Recent discussions
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ILCOR Staff
The extensive studies and findings are commendable. Looking for answers via evidenced-based practice continues to be the driving force behind finding the answers posted for FIO2 needs for preterm infants, sick infants, etc. and the numerous possible sequelae that can affect them. In our institution, we start off with lowest O2 concentration and increase it based on pre-ductal SpO2 target. -
ILCOR Staff
I agree with the recomandation starting with lower concentration FiO2 and modulating FiO2 if you need to. -
ILCOR Staff
I agree starting at a lower concentration (30%) and adjusting upward as needed per pulse oxymetry or HR monitors. Many times all we need to do is support them with pression, CPAP, more than higher FiO2; other times we must increase FiO2 to adjust the patients needs -
ILCOR Staff
The difference in mortality is compelling. Starting with 21% FiO2 in mildly depressed term neonates with in-utero primary apnea is reasonable. In moderate to severely compromised term infants who suffered from secondary apnea in-utero, starting with slightly higher FiO2, like 30%-40% may be prudent and needed in order to reverse the process of severe hypoxia and persistent R-L shunting. It may be increased thereafter as per the improvement, assessed q 15-30 seconds. A good FRC established with the use of adequate positive pressure breaths may decrease the need of high FiO2. Judgement must be used about escalating FiO2 to 100%, as severely depressed moribund term babies in imminent threat of death may be difficult to reverse and need it. Such cases are also most susceptible to medicolegal liability. Use of 100% oxygen should not be completely ruled out. Establishing optimum perfusion is critical to assure expected response from PPV/FiO2 supplementation. -
ILCOR Staff
The use of supplemental oxygen in the assistance to term and preterm newborn at birth with FiO2 of 21% is feasible, reduces costs and improves some neonatal outcomes. -
ILCOR Staff
I always start with intermediate concentrations such as 30% oxygen. And I rarely need to use oxygen concentrations above 40%. And I can often reduce it by as much as 21%. -
ILCOR Staff
Overall conclusion is that there is no difference in major outcomes with using either lower or higher FiO2 in resuscitation. The corollary is, higher FiO2 is as safe and effective as lower. So why stress on lower FiO2? Hypoxia even if transient can cause further injury to premature brain, or to a compromised term brain which needs resuscitation. It can cause multiple organ damage and malfunction. Hypoxia is defined by decreased oxygen delivery to tissues and depends in a major way on hematocrit and tissue perfusion, even more than oxygen saturation and arterial partial pressure of O2. Maintaining intravascular volume may be as important as providing oxygen. Ideal oxygen saturation changes within minutes and hours after birth. The question is which one is more hazardous- hypoxia or hyperoxia. Multiple variables in this comparison matter, like, etiology, severity, extent, duration etc. There are so many varying situation and confounding variables in a case needing oxygen resuscitation that to make a blanket statement on FiO2 in this regard may not best serve the purpose. In fact this is what the conclusions here indicate. During resuscitation, each case should be evaluated on its own merits and best judgement be used towards establishing good oxygen delivery to tissues by providing adequate oxygen and optimizing intravascular volume without delay. -
ILCOR Staff
I agree with the analysis, but have some concern about the conclusion. An initial FiO2 of 21 to 30% may not be the safest option based on the published data so far. I know of 14 published RCTs of 'low' versus 'high' initial FiO2 for preterm resuscitation and these have been subjected (in various combinations) to at least 7 Systematic reviews. There is no convincing evidence of benefit or harm from either strategy. The data relating to term babies and short term measurement of oxidative stress are cause for concern in relation to high oxygen strategies however. Conversely, a report from the Canadian Neonatal Network (Rabi et al - Resuscitation et al 2015) on a very large preterm cohort, reported an increased rate of death or neurological injury following introduction of a policy to use air as an initial resuscitation gas. The use of 'some' oxygen appears to be sensible. The Torpido trial (Oei - Pediatrics 2017) very helpfully reported FiO2 during preterm resuscitation starting initially with 100% or air and subsequently adjusted by pulse oximetry to achieve an SpO2 of 80 to 95% by 5 minutes. It appears form their data (Figure 4 in the original paper) that an FiO2 of 40% was required by the majority. This paper also reported that failure to achieve the SpO2 target by 5 minutes of age was independently associated with mortality (although it is not clear whether this was a consequence of treatment or an index of initial illness severity) and also, in a non-pre-specified analysis, found an increase mortality rate at <28 weeks when resuscitation was started in air compared to starting in 100% oxygen. Given all of that, we have decided locally that starting preterm resuscitation with "some oxygen" means starting with 40% and titrating subsequently using pulse oximetry. Further studies required! -
ILCOR Staff
I believe very much in the recommendations of ILCOR. We have indeed observed that neonates respond very well to cardiorespiratory resuscitation even without the use of supplemental oxygen and, when necessary, low inspired fractions of O2. I observe that positive expiratory pressure is more effective than increases in the inspired fraction of O2. -
ILCOR Staff
I accept the information and the recommendations and will practice accordingly until there is evidence to the contrary.