Don't give oxygen?

[ABQLNDRN]

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.

[Jokerhill]

I was suprised to see this, this way, I get the resedents who don't know anything about this and have needed to take the O2 away myself twice lately on babies who were out on our post partum floor with mom and had ductal dependent heart defects (undiagnosed). Giving O2 can stimulate the ductus to close. A couple of weeks ago one of the other charge nurse went to check on one and by the time we got the baby in the NICU the ductus was closed and he was shutting down no pulse pressure at all and already posturing. We intubated using 21% and tried art sticks and for IV's all failed, we could not get the PGE going fast enough. Once MD got the umbilical lines and fluids and PGE going, we were doing compressions and giving epi. We tried 100% fio2 as well just to try it all but nothing helped by this time, we only had him for an hour so it can go fast. And yes the duct will open and close causing the fast O2 sat changes with or with out O2 being given. Things to look for are non-respnsive to O2, abnormal murmurs (not your normal PDA murmur), it is hard to pinpoint the hearts PMI, pre and post ductal pulse ox readings will be different, the skin will be a general Grayish color, and in most cases cardiomegaly will be seen on X-RAY. I have had 4 cardiac kids lately it seems to be the in thing. It is not something we see a lot of and we have to transfer out so I am not putting myself up as an expert, but it is not something I will forget. So if you suspect a ductal-dependent cyanotic heart defect and you help that ductus to close by giving 100% FIO2 you may be sorry and can land in court.(You can look up the patho phys. of why this happens, as it is to long and to boring to type here). So over all I agree with the resident if he/she had more information than you did from experience or from the assessment. I hate to agree with them (NICU staff MD's are another thing, but I don't always agree with them either).

[RainDreamer, BSN, RN]

But the resident should have given the nurse the information that she/he had and why they were thinking this kid had a cardiac problem. The resident just said "there are certain cardiac disorders that could be made worse by giving oxygen"? Well yeah that's true, but why was it thought that THIS particular kid had a cardiac disorder? Was an echo done? Was there an audible murmur? The resident should have given more information instead of just making a general statement like that.

And if the kid was responding to the oxygen with higher sats, like the OP said, then it doesn't sound like it was even a cardiac issue.

[Jokerhill]

As I said the person with the most information should make that call. Not a nurse that was doing something else in the room and only had one part of the puzzel to go by. The other nurse "Sara" should have been given all the info and have done an assessement herself. This nurse with only the O2 sat was out of the loop and if she felt something was wrong should have stepped up got the info she needed and said so, It is our job to protect these patients they can't talk or think for themself. You may not know what cardiac issue he has but you know it's cardiac befor the echo is done. But the best thing done was it was taken out of the hands of the resident and taken to the NICU to be cared for. I don't think she was wrong in not jumping in however as it could just result into an argument and turf war slowing care by not getting the baby to the NICU. Now if it was going to take a long time to get it to the NICU and I think the care is poor and will have an effect the out come, the war is on.

[BittyBabyGrower, MSN, RN]

Yep, there are some disorders that don't need the oxygen, but you don't know WHAT is wrong with that kid, so prudently, give the O2 until you get the kid where it can be handled efficently. If someone from the nursery brought us a kid satting in the 70's without O2, I'll tell you, heads would roll. I really don't think that this would be litigated in court if there was not a known cardiac defect and we gave the kid O2...and that duct isn't going to slam shut right away.

Once the kid is in nicu, we'd do an O2 challenge...if it didn't do anything, then we drop the O2 down and call cardiology, get a chest xray, check ABG's after we put lines in. Not doing anything in the nursery is what will get you in trouble...you must always think, what would the "reasonably prudent nurse" do? If it meant going over that resident's head, so be it. I'd have been on the phone to the NICU myself looking for a fellow or attending!

[dawngloves, BSN, RN]

I have to agree with BBG. I don't want anyone to think they can't give a baby in the nursery o2 because it might be a hypoplast. Even NRP guidlines suggest giving 100% o2 at deliveries and there is no way you could diagnose a previously undiagnosed HLH in a DR.

[Jolie, BSN]

I have to agree with BBG. I don't want anyone to think they can't give a baby in the nursery o2 because it might be a hypoplast. Even NRP guidlines suggest giving 100% o2 at deliveries and there is no way you could diagnose a previously undiagnosed HLH in a DR.

I think we're comparing apples and oranges here. No one is suggesting with-holding O2 in the delivery room. This did not occur in the delivery room. The baby was in the newborn nursery with an RN and MD present at the bedside assessing and preparing to transfer to baby to the NICU. The resident had more information about the baby than the OP, who indicated that she was observing from across the room when she made the suggestion to give O2. The resident could have done a better job of explaining the rationale for not giving O2 in that situation, but it is possible that she had formulated a tentative opinion of a potential heart defect, based on her observations of the baby de-satting despite O2 therapy.

[BittyBabyGrower, MSN, RN]

I don't think it is apples and oranges....like I said, the resident, and a new one at that, was making a presumptive diagnosis without confirming it. I think we have all seen kids that continue to sat in the 70's despite blowby when they are really septic or going into PPHN. I think the point here is that if you have a kid desatting like that, slap some 02 on and get it somewhere else than in your nursery. If I were across that room I would have said the same thing, and unless that resident had orders from an attending not to give 02, and he/she isn't acting in the best interest of the patient then you crawl up that ladder to the charge nurse, etc to get that kid out of there ASAP. Unless we have x-ray/echo vision, we aren't going to know if the kid is cardiac until the tests are done, until then, you treat prudently.

[dawngloves, BSN, RN]

I stand by my post.No matter the setting, DR, newborn nursery, NICU, if your pt is satting less than 95 % and you have no diagnosis, you would be negligent not to give o2.

[Jolie, BSN]

I'm not trying to be argumentative here, just trying to make the point that there are times when it is inappropriate as a bystander to insist on interventions when there are other care-givers present at the bedside who know more than we do. Maybe it's a raw subject with me. Let me explain.

A neighbor recently gave birth to a baby diagnosed prenatally with cardiac defects and genetic abnormalities that were not compatible with life beyond a few weeks or months. She and her husband made their wishes known in advance that if the baby was capable of feeding, they wanted to treat her as a "normal" newborn, room-in, and take her home. Mom had a C-section, so anticipated a 3 day hospital stay. The first 2 days went well, with the baby able to feed and room-in uneventfully. On day 3, prior to DC, the baby suddenly decompensated. Mom and Dad, who had previously not wanted the baby to go to the NICU, decided to admit her there, not for treatment, but because they had private family rooms where they could be with her while having immediate access to nursing support, more so than on the mother-baby unit. They realized that their precious baby was going to die, and they were terrified of that happening while they were alone with her in a post-partum room.

I realize that this is an extreme example, not likely to be repeated any time soon, but it does point out the importance of knowing a baby's history before insisting on interventions, especially when we are in the role of "bystander".

In the OP's situation, there was a resident and RN present at the bedside. While it did not appear to the OP that they were taking appropriate actions, it is entirely possible that this "lack" of intervention was driven by knowledge not posessed by the OP. What was the mother's prenatal history? What were the circumstances of the delivery? Any set up for sepsis? What were the cord gasses? What was the baby's gestational age and weight? What were the baby's vitals, including 4 extremity B/P? Had pre-and post-ductal O2 sats been checked? What was the baby's respiratory status (other than de-satting)? Any grunting, retracting, nasal flaring? What was the baby's Hct? (Have you ever seen a polycythemic baby desat despite an appropriate paO2?) Were pulses palpable and equal in all extremities? Were they bounding? Where was the baby's PMI? Any murmur? What meds had mom and baby received?

Maybe I'm giving this resident too much credit, but it seems likely to me that she had already consulted with a neonatologist, especially since she was insistent that the baby be transferred without O2. That doesn't sound like an order I would be likely to receive from an inexperienced resident.

Just my opinion that we need to know the facts before imposing interventions on a baby who is under someone else's care. That is a whole lot different than failing to follow accepted standards of care for a baby whose condition is completely unknown, such as a new delivery.

[dawngloves, BSN, RN]

And I can appreciate that , Jolie. But the pt you mention had a diagnosed problem. The pt in the original post post had, "no apparent reason" for desatting.

[danissa, LPN, LVN]

I stand by my post.No matter the setting, DR, newborn nursery, NICU, if your pt is satting less than 95 % and you have no diagnosis, you would be negligent not to give o2.

less than 95%????? Why would you NEED to give o2 at say 94%?