (p = .02) as well as heart rate (p = .004). Conclusions Prone or supine positioning of term neonates after scheduled cesarean delivery resulted in comparable respiratory outcomes including the need for resuscitation in the first minutes of life.

The Search for Optimal Oxygen Saturation Targets in Critically Ill Patients: Observational Data From Large ICU Databases

Although low oxygen saturations are generally regarded as deleterious, recent studies in ICU patients have shown that a liberal oxygen strategy increases mortality. However, the optimal oxygen saturation target remains unclear. The goal of this study was to determine the optimal range by using real-world data. Replicate retrospective analyses were conducted of two electronic medical record databases: the eICU Collaborative Research Database (eICU-CRD) and the Medical Information Mart for Intensive Care III database (MIMIC). Only patients with at least 48h of oxygen therapy were included. Nonlinear regression was used to analyze the association between median pulse oximetry-derived oxygen saturation (Spo2) and hospital mortality. We derived an optimal range of Spo2 and analyzed the association between the percentage of time within the optimal range of Spo2 and hospital mortality. All models adjusted for age, BMI, sex, and Sequential Organ Failure Assessment score. Subgroup analyses included ICU types, main diagnosis, and comorbidities. The analysis identified 26,723 patients from eICU-CRD and 8,564 patients from MIMIC. The optimal range of Spo2 was 94%to 98%in both databases. The percentage of time patients were within the optimal range of Spo2 was associated with decreased hospital mortality (OR of 80%vs40%of the measurements within the optimal range, 0.42 [95%CI, 0.40-0.43] for eICU-CRD and 0.53 [95%CI, 0.50-0.55] for MIMIC). This association was consistent across subgroup analyses. The optimal range of Spo2 was 94%to 98%and should inform future trials of oxygen therapy.

Computer model of oxygenation in neonates

Abstract Maintaining a prescribed peripheral oxygen saturation (SpO2) target during routine care of neonates is challenging and inspired fraction of oxygen (FiO2) titration practices differ among caregivers and centers. Algorithms for automatic feedback control of SpO2 are being developed and tested, that would adapt to the changing neonatal organism and better maintain the required SpO2 target range. While clinical data is necessary to validate differences in the titration strategies, a continuous physiological model of oxygenation in neonates would facilitate baseline testing of different approaches, manual or automated. The objective of our study was to enhance a mathematical model of oxygenation of the neonate and to compare the performance of the model with available clinical data. We have implemented the diffusion resistance into the model as well as a variable oxyhemoglobin dissociation relationship and the bias between arterial and peripheral oxygen saturation. Values of model parameters were scaled to fit preterm infant scenarios. The comparison of the clinical data and computer simulations suggest that the model can reliably simulate episodes of oxygen desaturation and describe the relation between ventilation, FiO2and SpO2. It appears that the model may be an effective tool to test manual and automatic FiO2titration strategies.

The "Just Right" Amount of Oxygen. Improving Oxygen Use in a Rwandan Emergency Department.

Rationale: Despite oxygen's classification as an essential medication by the World Health Organization, it is inconsistently available in many resource-constrained settings. Hypoxemia is associated with increased mortality, and mounting evidence suggests that hyperoxia may also be associated with adverse outcomes.Objectives: To determine if overuse of oxygen for some patients in a Rwandan tertiary care hospital emergency department might coexist with oxygen shortages and underuse of oxygen for other patients, and whether an educational intervention coupled with provision of pulse oximeters could improve the distribution of limited oxygen resources.Methods: We screened all patients in the adult emergency department (ED) of the University Teaching Hospital of Kigali for hypoxemia and receipt of oxygen therapy for 5 weeks. After completing baseline data collection, we provided pulse oximeters and conducted a didactic training with pre- and posttests on oxygen titration, with a chosen target oxygen saturation (SpO2) of 90% to 95%. Four and 12 weeks after the intervention, we evaluated all patients in the ED again for SpO2 and receipt of oxygen therapy for 4 weeks each period. We also recorded ED oxygen use and availability of reserve oxygen for the hospital during the three study periods.Results: During all data collection periods, 214 of 1,765 (12.1%) unique patients screened were hypoxemic. The proportion of patient-days with appropriately titrated oxygen therapy (SpO2, 90-95%) increased from 18.7% at baseline to 38.5% and 42.0% at 4 and 12 weeks postintervention (P < 0.001). On a multiple-choice examination testing knowledge of appropriate oxygen titration, clinicians' scores improved from average 60% (interquartile range [IQR], 40-80%) correct to 80% (IQR, 60-80%) correct immediately after the educational intervention (P < 0.001). Oxygen use in the ED decreased from a median of 32.0 (IQR, 28.0-35.0) tanks per day to 25.5 (IQR, 24.0-29.0) and 16.0 (IQR, 12.5-21.0) tanks per day at Weeks 4 and 12, respectively (P < 0.001), and the median daily number of tanks in reserve for the hospital appeared to increase, although this did not reach statistical significance (30.0 [IQR, 9.0-46.0], 86.5 [IQR, 74.0-92.0], and 75.5 [IQR, 8.5-88.5], respectively; P = 0.07).Conclusions: Among patients in a Rwandan adult ED, 12.1% of patients were hypoxemic and 81.3% of patient-days were either under- or overtreated with oxygen during baseline data collection on the basis of our defined target of SpO2 90% to 95%. Follow-up results at 4 and 12 weeks postintervention demonstrated sustained improvement in oxygen titration and likely increased availability of oxygen resources.

Dutch Neonatal Intensive Care Nurses' Perceptions of Pulse Oximeter Saturation Target Limits for Preterm Infants

PurposeTo conduct a national survey to assess practice, knowledge, barriers, and perceptions regarding oxygen saturation (SpO2) target limits among Dutch neonatal intensive care unit (NICU) nurses. Design and methodsCross-sectional, web-based survey among 667 nurses from 9 level 3 Dutch NICUs. Part of the questions were based on a clinical scenario (28-weeks preterm infant, treated with CPAP, FiO2 0.4). Results328 (53.6%) nurses responded to the survey. Of these, 281 (85.7%) reported to know the local policy of SpO2 target limits, and 261 (79.6%) and 244 (74.4%) rightly identified the lower and upper limit, respectively. Six NICUs recently increased their lower SpO2 limit and for 62.0% of their nurses this led to a significant alarm increase. For the majority of the respondents, the baby from the clinical scenario would spend <10% of the time outside the lower or upper SpO2 limits. Automated oxygen control systems were considered a good idea by 59.2% of the respondents, but 53.9% considered allowing parents to participate in FiO2 titration a bad or very bad idea. ConclusionsThe majority of the respondents identified their unit's policy-specified SpO2 target limits and reported that the increase in SpO2 target limits may have led to more alarms. Titration of FiO2 is a part of care that respondents were reluctant to share with parents. Practice implicationsA potential increase in the number of SpO2 alarms may lead to alarm fatigue. Although family-centered care philosophy is widely accepted across Dutch NICUs, there are still barriers to overcome.

Improving neonatal resuscitation in Tennessee: a large-scale, quality improvement project.

We report a statewide collaborative quality initiative to improve resuscitation and stabilization practices following introduction of the 6th edition of the Neonatal Resuscitation Program. Participants drafted a consensus toolkit of interventions and corresponding measures. Hospital teams collected baseline data, and implemented changes using PDSA-cycles and statistical process control charts. Nine Tennessee NICUs submitted data on 3771 resuscitations. "Special cause" improvements were achieved and sustained for pre-resuscitation checklists (77-90%) and team briefings (80-92%). Time to intravenous access (50-42 min), glucose infusion initiation (73-60 min), and antibiotic dosing (113-98 min) were also significantly reduced. Teams were unable to meet new NRP oxygen saturation targets. Improvements in post-resuscitation debriefing were not sustained, while communication with parents declined significantly (68-60%). Large-scale collaboration facilitated statewide implementation of new guidelines, while highlighting under-appreciated systems challenges among competing resource demands.

Impact of higher target oxygen saturation levels on postnatal weight gain as a predictor for retinopathy of prematurity

The weight, insulin-like growth factor, neonatal, retinopathy of prematurity algorithm (WINROP) predicts severe ROP based on postnatal weight gain and has been validated in several studies. Oxygen supplementation is a well-known risk factor for ROP. In our NICU, target oxygen saturation levels were increased in 2014 which may affect the validity of WINROP.