Pedi pt w/ CHF and O2 Sat 93%

[8jimi8ICURN]

Child on Room Air

Do you: Call the doctor or Apply oxygen?

[ChristineN, BSN, RN]

What are the SaO2 limits for this child? Most of our kids are allowed to go down to 92%. Also, in my peds hospital, we aren't allowed to apply O2 without a doctor's order (I personally disagree with this rule...)

[8jimi8ICURN]

Sorry I didn't flesh it out more, i wanted to leave it pretty bare to see what people were thinking right out of the gate without seeing any of my biases.

There weren't any parameters per se because it was just a scenario on an exam, but The teacher's rationale at the end of the test was " blah blah bradycardia blah blah call the doctor"

I just wanted to get some rationales of some pedi nurses b/c even in my pedi rotation I saw kids with O2 this low and we never called the doc. Our whole class disagreed with the teacher's answer which was: Call the doctor. Being that O2 is a medication and we cannot prescribe it. (And of course from our med/surg focus, we have all learned the bad habit of turning the O2 up as our first intervention.... i know i know)

I think everyone probably will disagree with "call the doctor for an O2 sat of 93%" It just makes so much more sense to give the kid some O2 before you run off to call the doctor.

I mean... in my EMT-B class that is one of the primary responses that we have is Apply hi flow O2, but of course that is pre-hospital and there are already standing orders.

Does anyone think that the "child with CHF" provides any clue as to why a doctor would need to be called on this? I understand the rationale that my teacher is giving (and based on the 4 answers we had to pick from, Call the doc, or apply o2 were the only viable answers) Honestly i would even try some other interventions before calling a doc for a sat of 93%. I just feel the doctor would feel pestered and annoyed that I would call with something like that.

Thanks for your time.

[NotReady4PrimeTime, RN]

More important here is why does the child have CHF? If the child has certain cardiac defects, such as hypoplastic left heart syndrome prior to Fontan procedure, tetralogy of Fallot, tricuspid atresia, pulmonary atresia with or without ventricular septal defect, Ebstein's anomaly or single ventricle with pulmonary or aortic atresia, that have been palliated by Blalock-Taussig shunt, having sats higher than the mid-80's for more than a short time will be fatal. The BT shunt connects a systemic artery tot he pulmonary artery, allowing for more balanced oxygenation of the blood. But too much O2 will cause the pulmonary vascular bed to clamp down and the child will start to decompensate. These children run higher hemoglobins to compensate for the low saturation, and should never have a sat in the 90's. That is why many peds hospitals have a no o2 without a doctor's orders policy.

[8jimi8ICURN]

thanks for your response. That makes a great deal of sense. We were actually tested on pedi-cardiac on this exam, so your examples make complete sense to me.

the question was very very plain " You are caring for a child with CHF who has an O2 saturation of 93% your response is to..."

and then 2 absolutely wrong answers mixed in with call the doc, or apply o2.

in the teacher's rationale, she stated something i can't remember about decreasing O2 leading to bradycardia :. we should call the doc as the correct answer.

But she did not include anything about bradycardia in the question, or any of the answers. All of your examples make sense as to why a sat of 93% would be a reason to call the doctor, but i am just going to go with

"its a bad question with a poor rationale for an answer" She was asking us to infer bradycardia without any clue. I'm pretty sure that about 90% of the class missed that question. If i was really really worried, i would ask my charge nurse, or another peer... :)

[NotReady4PrimeTime, RN]

It's true that hypoxia may lead to bradycardia in children, but generally speaking, a sat of 93% isn't going to. I would expect to see bradycardia in an otherwise healthy child whose sats were

One should not have to infer things like that from an exam question. We're told repeatedly not to read into the question, if the information is not presented in the stem, it won't be in the answer. So your evaluation of the question as a poorly drafted question with an even worse rationale, was spot on. The answer, call the doctor, was correct, but not because of potential bradycardia.