Managing O2 changes in preemie

LoveTheNICU · Mar 4, 2009

This is one of those questions that plauges the NICU, so it's completely normal to be confused by this! The overriding thing that I try to remember in this situation is that in GENERAL, too much oxygen is much more harmful than too little, especially when dealing with the tiny micros. I read some research recently that said even in babies allowed to have SpO2s in the 70s for 10-20 minutes at a time, the risk of CP or developmental delays did not increase. However, spending relatively little time with high SpO2s (>95%) was certainly associated with an increased risk of ROP and CLD. I will try to find and post the link to that study if I can. The other piece of research out of that study was that the rapid swings in FiO2 needs are more damaging than a few minutes of decreased sats- meaning it is better to leave the kiddo to recover on their own than crank them up right away.

The other concept that is difficult to understand in relation to this is what your pulse oximeter is really telling you. In the case of lower saturation, your SpO2 will do a fairly good job of reflecting a decrease in your PaO2 (should you get a blood gas). However, a baby whose SpO2 is 100% could have a PaO2 of 85, or of 150! The pulse oximeter cannot determine that, and it is as the PaO2 rises that your oxygen associated complications increase. Make sense?

You are doing the right thing by going to the bedside and assessing your baby, making sure there isn't something besides "normal preemie" that is causing him to desaturate, such as kinked tubing. I know that it is hard to stand back and wait, especially with parents near by or that blasted alarm sounding. Unfortunately, there is no set time limit for how long to wait- it would be awesome if they did a study and said, "Oh, yes, it is safe to increase the FiO2 after 2.37 minutes..." but that will never happen. Instead, look at the baby and the monitor. Is the child agitated? Could some gentle containment help? Is he becoming dusky or working harder to breathe? Is bradycardia beginning? Are his saturations continuing to decrease, or have they stabilized at a lower number and begun to slowly come back up? All of these things play into your decision to increase the FiO2.

When you do decide, after some careful assessment, that he could use a little bump, go s-l-o-w-l-y. My NNP professors recommend 2-5% to begin. Then wait again, and assess. If after another couple minutes (literally, minutes) he needs more O2, do another small bump. Remember, too, to turn the baby back down slowly after they have recovered, as well- those big swings are killers! You are doing the right thing by trying to care for him in a efficient and calm manner (such as with diaper changes), but keep in mind that often these little guys just don't have the capacity to have their care clustered as much as we would like. If he is ok for the first part of your hands on cares, then kinda freaks and desats, maybe he needs a 10 minute break or so. Stop, chart what you've already done, and let him recover.Then, once he is comfortable again, you can finish what you need to do, and THEN leave him undisturbed for as long as possible.

It is awesome to know that you are thinking about this in your patients. You will see the nurses- every unit has them- that have worked there long enough to remember when every baby was placed in 100% FiO2. When their baby desats, they hop on over and crank them up a good 30-50%, or worse, hit the dreaded "suction" button on the vent that automatically gives 100% FiO2. It is the way they were trained, and often, even with education, old habits die hard. It is hard, too, as a new grad, when you feel like you aren't DOING anything to help the baby in front of you- I understand. But know in your heart that waiting is helping, and be prepared to explain this to families or even other nurses who say, "Why aren't you DOING something?" Reassure moms that a few minutes of desats will not brain damage their child, and that minimizing FiO2 changes will improve their long term outcomes. Talk to your unit educator or former preceptor if you need some back up on that.

Finally, in terms of taking care of a 24 weeker. Make sure the environment in his bed is comfortable and he is positioned well (extremities brough to midline, head neutral, shoulders and hips rounded, good boundaries). Keep it dark and quiet in his area. If going from prone to supine for cares, turn him slowly and support his head well. All of these little things may help improve on the number of desaturations he has, and the "shock" of hands on cares. Encourage kangaroo time with mom, as allowed in your unit. And know that as a new grad, this is very, very hard, and it sounds like you are doing a great job!! :yeah:

fiveofpeep · Mar 4, 2009

that was very informative. thank you :)

twizzlers67 · Mar 4, 2009

Thank you, I feel a lot more comfortable now not jumping on that oxygen dial right away. I will definitely go slow when I do need to turn it up as well. And I think you're right that I may need to give him a little break when he starts to desat with hands on cares and I'll see what I can do to help position him a little more comfortably.

Galore · Mar 5, 2009

Our unit has a protocol that we're supposed to follow, it takes some of the guesswork out of it when you're new. If O2 sats are >70%, you silence the alarm and observe for a minute or two. If sats are still >70% but in the desat range x2 or 3, then you may increase the FiO2 by ~3-5%. If sats

dawnebeth · Mar 6, 2009

All the other posters gave great advice. It is really difficult to sit and watch a preemie desat--and most 24 weekers are elevator babies--they constantly go up and down in their sats. If you get to know a baby well, you become most sensitive to his ways and are able to monitor his desats more accurately. Baby A just constantly desats all day long and that's her way, so you can sit back and reassure parents that although she's in 79 percent, she generally comes back on her own within five minutes, only to drop again a half hour later. If Baby B rarely desats and suddenly she's 63 and blue, then definitely turn her upmaybe from 40 to 50, and check all the usual suspects like needs suctioning, position change, diaper change (so often it's such a little thing!), and then inch her back down afterwards.

I remember when I was brand new, I couldn't fathom how anyone could let the micro-preemies alone for an hour or two without touching them, but in fact, that's the best thing of all. Get everything you can done all at once and try not to touch them for as long as possible. Lying on her tummy, tucked in good position, in the lowest possible oxygen to keep her sats in the high 80's to low 90's, the isolette covered with a blanket, and then pretend to ignore her. Of course, you aren't--you're assessing color and body movements as well as all the machines every few minutes. It gets easier!

Dawn

RainDreamer, BSN, RN · Mar 7, 2009

Excellent post by LovetheNICU :up:

When I have a baby that does what you describe, the main thing I look at is how old the baby is. Is this a new 24 weeker? If it's a 24 weeker that is only days to a week old, and they continue to desat (up/down with their sats pretty consistently), then I would be concerned. But if it's a 24 weeker that is now a few weeks old, then I wouldn't be as concerned. Why? Because minor BPD can start setting in after the first 2 weeks. They will desat and be up and down on their sats throughout your shift. They bring their sats up on their own though and you rarely need to intervene. These kids just need to grow and let their lungs heal/develop.

twizzlers67 · Mar 7, 2009

Thank you all for your great advice! And raindreamer, yes it is a new 24 wkr. I understand what you mean with the old 24wkrs who are normally a little labile, what sort of things would you be worried about/look out for in this instance?

NICUnurseKatie · Mar 7, 2009

We follow the COMP-ROP for our sat limits and I feel like sometimes they are too restricting on our teeny ones. Our common-sense MD will immediately order sats to be 75-92% and q6hour touch times. I feel that with tight limits you're constantly adjusting 02, which is far more harmful than letting a child sat 77 for a while. I have a 24 weeker primary right now and he is 2 weeks old. I have worked out a routine that works perfectly with him. He is on HFOV. 20min. prior to touch he gets a Versed/Fentanyl cocktail, minimal doses. I bump him up by 2-3% before I even go into the bed. I do not change his position until the very end, doing all of my care while he remains positioned in his snuggly. Then I give him a break and go back in and change diaper, reposition, suction if needed. We have probes for vitals so I try not to touch him at all in between. He usually doesn't need any additional meds. Parents come in a touch times to interact if he tolerates.

300g · Mar 8, 2009

That's a fantastic response by LoveTheNICU! :yeah:

Just a couple lil things to add... I really don't adjust the FiO2 unless the sats drop into the 60's or prolonged 70's and that's generally only 2-5% while I assess what the "real" problem is. Remember, oxygen is a powerful vasoconstrictor too. Although it irritates other nurses, after I've assessed all other factors and this baby is simply on an O2 sat rollercoaster... I silence the alarms and say "they'll brady when they mean it." :jester:

Two other things to consider (that maybe I've overlooked in other posts) are PDA and Hct.

Sweeper933 · Mar 8, 2009

I silence the alarms and say "they'll brady when they mean it."

I second that!!!

My current primary is a former 24 weeker (now over 6 weeks old). He used to desat into the 50's on a regular basis for "no reason". You could crank him to 100% (not that I did) and he would still do it. He would come back up when he was good and ready :wink2:

BittyBabyGrower, MSN, RN · Mar 8, 2009

We have a rapid wean protocol we follow. We get them to RA as quickly as we can, set the limits 85-94% and adjust accordingly. The alarms are enough to set your teeth on edge! Our monitors have an alarm delay of 90 seconds for desats...if they stay down over 90 sec then it will alarm and we act accordingly. Most kids just jump up and down, up and down. We keep them on the lower side of the limit until their eyes are fully vascularized or are recovering from laser.