Don't give oxygen?

  1. 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.
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  2. 22 Comments

  3. by   ABQLNDRN
    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%?
  4. by   JoycMarr
    depends on the circumstances. I've seen a MD angry at a nurse who slapped a 100% nonrebreather on a COPD'er pt.
  5. by   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.
  6. by   ortholuv
    Never. Was the pt a DNR??
  7. by   bargainhound
    delete message, I did not know pt was neonate.
    Last edit by bargainhound on Feb 4, '07 : Reason: did not know pt was a neonate
  8. by   muffie
    can you elaborate on the clinical pic a little more
  9. by   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.
  10. by   ABQLNDRN
    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.
    Last edit by ABQLNDRN on Feb 4, '07
  11. by   ABQLNDRN
    Quote from 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.
  12. by   ABQLNDRN
    Quote from 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.
    AWESOME answer. Thank you so much. The baby did respond to O2 intervention and was past the transitional phase.
  13. by   RainDreamer
    That resident was out of line to talk to you like that, without even giving more of an explanation. And how did they know for sure if the baby had a cardiac defect? She was just assuming? If the baby responded to oxygen, then it doesn't sound like a cardiac problem, as those kids don't sat higher with an increase in oxygen.

    I've had a HLHS kid that was satting too high on room air, so they put him under a nitrogen hood to decrease the percentage of oxygen he was breathing.

    But without knowing the exact diagnosis for sure, that resident was out of line to say that to you.
  14. by   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).

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