Pulse oximetry/SpO2 Target values

1
Pulse oximetry/SpO2Target values
Absorbance
Absorbance
RED (660nm)
INFRARED (910nm)
MetHb
HbO2
HbR
Wavelength
Jubran A. Crit Care, 1999
Limitations MetHb !
2
Target SpO2 ?

• BOOST Trial (Askie LM et al. NEJM, 2003)

Aim the study To compare targets SpO2 91-94
vs 95-98
Population Preterm infants lt 30 weeks GA O2
dependant at 32 weeks PCA
End-Point Chronic Lung Disease Neurodevelopmental
outcome at 12 months
3
Askie LM et al. NEJM, 2003
4
Askie LM et al. NEJM, 2003
5
N358
SpO2 95-98 N180
SpO2 91-94 N178
CLD (36 w) 46 64 Home O2
17 30 Duration O2 17d 40d Death
3 5
Askie LM et al. NEJM, 2003
6
N358
At the age of 12 months
SpO2 95-98 N180
SpO2 91-94 N178
Major neurodevelopmental anomalies
24 23 Weight 9.1 kg 9.2kg
Askie LM et al. NEJM, 2003
7
Target SpO2 ?

• BOOST Trial (Askie LM et al. NEJM, 2003)
• STOP-ROP study (Pediatrics, 2000)

Aim of the study To compare target SpO2 89-94
vs 96-99
Population Preterm infants with Retinopathy
End-Point ROP Chronic Lung Disease
8
N649
SpO2 96-99 N325 25.4 weeks 35.4
SpO2 89-94 N324 GA25.4 weeks PCA35.3
ROP progression 48 41 At 3 months
corrected age hospitalization
6 12 Death 3 5
Pediatrics, 2000
9
Target SpO2 ?

• BOOST Trial (Askie LM et al. NEJM, 2003)
• STOP-ROP study (Pediatrics, 2000)

Summary 1 Compared with target SpO2 96-99,
target SpO2 between 89 and 94 reduces the risk
of CLD, duration of O2 therapy, and home O2 need
but what about lower SpO2 target ?
10
Target SpO2 ?

• BOOST II Trial, NEJM 2013

Aim the study To compare targets SpO2 85-89
vs 91-95
Population Preterm infants lt 28 weeks GA
(N2448) To 36 weeks PCA
End-Point Disability-free survival
11
Stenson et al. NEJM, 2013
12
Stenson et al. NEJM, 2013
13
Stenson et al. NEJM, 2013
14
Target SpO2 ?

• B Schmidt, JAMA 2013

Aim the study To compare targets SpO2 85-89
vs 91-95
Population Preterm infants lt 28 weeks GA
(N1201) To 36-40 weeks PCA
End-Point Death or Disability at age 18 months
15
Smidt B et al, JAMA 2013
16
Take home message

• In preterm infants lt 28 weeks GA
• SpO2 gt 96 est associée à
• ? CLD
• ? O2 duration
• ? ROP
• Hyperoxemia can occur with SpO2 target between
  90-96
• SpO2 lt 89 est associée à
• ? mortality (? NEC ?)
• ? ROP

Target SpO2 between 89 and 96
17
Dates à retenir !

• Le 14 Février 2014 de 9h à 18h Formation
  EIRENE/GEN aux Soins Palliatifs (Inscription
  nécessaire)
• Le 5 Juin 2014 à Rouen 9ème Journée
  Paramédicale du G4 en Médecine Néonatale
• Le 12 Juin 2014 à Roncq, Amphytrion 5ème
  réunion commune Collège Obstétriciens / GEN
• Le 19 Juin 2014 à Lille Journée Régionale de
  Pédiatrie

18
Target SpO2 ?

• SpO2 Hyperoxemia can occur with SpO2 target
  between 90-96
• Physiologic evidence suggest that O2 delivery
  can be normal when SpO2 is lower than 88,
  providing adequate cardiac output and hemoglobin
  concentration
• Clinical data suggest that target SpO2 between
  70 and 90 reduces ROP, O2 need without
  increasing neurological impairment in very
  preterm infants.

19
Stenson et al. NEJM, 2013
20
Stenson et al. NEJM, 2013
21
Absorbance
Pulsatile blood flow (arterial)
Elimination of the nonpulsatile component of the
absorbance
No pulsatile blood flow (venous, capillary)
Tissue (myoglobin, bone)
Time
Red/Infrared Absorbance (SpO2)
distal perfusion index
Limitations Low distal perfusion !
SvO2
22
Evidence for a benefit of SpO2 lt 90-95 in the
preterm infant ?
Jubran A. Crit Care, 1999

• Physiologic data
• Evidence for deleterious effects of high PaO2
  (gt80mmHg?)
• Increase the risk of ROP and respiratory
  morbidity (Askie LM. Cochrane, 2001)
• Risk of hyperoxemia with SpO2 range 90-95 ?

SpO2
95
90
PaO2 (mmHg)
42
110
23
Evidence for a benefit for SpO2 lt 90-95 in the
preterm infant ?

• Physiologic data
• Components of the tissue oxygenation

Fetal circulation
PaO2 18 mmHg ! SaO2 60 !
24
O2 delivery 1.3 x AoFlow x Hb x SpO2
PvO2
O2 consumption
25
Anaerobic metabolism
Aerobic metabolism
EO2
VO2
Lactate
PvO2
PvO2
O2 Delivery 1.3 x AoFlow x Hb x SpO2
Critical DO2
26
Evidence for a benefit for SpO2 lt 90-95 in the
preterm infant ?

• 1. Physiologic data
• Lack of evidence for hypoxia in hypoxemic preterm
  infants (Petrova A et al. Pediatr Crit Care Med,
  2006)
• Prospective study
• 10 preterm infants 24-32 weeks GA
• Mesurement of tissular oxygenation (NIRS, brain
  and kidney) when SpO2 lt 80

No tissular hypoxia (Tissular SO2 and Fractional
O2 Extraction Adequate)
27
Evidence for a benefit for SpO2 lt 90-95 in the
preterm infant ?

• 2. Clinical data
• Tin W et al. Arch Dis Child Fetal Ed, 2001
• Retrospective study
• 295 preterm infants lt 28 weeks GA
• Comparison of different policies Target SpO2
  70-90 vs 88-98

28
Outcome of the preterm infants according to the
policy of target SpO2
Tin W et al. Arch Dis Child Fetal Ed, 2001
29
Respiratory outcome
Tin W et al. Arch Dis Child Fetal Ed, 2001
30
Tin W et al. Arch Dis Child Fetal Ed, 2001
31
Evidence for a benefit for SpO2 lt 90-95 in the
preterm infant ?

• 2. Clinical data
• Deulofeut R et al. J Perinat, 2006
• Retrospective study
• Comparison of 2 historical periods
• 2000-2002 Target SpO2 92-100
• 2003-2004 Target SpO2 85-92

• 502 preterm infants lt 1250g
• Period 2003-2004
• Less ROP
• Less CLD
• Higher Mental Developmental Index (89 vs 80)

32
Target SpO2 Pre- and/or Post ductal ?

• Persistent Pulmonary Hypertension
• Of the Newborn/Preterm
• Premature Rupture of the Membranes
• Sepsis
• Severe HMD

RA
RV
LV
Pre-ductal higher SpO2
DA
PA
Post-ductal lower SpO2
DO2 1.3 x AoFlow x Hb x SpO2
33
Target SpO2 Pre- and/or Post ductal ?
In the premature infant, Pre-ductal SpO2 should
be used to set FiO2 !
RA
RV
LV
Pre-ductal higher SpO2
DA
PA
Post-ductal lower SpO2
DO2 1.3 x AoFlow x Hb x SpO2
34
Target PCO2/TcPCO2 ?

• Evidence for adverse effects of low PCO2 lt 35mmHg
• Increase the risk of BPD/CLD (Avery ME et al
  Pediatrics 1987. Garland et al Arch Pediatr
  Adolesc Med, 1995)
• Increase the risk of Periventricular
  Leucomalacia (Graziani LJ, et al. Pediatrics
  1992. Fujimoto S, et al. Arch Dis Child 1994)

35
Premature infants 400 à 1200 g
Severe IVH N179
No severe IVH N670
PaCO2 in the first 4 days after birth
Pediatrics 2007119299
36
Effects of the fluctuations of PaCO2 on the risk
of IVH
Fabre J et al. Pediatrics 2007119299
37
Target PCO2 ?

• Summary 1
• Adverse lung and brain effects of
• Low PCO2 lt35 mmHg
• Fluctuating PCO2

38
Target PCO2/TcPCO2 ?
2. Evidence for beneficial effects of moderate
hypercapnia 45-55 mmHg
Premature infants 600 à 1200 g, lt 24 hrs MV
Target PCO2
35-45 mmHg N24 26 weeks 850 g
45-55 mmHg N25 26 weeks 850 g
End-point Duration of mechanical ventilation
Mariani. Pediatrics, 1999
39
Actual values of PaCO2 according the target PaCO2
Mariani. Pediatrics, 1999
40
Effects of the target PaCO2 on the peak
inspiratory pressure
Mariani. Pediatrics, 1999
41
Effects of the target PaCO2 on the duration of MV
Mariani. Pediatrics, 1999
42
Effects of the target PaCO2 on the nonrespiratory
outcomes
Mariani. Pediatrics, 1999
43
Target PCO2/TcPCO2 ?
3. Why not gt 55 mmHg ???
Premature infants 400 à 1200 g
Severe IVH N176
No severe IVH N670
PaCO2 in the first 4 days after birth
Fabre J et al. Pediatrics 2007119299
44
Fabre J et al. Pediatrics 2007119299
45
Target SpO2 / PCO2 in the preterm infant ?

• Back home message
• SpO2
• Preductal SpO2, instead of postductal, should be
  monitered during the first days after birth
• Target SpO2 should not be gt 95
• Target SpO2 lt 92 may be preferred in extremely
  preterm infants

46
Target SpO2 / PCO2 in the preterm infant ?

• Back home message
• PCO2
• Special care should be taken to prevent
  hypocapnia (lt35 mmHg) and acute fluctuations of
  PCO2
• Moderate hypercapnia (45-55 mmHg) is associated
  with lower morbidity than normal PCO2
• Too much of a good thing (CO2) may cause adverse
  cerebral effects, at least within the first few
  days of life (PaCO2 gt 60 mmHg) !

47

• Hypotension
• Preterm AoP lt GA 2 mmHg/d, until 35 mmHg
• Full-term AoP lt 40 mmHg

48
aEEG
Ischemic Threshold ?
CBF
Kissack, Pediatr Res 2004 Victor, Pediatr Res 2006
49
La PA nest pas la perfusion
45 preterm infants lt1500g Age lt36h Mechanically
ventilated No DA ou lt1.5mm
Kucklow M, J Pediatr. 1996 Pladys P, Eur J
Pediatr. 1999
50
O2 Delivery 1.3 x Qc x Hb x SpO2
AoP Qc x SVR
Systemic Vascular Resistances (SVR)
Systemic Blood flow (Qc)
Preload
Contractility
Afterload
Heart Rate
Tibby SM, Arch. Dis. Child. 2003
51
2. Characteristics of shock in the newborn infant

• 2.a. Clinical symptoms
• Skin color grey, pallor
• Tachycardia gt 160 / min
• Capillary Refill Time gt 3 s

52
Temps de recoloration cutané
Cutaneous Refill Time
r -0,74, p lt 0,001
N40 GA 31 4 Weeks PCA 31 3 Weeks No DA
Pladys Crit Care Med 1998
53

• Oliguria lt 1 ml/kg.h
• Apneas
• Hypotonia
• Hyperglycemia
• Metabolic acidosis

54

• CAUTION Neonates with shock can have
• Normal AoP !
• Red color of the skin !
• No tachycardia (preterm) !

55

• Alarmes redondantes !
• TcPO2 SpO2
• SpO2 Fréquence respiratoire
• SpO2 pré- et post-ductale
• TcPCO2 Vt - Vmin
• Alarmes pour faire quoi ?
• Gestes immédiats pour urgence vitale
• Bradycardie
• Désaturation
• Ou Alerter Urgence différée
• Tachycardie

56
B Birth D Discharge
Tin W et al. Arch Dis Child Fetal Ed, 2001