O2 bad if pt already 100% RA?

[Emergent]

I recently heard that O2 is contraindicated if pt already has great sats. In the ER, though, part of some of our protocols is O2 on all. Any hard facts with rationale? I would love to learn best practice for this situation

[TU RN, DNP, CRNA]

Wow awesome response LearningByMistakes!! Thank you!

[applewhitern, BSN, RN]

This article from 2002 is referring to high-flow 02, specifically non-rebreathers, compared to lower-flow 02, such as 02 at 2 lpm per n/c. You really need to assess your patient and follow your ER's specific protocol, not some random article pulled off the internet, such as this one. You stated, "part of some of our protocols," so that more than likely means anyone with respiratory distress, chest pain, etc? Surely your protocol isn't to apply 02 to everybody who comes into the ER, regardless of need? If you follow ACLS protocol, and the protocol as written by your medical director, and the ER doctor's orders, then you won't be wrong.

[Altra, BSN, RN]

Exactly what applewhitern said ...

I would have hoped that the OP would clarify that this post was not about *all* patients to present to his/her ED, but all patients whose chief complaint includes O2 in the protocol.

For cripes sake ...

[TraumaSurfer]

It depends on the clinical situation. Some situations may have a need for the "risk of free radical" damage to offset a more immediate risk.

[MunoRN, RN]

Until recently, really the only generally accepted reason to put O2 on someone with a normal Sat was the chest pain/ACS algorithm, although even that has been removed. Supplemental O2 is only recommended in someone with a saturation of

[Emergent, RN]

Until recently, really the only generally accepted reason to put O2 on someone with a normal Sat was the chest pain/ACS algorithm, although even that has been removed. Supplemental O2 is only recommended in someone with a saturation of

Yes, this is exactly what I heard during my recent acls renewal, told by our trauma coordinator. Yet when we hit the cardiac button for a cp pt, application of O2 for all pts comes up in the order set

[OCNRN63, RN]

To reiterate: No respiratory symptoms, normal sats, no need for supplemental oxygen.

We're not talking about people who have respiratory symptoms (working hard to maintain sats) or people who desat on movement (abnormal finding). Of course this involves assessment. But it's ridiculous to have a blanket protocol that everyone who walks in the door for any reason gets supplemental oxygen, which is the OP's question. There is no rational reason at all for that protocol.

Many EDs use O2 as part of their cocktail for treating migraine. Not a resp. situation, but is an example of using O2 even though the pt. has good sats.

[TraumaSurfer]

Never assume the SaO2 is 100% just because of an SpO2 number with or without symtoms. Unless you understand the components measured, your assumption could be wrong.

The other components are measured by Co-Oximentry when a more accurate break down is required but none the less they are still present. The SaO2 on a regular blood gas is calculated and can also mislead some who do not fully understand oxygen in the blood. Until a history is taken and you know more about the patient, their situation and MEDICATIONs a blanket protocol might be warranted. After that, it should be a nursing judgment.

The components which make up an actual measured SaO2 are O2Hb, COHb, MetHb and HHb (deoxyhemoglobin). Is the patient a smoker or do they live/work in a smoky environment which affect COHb? This is a vital pre-op question since the SpO2 monitor is used during surgery and any variables affecting it must be noted. What type of meds? Chemo? Nitrates? Pyridium (UTI)? These can affect MetHb. What about Sickle Cell or other factors affecting HHb? Anyone know why we do ScvO2 or SvO2 analysis in the ICU or a Venous (preferably central) blood gas in the ED on some patients?

There are also factors which shift the oxyhemoglobin curve to affect the SpO2. This is why some sepsis protocols start with O2 temperature correction is done on ABGs at certain temperatures.

I have also seen hypoxic patients with an SpO2 of 70% deny any shortness of breath.

We also know there are exceptions to the O2 rule for nonpulmonary patients such as certain headaches which O2 has been proven effective or for a confirmed pneumocephalus associated with CPAP/BiPAP therapy.

Don't jump to conclusions just based on one number especially since if this patient did come to the ED for some emergent reason. Do your assessment first. No one can tell you a blanket protocol applies or does not apply to your patient.

As far as O2 charge, it is usually around $22 for a set up in the ED. Once the patient is admitted to the hospital they get a day charge. Those green O2 tanks and that big liquid tank beside the hospital are not free. They are very costly and must come from some budget which might be RT. If your hospital is phasing out the RT department or it goes under nursing, don't complain when cutbacks on other supplies are done to offset necessary expenditures because you feel the O2 charge is silly.

[Esme12, ASN, BSN, RN]

Wow awesome response LearningByMistakes!! Thank you!

That was not from learning by mistakes article.... http://www.ems1.com/columnists/mike-...n-oxygen-hurt/

Can oxygen hurt?Mike McEvoy

Drug we use most often can cause harm if we give it without good reason

Which is an article of his opinion based on his research

[Emergent, RN]

I emailed my manager asking her to look into the issue, letting her know what the trauma coordinator said. One of our docs said that the order set really needs to be changed, that it's not appropriate to always give O2, even to a chest pain pt.

[TraumaSurfer]

That was not from learning by mistakes article.... http://www.ems1.com/columnists/mike-...n-oxygen-hurt/

Can oxygen hurt?Mike McEvoy

Drug we use most often can cause harm if we give it without good reason

Did anybody actually look at the references used for this article? Sometimes it is difficult to use an article such as this one by Mr. McEvoy which is composed of exerts taken to support his own opinion.

References:

Akero A, Christensen CC, Edvardsen A, et al. Hypoxaemia in chronic obstructive pulmonary disease patients during a commercial flight. Eur Respir J 2005;25:725–30.

Cottrell JJ, Lebovitz BL, Fennell RG, et al. Inflight arterial saturation: continuous monitoring by pulse oximetry. Aviat Space Environ Med 1995;66:126–30.

Hoffman CE, Clark RT, Brown EB. Blood oxygen saturations and duration of consciousness in anoxia at high altitudes. Am J Physiol 1946;145:685–92.

Alteiemer WA, Sinclair SE. Hyperoxia in the intensive care unit: why more is not always better. Curr Opin Crit Care 2007;13:73-78.

O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O'Neil BJ, Travers AH and Yannopoulos D. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science Part 10: Acute Coronary Syndromes. Circulation 2010; 122: S787-S817.

Ronning OM, Guldvog B. Should Stroke Victims Routinely Receive Supplemental Oxygen? A Quasi-Randomized Controlled Trial. Stroke 1999;30:2033-2037.

Rabi Y, Rabi D, Yee W: Room air resuscitation of the depressed newborn: a systematic review and meta-analysis. Resuscitation 2007;72:353-363.

Davis PG, Tan A, O’Donnell CP, et al: Resuscitation of newborn infants with 100% oxygen or air: a systematic review and meta-analysis. Lancet 2004;364:1329-1333.

Stockinger ZT, McSwain NE. Prehospital Supplemental Oxygen in Trauma Patients: Its Efficacy and Implications for Military Medical Care. Mil Med. 2004;169:609-612.

Austin MA, Wills KE, Blizzard L, Walters EH, Wood-Baker R. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. BMJ 2010;341:c5462.

Kilgannon JH, Jones AE, Parillo JE, at al. Emergency Medicine Shock Research Network (EMShockNet) Investigators. Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest. Circulation 2011;14:2717-2722.

Harten JM, Anderson KJ, Kinsella J, et al. Normobaric hyperoxia reduces cardiac index in patients after coronary artery bypass surgery. J Cardiothorac Vasc Anesth 2005;19:173–5.

McNulty PH, et al. Effects of supplemental oxygen administration on coronary blood flow in patients undergoing cardiac catheterization. Am J Physiol Heart Circ Physiol 2005; 288: H1057-H1062.

Bledsoe BE, Anderson E, Hodnick R, Johnson S, Dievendorf E. Low-Fractional Oxygen Concentration Continuous Positive Airway Pressure Is Effective In The Prehospital Setting. Prehosp Emerg Care 2012;16:217-221.

How do you determine "hyperoxia" by SpO2 alone? An SpO2 alone will not tell you if the PaO2 is over 300 mmHg. 40% on a normal person with no existing cardiopulmonary disease might should get 235 mmHg by calculation.

Some of the studies were done after 24 hours in the ICU with a known PaO2 value over 300 mmHg. This only shows these hospitals need to revamp their weaning protocols since the affects of oxygen at this level for 24 hours has been known for the past 30 years.

The prehospital studies demonstrates the EDs involved might want to review the ERS, ATS or Gold standards for treating COPD. Oxygen alone is not the only reason for increased mortality rates.

The BMJ article was so poorly researched it was dismissed as having much if any significance. But, some read the catchy title about O2 in prehospital increasing mortality but failed to read the article itself. Even the authors admitted the short comings of their research in the article. Without the data of what treatment was done besides just O2, it again just makes the EDs look incompetent in the care of a COPD patient.

It is also no mystery that when a patient looks sick and is unstable, they will get a NRB mask and may die before someone who just gets a 2 L NC and looks more stable.

Has anybody take NRP (neonatal resuscitation) and know the story behind this or the actual guidelines? If a baby needs oxygen, they get it. Does anyone know where the studies were done initially for room air resuscitations with infants and why?

So don't be too quick to produce an opinionated overview article or any article without first reading it to see if it actually pertains to your situation. You could look like someone who only looks at catchy titles and lacks a thorough understanding of the bigger picture or why some protocols are written as they are.

[applewhitern, BSN, RN]

I looked at the references~ one reason why I wasn't impressed with it.