[maralenn]

I was wondering if you all could tell me what cardiac disorder a neonate could have that would make giving blow-by oxygen detrimental.

Here's why--I was hanging out in the nursery charting while a big hubbub was going on with a couple of docs and my RN friend, who was charge that day. A neonate, who was the focus of the hubbub, was having trouble staying oxygenated. There was no apparent pattern or cause for this kid's O2 sats to drop. At one point, I watched the sats go from 90 to 88 to 85 to 80...I said to my friend, "You might want to give that kid blow-by..." then it dropped to 75. I said to my friend (name changed), "Sara, GIVE that kid some blow-by." I think the reason she didn't do it on her own was because the residents were confusing her.

Well, the resident got TICKED and said "OK--turn that oxygen off" when the kid got to 88. The pt was being prepared for transport to the NICU. The resident didn't say anything to me, but very explicitly told the transporting RN NOT to give this kid O2 on the way down because there are certain cardiac disorders that could be made worse by giving oxygen.

Call me crazy, but I always thought it was a standard intervention to give oxygen when a pt's sats dropped below 85 . Am I wrong? I feel as though, had I not said anything during that whole incident, I would've been just as responsible as the rest of them for a bad outcome related to withhholding O2.

[maralenn]

Have any of you ever seen a doc get mad at you for giving a pt oxygen after the pt's sats dropped to say, 75%?

[JoycMarr]

depends on the circumstances. I've seen a MD angry at a nurse who slapped a 100% nonrebreather on a COPD'er pt.

[SCRN1]

Not at me, but at another nurse when she gave it to a COPDer (it was more than 2 liters). How many liters did this nurse give and did the patient have COPD? If it's more than 2L, we are to get a doctor's order. O2 is a med and it's only within our scope of practice to give up to 2L without an order.

[ortholuv]

Never. Was the pt a DNR??

[bargainhound]

delete message, I did not know pt was neonate.

[muffie]

can you elaborate on the clinical pic a little more

[Jolie]

Babies with ductal-dependent cyanotic heart defects won't benefit from oxygen administration, and may be harmed by it.

Newborn infants are used to very low paO2 in utero (around 35) and generally won't suffer significant harm from low paO2 in the immediate newborn period. Administration of high concentrations of supplemental O2 may hasten the closure of the ductus arteriosis, which would be very detrimental to an infant with a ductal-dependent cyanotic heart defect.

Since it is impossible to diagnose such a defect based on a quick physical exam, the resident was prudent to D/C the oxygen pending a work-up. Babies with respiratory disease will usually respond to supplemental O2. Since that didn't happen in your case, the resident theorized that the baby had a cardiac, not respiratory problem. Upon admission to the NICU, the baby should have had an ABG, CXR, EKG, septic work-up, and possibly an ECHO. Those tests would have shed light on the baby's problem, and would form the basis of treatment, which may have included prostaglandin administration to maintain the PDA if the baby did have a ductal-dependent heart defect.

[maralenn]

The pt was a baby whose sats were dropping spontaneously and for no outwardly apparent reason.The doc was sitting in a chair, writing transport orders (the pt was going to the NICU) and just watching the sats drop. I was merely in the vicinity of the occurence and the RN who was taking care of the pt. was being confused by the docs on what to do. When I saw the pt's saturation drop to 80%, I suggested blow-by. When I saw it go to 75%, I said, "Give the pt. blow-by." The doc who got mad is a brand-new resident. She said that there are certain cardiac disorders that can be made worse by giving oxygen. I was trained, as we all are, to initiate life-saving interventions within our scope of practice. The RN did only use 2L. I just was not willing to see how low the doc was going to let the sats drop; that's why I "hit the override" button and said what I did. Plus, if something bad had happened to the pt as a result of a lack of intervention, I would've been held liable as well.

[maralenn]

Originally Posted by Jolie

Since the OP posted a similar question in the NICU forum, I think she is questioning the management of a newborn with a possible heart defect.

Babies with cyanotic, ductal-dependent heart lesions will usually not respond to O2 administration, and may be harmed by it.

Oh, okay. I was wondering what it could be. The baby did perk up with O2 intervention.