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American Academy of Pediatrics
PCEP Book III: Neonatal Care / Edition 3

PCEP Book III: Neonatal Care / Edition 3

by Robert A. Sinkin


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PCEP Book III: Neonatal Care / Edition 3

Time-saving, low-cost solutions for self-paced learning or instructor-led training!
Developed for health care professionals who provide care to pregnant women and newborns, the Perinatal Continuing Education Program (PCEP) is a comprehensive, self-paced education program in four volumes.

Completely updated and revised with leading-edge procedures and techniques, Book III: Neonatal Care, 3rd Edition features 10 units covering information and skills assessment and initial management of frequently encountered neonatal illnesses, plus the comprehensive unit review Is the Baby Sick?, which ties all neonatal therapies and skills together for management of sick and at-risk newborns.

PCEP is a proven educational tool for:

  • Improving perinatal care know-how, policies, practices and procedures
  • Establishing organization-wide care goals and routines
  • Teaching both practical skills and cognitive knowledge
  • Saving time and money -- streamline the learning process
  • Reducing care risks through staff-wide consistency of knowledge and skills competency
  • Encouraging cooperation and communication among diverse staff
  • Simplifying education planning and budgeting

Product Details

ISBN-13: 9781610020565
Publisher: American Academy of Pediatrics
Publication date: 10/01/2016
Edition description: Workbook
Pages: 387
Product dimensions: 8.40(w) x 10.70(h) x 1.00(d)

About the Author

Christian A. Chisholm, MD is an Associate Professor of Obstetrics and Gynecology at the Univerisity of Virginia School of Medicine.

Read an Excerpt

Neonatal Care

Book III

By American Academy of Pediatrics

American Academy of Pediatrics

Copyright © 2017 University of Virginia Patent Foundation
All rights reserved.
ISBN: 978-1-61002-056-5


Unit 1: Oxygen

Objectives 2

1. How much oxygen does a baby need? 5

2. How is the amount of oxygen measured? 5

3. How does oxyhemoglobin saturation (Spo2) compare to arterial blood oxygen (Pao2)? 7

4. What is the best way to monitor a baby's oxygenation? 8

5. When does a baby need supplemental oxygen? 8

6. How much oxygen do you administer to a baby? 9

7. When does a baby not need supplemental oxygen? 10

8. How should oxygen be given? 10

9. How can you use a pulse oximeter to adjust inspired oxygen? 13

10. When do you obtain an arterial blood gas measurement? 14

11. What are the problems related to oxygen therapy? 14

12. What are reference arterial blood gas values and how are capillary and venous blood gas values used? 15

Tables and Figures

Table 1.1. Approximate Relationship of Spo2 and Pao2 7

Figure 1.1. Equipment Needed for Administering Oxygen, Measuring Delivered Oxygen, and Measuring Baby's Blood Oxygen 6

Figure 1.2. Relationship of Pao2 and Spo2 8

Figure 1.3. Pre-ductal Oxygenation Saturation Changes Following Birth (Median and Interquartile Range) 9

Figure 1.4. Components Required for Administering and Measuring Oxygen 11

Recommended Routines 19

Skill Units

Administering Oxygen 25

Measuring Oxygen Concentration 27

Blending Oxygen and Compressed Air 29

Heating and Humidifying an Oxygen/Air Mixture 32

Monitoring Oxygen 37

Peripheral Arterial Blood Gas Sampling 38


In this unit you will learn to

A. Identify babies who require supplemental oxygen.

B. Administer oxygen as a drug while understanding its benefits and hazards.

C. Operate the appropriate equipment for the controlled delivery of oxygen.

D. Monitor a baby's oxygenation.

Both too little and too much oxygen can be harmful.

Too little oxygen in the blood can cause damage to the brain and other vital organs.

Too much oxygen in the blood can cause damage to the eyes and other organs.

Too much inspired oxygen can cause damage to the lungs.

1. How much oxygen does a baby need?

Oxygen is essential for our survival, but oxygen can also be toxic in excess. Tissues require oxygen to metabolize normally. However, during metabolism involving oxygen, chemical reactions release toxic substances (oxygen free radicals) that can cause tissue injury. Free radicals are even more injurious to tissues that have already experienced a period of oxygen deprivation from asphyxia or hypoperfusion, such as that which may occur during a complicated pregnancy and delivery. Air-breathing mammals normally produce enzymes and other molecules that scavenge oxygen free radicals before they can produce significant injury. The fetus, however, develops in a very low oxygen environment and has not yet fully developed free radical scavengers until born at term. Therefore, a baby who is preterm, has acquired a serious infection, has experienced an asphyxial event, has respiratory disease, or is otherwise compromised has particularly high risk from exposure to too little or too much oxygen.

When a healthy fetus is born and undergoes transition from receiving oxygen via the placenta to using the lungs to extract oxygen from the air, the amount of oxygen dissolved in the plasma and bound to hemoglobin in arterial blood increases dramatically over a period of approximately 10 minutes following birth. This increase occurs because the amount of oxygen available in the room air being breathed by the baby is substantially greater than the amount of oxygen transferred across the placenta from the mother's circulation. If the baby's lungs are compromised, normal increase in blood oxygenation may not occur and the baby may become oxygen deprived unless the concentration of oxygen that the baby breathes is increased from the 21% contained in room air to some greater percentage. Conversely, if the concentration being breathed by the baby is excessive, arterial blood oxygenation can easily become too high. Hypoxemia (low blood oxygen) or hyperoxemia (high blood oxygen) can be harmful, so it is very important that a sick baby's arterial blood oxygen be maintained in the range normally found in a healthy baby who is breathing room air.

2. How is the amount of oxygen measured?

Oxygen concentration should be measured in the baby's inspired air and in the baby's blood (Figure 1.1).

A. Inspired oxygen concentration

Inspired oxygen concentration is frequently abbreviated as Fio2 (fraction of inspired oxygen) and is the amount of oxygen a baby breathes. The Fio2 is measured by an oxygen analyzer, which is a sensing device placed near the baby's nose (Figure 1.1) or in-line with a device for delivering positive pressure. Most analyzers provide a constant readout of the oxygen concentration.

Fraction of inspired oxygen (Fio2) is the fraction or percentage of oxygen in the space being measured. Natural, "room" air includes 21% oxygen, which is equivalent to Fio2 of 0.21. Oxygen-enriched air has a higher Fio2 than 0.21, up to 1.00, which means 100% oxygen. In this unit, percentages are used.

B. Arterial blood oxygen levels

Oxygen is carried in blood attached to hemoglobin in red blood cells and dissolved in plasma. The amount bound to hemoglobin (oxyhemoglobin) is expressed as Spo2, measured in percentage of saturation, and concentration in plasma is expressed as Pao2, measured in mm Hg.

Arterial blood must be used for Pao2 determinations.

Venous and capillary blood do not give accurate estimates of oxygenation.

1. Oxyhemoglobin saturation

When there is no oxygen bound to hemoglobin, it is "0% saturated"; when the hemoglobin is carrying as much oxygen as possible, it is "100% saturated."

Hemoglobin changes color from blue to red as it becomes increasingly saturated with oxygen. A pulse oximeter detects the color of the blood and gives a reading expressed as percentage of saturation. It does this by shining a tiny light through the skin, registering the color of the light coming from the skin (which is determined by the color of blood in the arteries), and thus estimating oxygen saturation, without requiring a blood sample to be drawn.

The desired level of oxyhemoglobin saturation in a baby is generally 85% to 95%. Many neonatologists will advise using 88% to 92% saturation as a target but will set oximeters to alarm below 85% and above 95%.

2. Arterial blood oxygen dissolved in plasma

Arterial blood oxygen levels are shown as the Pao2 value from arterial blood gas measurements. The blood to be analyzed is usually drawn from an umbilical artery catheter (see Unit 3, Umbilical Catheters, in this book), a peripheral arterial catheter, or a peripheral arterial stick (see Skill Unit: Monitoring Oxygen, Peripheral Arterial Blood Gas Sampling, in this book). If an arterial catheter cannot be inserted, monitor oxygenation with continuous pulse oximetry until transport to a higher level of care can be arranged. The desired level of Pao2 in any baby (sick, well, preterm, post-term) is generally 45 to 65 mm Hg.

Babies with varying degrees of lung disease will require different levels of Fio2 to maintain desired arterial blood oxygen level. For example, a baby with severe respiratory distress syndrome may require Fio2 ranging up to 100% to maintain a Pao2 between 45 and 65 mm Hg, while a baby with mild respiratory distress syndrome may require only 30% oxygen to maintain a Pao2 between 45 and 65 mm Hg.

Note: There is disagreement among experts as to the appropriate range of Pao2 and oxyhemoglobin saturation. Know the acceptable range for your hospital. Also, the target range will be different immediately following birth. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.)

3. How does oxyhemoglobin saturation (Spo2) compare to arterial blood oxygen (Pao2)?

Oxygen tension (or partial pressure) in a blood sample (Pao2) can range from 0 to approximately 500 mm Hg; oxyhemoglobin saturation (Spo2) can range from 0% to 100%. When Spo2 is greater than 95%, the hemoglobin is almost fully saturated with oxygen, and a small increase in saturation can correspond to a large increase in Pao2. If Spo2 saturation is greater than approximately 95%, Pao2 could be acceptable (45–65 mm Hg) or undesirably high (greater than 65 mm Hg) (Table 1.1).

The approximate relationship of Pao2 and oxyhemoglobin saturation is shown in Table 1.1 and Figure 1.2.

The shaded area of Figure 1.2 shows the approximate relationship between 85% to 95% oxyhemoglobin saturation and 45 to 65 mm Hg arterial blood oxygen level for a slightly preterm baby during the first few days following birth.

For some babies, simultaneous measurements of Pao2 and Spo2 may give results quite different than those predicted by the graph. The precise relationship of oxygen saturation and Pao2 is affected by several factors, such as age since birth, the presence of acidosis, characteristics of hemoglobin (eg, methemoglobin, hemoglobin S), and whether the baby has had a blood transfusion.

4. What is the best way to monitor a baby's oxygenation?

A baby's blood oxygen level will frequently fluctuate from minute to minute, particularly if the baby is distressed or undergoing any sort of procedure. A pulse oximeter can be used to monitor these changes so you will know quickly when the baby's oxygenation is persistently out of the desirable range and requires attention. However, because pulse oximeters only report Spo2, which has a variable relationship to Pao2, the baby's Pao2 should be measured intermittently with a sample of arterial blood. Watch for oximeter readings to stabilize to know the best time to obtain an arterial blood sample that reflects the baby's resting state (not changes that may occur with, eg, crying, stress during procedures).

The best way to monitor a baby's blood oxygen is to

• Follow trends or changes in Spo2 with a pulse oximeter. and

• Measure Pao2 intermittently from samples of arterial blood.

5. When does a baby need supplemental oxygen?

Babies require oxygen therapy when the concentration of oxygen in arterial blood is low and the oxygen needs of a sick baby vary over time. Therefore, the only sure way to determine if a baby is receiving the correct amount of oxygen is to measure Spo2 continuously by pulse oximetry and periodically measure Pao2 by arterial blood gas sample.

In emergency situations, a baby may need oxygen immediately. First, give oxygen; then measure the Spo2 or Pao2 as soon as possible. The following signs show that a baby needs oxygen:

A. Central cyanosis

Generally, a baby's body will look blue. This overall color change may be dramatic or much less obvious. The best clinical sign of central cyanosis is a bluish appearance of the lips, inside of the mouth, and conjunctival surface of the eyelids. Central cyanosis indicates the baby needs immediate oxygen therapy. However, studies have shown that clinical assessment of cyanosis is very inconsistent; therefore, if a baby receives oxygen therapy for more than a brief period, the baby's Spo2 or Pao2 must be measured.

B. Need for resuscitation

When a baby's respiratory rate and heart rate are very slow or have stopped, ventilation must be improved immediately to help restore the baby's vital signs. Oxygen concentrations required during assisted ventilation may range from 21% (room air) to as high as 100% as guided by pulse oximetry. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.)

C. Respiratory distress

Some babies have difficulty breathing and will require extra oxygen for long periods. (See Unit 2, Respiratory Distress, in this book.) For these babies, it is extremely important to ensure adequate ventilation, use continuous oximetry, and measure arterial blood oxygen levels (Pao2) frequently to avoid the hazards of too much or too little oxygen.

6. How much oxygen do you administer to a baby?

A. Resuscitation

The priority during resuscitation should be to establish ventilation and a normal heart rate. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.) Guidelines recommend starting the resuscitation of a term newborn with no supplemental oxygen (ie, room air) and beginning resuscitation of preterm babies (<35 weeks) with a low concentration of supplemental oxygen (eg, Fio2 21% — 30%). In either case, Fio2 should be adjusted to match reference arterial saturation values as guided by oximetry (Spo2). Reference values for the few minutes following birth will be quite low, so the oximetry goal will also begin low and gradually increase to the 88% to 92% range (Figure 1.3). Some degree of cyanosis may also be normal during the first few minutes after birth. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 5, Resuscitating the Newborn.)

B. Cyanosis

1. Immediate treatment

For cyanosis that appears in the nursery, decide on an initial oxygen concentration depending on the degree of cyanosis. For example, if a baby is deeply blue all over, choose 100%.

If the mucous membranes are only slightly dusky, choose approximately 30%. Increasing degrees of cyanosis between these extremes will require increasing concentrations of oxygen.

2. Adjust according to baby's response and Spo2

Place the baby in the chosen concentration and observe for the disappearance of central cyanosis. Attach a pulse oximeter as soon as possible. Adjust oxygen concentration up or down to achieve desired saturation. Obtain an arterial blood gas measurement.

C. Respiratory distress

Babies with respiratory distress need to be given oxygen only if they are cyanotic or have a low arterial blood oxygen concentration. The amount of oxygen required depends on the degree of cyanosis and how low Pao22 or Spo2 values are.

It is possible for a baby to be in respiratory distress, not be cyanotic, and still have a low arterial blood oxygen value. These babies should have continuous pulse oximetry monitoring and monitoring of arterial blood gas measurements and be given sufficient oxygen to keep arterial oxygenation within reference range.

Use of a pulse oximeter should not replace periodic arterial blood gas measurements, which also measure blood pH and carbon dioxide (CO2) concentration, in addition to blood oxygen concentration. A pulse oximeter, appropriately applied with results checked against arterial blood gas, is helpful in providing continuous estimates of arterial blood oxygen levels and should reduce the number of arterial blood measurements that are needed.

7. When does a babynotneed supplemental oxygen?

A. Acrocyanosis (only hands and feet blue)

Acrocyanosis without central cyanosis is not an indication for oxygen to be administered. This condition may be caused by reasons other than lack of oxygen (eg, cold stress, poor peripheral blood flow).

B. Prematurity without respiratory distress or cyanosis

Preterm babies should not be given supplemental oxygen unless they are cyanotic or have a low arterial blood oxygen level.

C. Babies with cyanotic congenital heart disease

During the first week or so after birth, some babies with certain types of congenital heart malformations will worsen if given high concentrations of supplemental oxygen. Use of supplemental oxygen and saturation targets for such babies should be determined by a pediatric cardiologist.

8. How should oxygen be given? (Figure 1.4)

The concentration of oxygen in room air is 21%. To deliver supplemental oxygen (22%–100%)

• Deliver oxygen blended with air, using equipment that will prevent fluctuations in oxygen concentration.

• Heat and humidify the oxygen/air mixture to the baby's neutral thermal environment temperature. (See Book I: Maternal and Fetal Evaluation and Immediate Newborn Care, Unit 7, Thermal Environment.)

• Measure the concentration of inspired oxygen (Fio2) precisely and continuously.

• Monitor oxyhemoglobin saturation (Spo2) continuously.

• Measure the concentration of oxygen in the baby's blood (Pao2) intermittently.

A. Blend oxygen and air

Oxygen from a wall outlet or tank is 100% oxygen, regardless of the liter-per-minute flow rate. The only way to get less than 100% oxygen is to mix the oxygen with air. Air for blending with oxygen is obtained from a wall outlet, compressed air tank, or electrical air compressor. An oxygen blender automatically regulates this blending of oxygen and compressed air to provide a specified and adjustable oxygen concentration. Blenders, however, are not always precise. An oxygen analyzer should be used to check the exact concentration of oxygen being delivered to a baby.

The flow rate of oxygen does not determine the concentration of oxygen inspired by a baby.

The amount of oxygen and compressed air blended together determine inspired oxygen concentration (Fio2).

B. Heat and humidify oxygen and air

Oxygen and air directly from wall outlets or tanks are cold and dry, even if a tank itself is warm. Oxygen and air must be warmed to avoid chilling the baby. Regulation of the temperature of the oxygen/air mixture is just as important as strict regulation of the baby's environmental temperature (neutral thermal environment). Oxygen and air must also be humidified to avoid drying the baby's mucous membranes and airways.

C. Prevent fluctuations in oxygen concentration

Fluctuations in Fio2 can affect vascular resistance and amount of blood flow through the lungs, resulting in even greater fluctuations in the amount of oxygen in the baby's arterial blood.

If Fio2 is lowered rapidly, the arteries to the lungs may constrict. This can seriously reduce blood flow to the lungs and result in a much lower Pao2 level. A consistently low Pao2 level, regardless of the cause, may lead to brain and other tissue damage.

The equipment used to deliver oxygen to babies who do not require assisted ventilation includes

1. Oxygen by hood

An oxygen hood is made from clear plastic material and is placed over a baby's head. It has an inlet on one side for the oxygen/air mixture and an opening on the opposite side to fit over the baby's neck.

During the acute phase of illness, the most effective way to maintain constant Fio2 for a baby who does not require assisted ventilation is to use an oxygen hood.


Excerpted from Neonatal Care by American Academy of Pediatrics. Copyright © 2017 University of Virginia Patent Foundation. Excerpted by permission of American Academy of Pediatrics.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Table of Contents

Unit 1: Oxygen
Unit 2: Respiratory Distress
Unit 3: Umbilical Catheters
Unit 4: Low Blood Pressure
Unit 5: Intravenous Therapy
Unit 6: Feeding
Unit 7: Hyperbilirubinemia
Unit 8: Infections
Unit 9: Review: Is the Baby Sick? Identifying and Caring for Sick and At-Risk Babies
Unit 10: Preparation for Neonatal Transport

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