Recent discussions
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ILCOR Staff
I agree with your treatment recommendations for term and late preterm newborns (≥ 35 weeks gestation). -
ILCOR Staff
Thanks Bill. Of course the Torpido trial was one of the prompts for this review as it was already changing practice. However, that trial was almost fatally flawed in recruiting so few of the potential candidates, failing to complete because of lack of equipoise and the fact that, as you mention, the relevant analysis was not pre-specified. In fact the authors did not feel that the study should change practice. We are therefore left with RCT evidence vs observational evidence. There is clearly, as acknowledged, a lot more research needed to cover all of the questions raised. Some oxygen may well be sensible but unfortunately the evidence available makes it very difficult to stipulate more than the document has. Your local decison to implement 40% as an initial concentration may well help if observational data can be produced to to inform future studies. As you say they are needed but have to be able to recruit and complete. (This is in no way to criticise the Torpido Group whose study was supported by many) -
ILCOR Staff
Interesting to note that review consensus on science, showed ‘no benefit or harm’ on such significant wide range of Fio2 (most of these are downgraded for risk of bias and imprecision!!!) except in the critical outcome of all cause long-term mortality (1-3 years), that too from observational cohort studies with ≤28 weeks gestation receiving respiratory support at birth showed benefit of lower initial oxygen concentration compared to higher initial oxygen concentration. Wonder if it makes difference, assuming that there was NO uniformity of type of oxygen blenders usage, type of ventilators (invasive and noninvasive), type of oxygen saturation monitor usages and type of disease treated in premature infants? Does it make difference in the 'no benefit or harm' outcomes? Also, curious to know, the composition of air as we know consist of 78% N/21% Ox2/ 1% Argon and 0.04% Co2; Argon is supposed to be asphyxiant. And so just curious and wonder mixing of air and oxygen with Argon will have any effect in preterm infants lungs and brain? Inhalation of argon/oxygen mixtures have been used in adult humans to measure coronary and cerebral blood flow. Argons beneficial neuroprotective and organ protective properties have been observed in animal experiments in vitro and in vivo, but rarely in human studies. Another question I have is in preterm infants, the mitochondrial bioenergetic dysfunction is a fundamental mechanism of organs failure in premature infants. And we know oxygen used in mitochondria to generate ATP during oxidative phosphorylation. Do we need more and better understanding of this 'Oxygen Molecule’? Wonder in the meantime, it may be better not to give too much or too little for NOW? -
ILCOR Staff
Thank you Debasis. I won't repeat my reply from your comment which was similar for term babies but the points remain pertinent. -
ILCOR Staff
Thank you Rita as you raise excellent points. We had hoped that the Justification and Evidence to Decision section would explain some of your thinking and discussions in arriving at this CoSTR? You are completely correct that in the situation where no advantage is seen, the lower initial oxygen has been preferred because of concern about "possible" toxicity (although proven for 100% in term babies). However, the gaps and especially a lack of knowledge about: The optimum oxygen requirements for specific gestational age groups Appropriate oxygen targets for preterm infants How to best titrate oxygen in the delivery room for preterm infants Information regarding how cord clamping management impacts oxygen use following birth You are correct that guidelines guide and individual assessment is still needed. However our individualistic actions should be subsequently justified and researched. -
ILCOR Staff
Thank you Rita as you raise excellent points. We had hoped that the Justification and Evidence to Decision section would explain some of your thinking and discussions in arriving at this CoSTR? You are completely correct that in the situation where no advantage is seen, the lower initial oxygen has been preferred because of concern about "possible" toxicity (although proven for 100% in term babies). However, the gaps and especially a lack of knowledge about: The optimum oxygen requirements for specific gestational age groups Appropriate oxygen targets for preterm infants How to best titrate oxygen in the delivery room for preterm infants Information regarding how cord clamping management impacts oxygen use following birth You are correct that guidelines guide and individual assessment is still needed. However our individualistic actions should be subsequently justified and researched. -
ILCOR Staff
Thank you for all the interaction and the many comments. -
ILCOR Staff
Thank you for your comment. There is little evidence to support 100% even with compressions but there is consensus at present in the absence of that evidence. -
ILCOR Staff
Thank you Debasis. I won't repeat my reply from your comment which was similar for term babies but the points remain pertinent. -
ILCOR Staff
Thank you. If you have good evidence for the relative costs in your own working environment that would be helpful if published.