Controversies & Oxygen DR Resuscitation Premature Infants

Living In Utero -- On the cliff

PaO mean minutes 2 (Range of 2-55 minutes)

NRP Position on Resuscitation zClear the airway zStimulate and Dry zProvide PPV with 100% oxygen zGradually withdraw oxygen, maintaining pink

Why 100% Oxygen ? zRestore oxygen for metabolism of lactate and to restore aerobic metabolism zReduce Pulmonary Vascular Resistance zHelp to prevent PPHN

Why NOT 100% Oxygen? zYou may not have Oxygen zExpensive if you don’t need it z If ischemic, there is reperfusion injury. More oxygen might make that worse. zMight it be harmful? Does an infant need time to transition? zAsphyxiated piglets resuscitate fine with RA

Animal Studies zPiglets: (earlier adult pigs) y8% oxygen until hypotensive & Base XS - 20 zRabbits: yMaternal hypoxia for fetal hypoxia zGerbils y15 min cerebral ischemia zLambs yhypopneic with water zDogs (adult) y9 min. cardiac arrest y RESULTS

The Question in Babies z1993*Ramji 82 odd, even, unblinded z1998* Saugstad 609 odd,even, unblinded z2000Vento 537 z2003*Vento 106 RCT, blinded zsubmitted Ramji 354 zSo 1,688 infants have been studied z(?)

Outcome Mortality z1993 z1998 z2000 z2003 zpending zTOTAL 7.1% 9.5% 15 % 20 % % 11% OR 0.63, [ ] MORTALITY Room Air 100% Oxygen

Other Outcomes In Room Air as vs 100% zTime to first cry about 1/2 min. sooner zTime to established Resp about 1 min. sooner z 1 min. APGARs higher (4 v 5) z 5 min. APGARs not Different z Diagnoses of HIE not significantly different, but favors RA

So What Will You Do ? zSaturday when you see the next depressed baby? zPosition on a Policy Committee y(Remember the RLF Experience) zAction at the National Level as an NRP instructor?

What about Preterms? Win Tin: 50 Years of Uncertainty in the NICU

A Request (pick up pen) zDoes your NICU have a policy on Oxygen Saturation Targets? zDo you write orders for Saturation Targets? zAssume an infant of 26 weeks, 800 grams in the first 3 days after birth yWhat saturation target orders would you write?

Stated Pulse Oximetry Goals NICU A 88-98% 70-90% NICU B Tin et al, Arch Dis Child Fetal Neonatal, 2001;84:F Results from Differing Pulse Oximetry Guidelines -- UK

Infants <28 weeks Tin et al, Arch Dis Child Fetal Neonatal, 2001;84:F106

Duration of ventilation (weeks) Proportion still being ventilated( %) % 75-93% Proportion Still Being Ventilated 88-98% Target 75-93% Target Duration of Ventilation (Days) Percent

Reduction in Rates of ROP An Historical Comparison --- USA Chow et al zBW g zRates of stage 3 or worse ROP zPre-intervention 1997 zIntervention 1998 forward yDelivery Room: blender and saturation monitor yNICU: proportional response, prompt weans yTarget saturations: 85-93% zOutcomes of births from zAnnually about 70 infants in this BW range

Laser Treatment of ROP Chow et al. Pediatrics 2003; 111:339

Incidence: Stage 3 or Worse ROP Chow et al. Pediatrics 2003; 111:339

The POST-ROP Study zPremature Oxygen Saturation Targeting for the prevention of Retinopathy of Prematurity zPlanning Stages zEditorial Forthcoming in Pediatrics zMulticenter, double blinded, 5 year follow- up zCurrently considering 85-90% v 91-96%

Thank you !