A Review of Oxygen Physiology and Appropriate Management of Oxygen Levels in Premature Neonates.

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.

Current Practices and Attitudes Regarding Use of Inhaled Nitric Oxide in the NICU: Results From a Survey of Members of the National Association of Neonatal Nurse Practitioners.

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.

Neonatal nurse practitioner workforce survey executive summary.

The Neonatal Nurse Practitioner Workforce Survey, led by Paula Timoney, DNP, ARNP, NNP-BC, and Debra Sansoucie, EdD, RN, NNP-BC, with the National Association of Neonatal Nurse Practitioners (NANNP), provides data collected from more than 600 neonatal nurse practitioners to examine workforce characteristics and needs. NANNP commissioned the survey because no comprehensive data existed for the neonatal nurse practitioner workforce. The executive summary given in this article highlights some of the survey's key findings in the areas of demographics, practice environment, scope of responsibilities, and job satisfaction. Readers are encouraged to review the complete text of the Neonatal Nurse Practitioner Workforce Survey for more in-depth data and recommendations regarding NNP education, scope of practice, and scope of responsibility in the ever-changing health care environment. The report will be available for purchase at http://www.nannstore.org in summer 2012.

The impact of a Donor Human Milk Program on the provision of mothers' own milk at discharge in very low birth weight infants.

OBJECTIVE: Examine the effect of a donor human milk (DHM) program on mothers' own milk feedings at discharge for very low birth weight (VLBW) infants. STUDY DESIGN: A single center retrospective analysis of feeding outcomes in preterm infants. Data were assigned as: (1) pre DHM era (2) Bridge DHM era (3) Full DHM era. Each era was divided into infants <1500 g (n = 724) or ≥1500 g (n = 784). RESULTS: Both the percentage of mothers' own milk feeds and percent of infants exclusively receiving mothers' own milk at discharge were increased in the <1500 g (p = 0.003, p = 0.002) and the ≥1500 g group (p = 0.007, p = 0.004) respectively, following the introduction of DHM for VLBW infants. CONCLUSION: Practice changes that accompany a donor milk program likely play a prominent role in the provision of mothers' own milk and exclusivity of breast milk feedings at discharge for very low birth weight infants.

Parents' Assessment of an Advanced-Practice Nurse and Care Coordination Assistant Model Medical Care Coordination Program for Children With Medical Complexity.

INTRODUCTION: Care for many children with medical complexity (CMC) is fragmented, leading to increased family dissatisfaction and stress. We evaluated the impact of an Advanced-Practice Nurse and Care Coordination Assistant model medical care coordination program (MCCP) for CMC at an urban tertiary pediatric hospital on caregivers' perceptions of several health care indicators. METHOD: A retrospective pre-post survey was administered to parents of CMC enrolled in an MCCP for a minimum of 6 months. Questions were grouped into four domains: quality of life, caregiver satisfaction, care coordination, and caregiver self-efficacy. Mean scores of questions in each domain were compared from before program enrollment with those at the time of survey completion, using paired sample t tests. RESULT: There was an increase in the mean score in all four domains. DISCUSSION: Parents of CMC experience an Advanced-Practice Nurse and Care Coordination Assistant model MCCP to be effective in improving the navigation of and satisfaction with their child's health care environment.

Determination of accuracy in neonates for non-invasive blood pressure device using an improved algorithm.

BACKGROUND: New software (SuperSTAT(R) algorithm) with enhancements aimed at shorter determination times was developed for a non-invasive blood pressure (NIBP) device and a clinical evaluation was conducted to verify accuracy. OBJECTIVE: To determine the accuracy of the new algorithm according to ANSI/AAMI SP10-1992 and SP10A-1996 American National Standard for Electronic or Automated Sphygmomanometers. METHODS: The blood pressure values obtained from the test device were compared to the intra-arterial blood pressure reference standard (IBP). RESULTS: The NIBP and IBP comparisons for systolic, diastolic, and mean arterial pressure met the 1992 ANSI/AAMI accuracy standards by being within a mean difference of +/- 5 mmHg and standard deviation of < or = 8 mmHg. CONCLUSION: Non-invasive blood pressure determinations taken with the new algorithm, developed to provide greater patient comfort due to faster determinations, were accurate when compared to neonatal IBP.