Background:Although oxygen is the most widely used therapeutic agent in neonatal care, optimal oxygen management remains uncertain.Purpose:We reviewed oxygen physiology and balance, key studies evaluating oxygen saturation targets, and strategies for oxygen use in the neonatal intensive care unit.Results:Oxygen is a potent vasodilator involved in the transition at birth to breathing. Supplemental oxygen is administered to reverse/prevent hypoxia; however, excessive oxygen can be toxic owing to the formation of reactive oxygen species. Current neonatal resuscitation guidelines recommend using room air for term infants in need of support, with titration to achieve oxygen saturation levels similar to uncompromised term infants. In premature infants, targeting a higher oxygen saturation range (eg, 91%-95%) may be safer than targeting a lower range (eg, 85%-89%), but more evidence is needed. In combined analyses, lower oxygen saturation levels increased mortality, suggesting that the higher target may be safer, but higher targets are associated with an increased risk of developing disorders of oxidative stress.Implications for Practice:Need for supplemental oxygen should be assessed according to the American Heart Association guidelines. If appropriate, oxygen should be administered using room air, with the goal of preventing hypoxia and avoiding hyperoxia. Use of oximeter alarms may help achieve this goal. Pulmonary vasodilators may improve oxygenation and reduce supplemental oxygen requirements.Implications for Research:Implementation of wider target ranges for oxygen saturation may be more practical and lead to improved outcomes; however, controlled trials are necessary to determine the impact on mortality and disability.
Newborn screening is the largest genetic testing effort for newborns in the U.S. Its purpose is to identify newborns who are at risk for metabolic, endocrine, or hematologic disorders. A review of the literature was conducted to determine the benefits of newborn screening; specimen collection timing and handling; ethical considerations of screening; as well as current practices regarding consent, notification of results, and follow-up procedures. The use of tandem mass spectrometry for expanded newborn screening and postmortem diagnosis of unexplained infant death was also reviewed. This article is intended to educate health care providers in the areas of controversy that surround the U.S. newborn screening program, with the hope of encouraging further research in this mportant area of newborn care.
Background: Hypoxic-ischemic encephalopathy (HIE) remains devastating for neonates despite widespread treatment with therapeutic hypothermia (TH). The heart rate characteristic (HRC) index score, a measure of heart rate variability, could prove useful in the management of neonates with HIE as new therapies emerge or when withdrawal-of-support decisions are being considered. Purpose: The main purpose was to describe correlation between HRC index scores and brain magnetic resonance imaging (MRI) severity of injury for neonates with HIE. Methods/Analysis: Low/high HRC index scores retrieved at initiation of TH (baseline), 24, 48, 72, and 96 hours, brain MRI severity of injury, and National Institute of Child Health and Human Development Death/Disability and Death scores were collected and analyzed retrospectively. Independent t tests and linear regression were used to examine relationships for each outcome measure. Results: Twenty-seven neonates were stratified into 2 groups: noninjury (n = 11) and injury (n = 16). Statistically significant relationships were observed. Strikingly, mean low HRC index score for the noninjury group ranged between 0.37 and 0.65 and was between 0.61 and 0.86 for the injury group. Mean high HRC index score for the noninjury group ranged between 0.66 and 1.02 and was between 1.04 and 1.41 for the injury group. Implications for Practice: HRC index score may be a useful guide in the future management of neonates with HIE. Implications for Research: This study established correlations between HRC index and MRI injury scores in neonates treated with TH. Further research is warranted to establish important relationships between brain injury and HRC index scores before this tool can be used clinically for this purpose.
Background:Excessive supplemental oxygen exposure in the neonatal intensive care unit (NICU) can be associated with oxygen-related toxicities, which can lead to negative clinical consequences. Use of inhaled nitric oxide (iNO) can be a successful strategy for avoiding hyperoxia in the NICU. iNO selectively produces pulmonary vasodilation and has been shown to improve oxygenation parameters across the spectrum of disease severity, from mild to very severe, in neonates with hypoxic respiratory failure associated with persistent pulmonary hypertension of the newborn.Purpose:An online survey was conducted among members of the National Association of Neonatal Nurse Practitioners to gain insight into the level of understanding and knowledge among neonatal nurse practitioners (NNPs) about optimizing supplemental oxygen exposure and the use of iNO in the NICU setting.Results:Of 937 NNP respondents, 51% reported that their healthcare team typically waits until the fraction of inspired oxygen level is 0.9 or more before adding iNO in patients not responding to oxygen ventilation alone. Among respondents with 1 or more iNO-treated patients per month, only 35% reported they know the oxygenation index level at which iNO should be initiated. Less than 20% of NNPs reported perceived benefits associated with early initiation of iNO for preventing progression to use of extracorporeal membrane oxygenation or reducing the length of hospital stay, and about one-third of respondents reported they believe early iNO use minimizes hyperoxia.Implications for Practice:More education is needed for NNPs regarding the negative effects of oxidative stress in neonates.Implications for Research:Additional clinical trials investigating the most beneficial strategies for avoiding neonatal hyperoxia are warranted.
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