SPOT

 

GENERAL INFORMATION

SPOT means: Special Preemie Oxygen Targeting

Oxygen is a drug

It can be a dangerous medication with potentially significant side effects in very low birthweight (VLBW) infants

Avoiding hypoxemia is important but prolonged hyperoxemia can lead to oxidative stress and injury

There is no evidence that VLBW infants need to be managed with an FiO2 that leads to surface oxygen saturation levels (SpO2) of 95% to 100%.

Actually these levels are potentially dangerous

In addition, repeated episodes of alternating hyperoxemia & hypoxemia can promote significant alterations in vascular tone in immature infants. 

By avoiding these episodes, risks to the developing vascular bed in various organ systems could be minimized

Alarm settings are 2 points above and 3 points below the oxygen saturation targets

Oxygen saturation targets are ordered by the MD/NNP.

A specific MD/NNP order is required to deviate (up or down) from the oxygen saturation targets

 

Infant’s Birthweight

Less than or equal to

 1500 gms

Infant’s Birthweight

Greater than

1500 gms

 O2 Saturation Targets

85-93%

"normoxia"

90-95 %

"normoxia"

Oximeter Alarm Settings

82-95%

87-97%

 

Last stable FiO2

The infant is stable--AND

The infant's O2 sat has remained within the oxygen saturation target range--AND

The infant's FiO2 for the last hour has remained unchanged

E.g.:  I'm in 35% for the last hour, I'm stable and my O2 sats have been within my oxygen saturation target range

Therefore:  my "last stable FiO2 is 35%"

 Each day during morning rounds the MD/NNP evaluates each infant's oxygen saturation target range

The infant's oxygen saturation target will generally be within the birthweight target range noted above.....for example

BW 822 gms (regardless of current weight) = oxygen saturation target is 85%--93% unless otherwise ordered

BW 1795 gms (regardless of current weight) = oxygen saturation target is 90%--95% unless otherwise ordered

The oximeter alarm settings do not change unless MD/NNP orders

 

HIGH SATURATIONS ON RESPIRATORY SUPPORT IN ROOM AIR

An infant's oxygen saturation is consistently above the upper limit of the oxygen alarm setting

E.g.:  upper limit is 95% and infant consistently is at 96%

E. g.:  upper limit is 97% and infant consistently is at 98%

Increase upper limit of oxygen alarm setting by 2 points

E.g.:  upper limit is 95% and infant consistently is at 96%---increase upper limit to 98%

E.g.: upper limit is 97% and infant consistently is at 98%---increase upper limit to 99%

Upper limit oxygen alarm settings may not exceed 99%

An upper limit oxygen alarm setting of 100% requires a specific MD/NNP order

 

WEaning the fio2 

Weaning occurs when the infant's O2 sats remain high (at the upper limit of their oxygen saturation target range)

The MD/NNP will order "the new oxygen saturation target" if indicated

FiO2 will be weaned by 2-5% 

E.g.:  O2 sats greater than 93% in infants with birthweight less than or equal to 1500 grams

E.g.:  O2 sats greater than 95% in infants with birthweight greather than 1500 grams

Weaning is accomplished as quickly as possible but no more than a 2-5% change at any 1 time

The person making the change (RN, RCP, NNP or MD) remains at the infant's bedside until you are assured the infant is stable in this new FiO2 

When infant's oxygen sats are stable at the new weaned FiO2 for at least 1 hour this becomes the infant's "last stable FiO2"

This represent the FiO2 that the infant requires to maintain normoxia

If increases in oxygen are indicated during care, procedures, etc. return to "last stable FiO2" ASAP

If you are unable to return to the "last stable FiO2" and  it is necessary to keep the FiO2 increased greater than 5%..............notify the MD/NNP

 

INCREASING the fio2 

Increasing occurs when the infant's O2 sats remain low (at the lower limit of their oxygen saturation target range)

BEFORE making any changes in the FiO2 evaluate both the infant and the monitor, e.g.:

Monitor tracking correctly, leads in place and attached

Need for suctioning, tube placement appropriate, etc

FiO2 is increased 

The person making the change (RN, RCP, NNP or MD) remains at the infant's bedside until they are assured the infant is stable in this new FiO2 

When infant's oxygen sats are stable at the new weaned FiO2 for at least 1 hour this becomes the infant's "last stable FiO2"

This represent the FiO2 that the infant requires to maintain normoxia

If you are unable to return to the "last stable FiO2" and  it is necessary to keep the FiO2 increased greater than 5%..............notify the MD/NNP

The MD/NNP will reassess the infant

 

OXYGEN DESATURATIONS DURING CARE

BEFORE making any changes in the FiO2 evaluate both the infant and the monitor  (see above)

This also provides time for the infant to self-correct

FiO2 is increased--rarely is the increase greater than 5-10% 

The person making the change (RN, RCP, NNP or MD) remains at the infant's bedside until they are assured the infant is stable in this new FiO2 

When infant's oxygen sats are stable at the new increased FiO2 for at least 1 hour this becomes the infant's "last stable FiO2"

If you are unable to return to the "last stable FiO2" and  it is necessary to keep the FiO2 increased greater than 5%..............notify the MD/NNP

The MD/NNP will reassess the infant

 

"APNEIC" SPELLS AND DESATURATIONS

BEFORE making any changes in the FiO2 evaluate both the infant and the monitor  (see above)

Use tactile stimulation

Manual breathes w/ventilator or  Initiate PPV

Position changes, etc.

FiO2 is increased--rarely is the increase greater than 5-10% 

The person making the change (RN, RCP, NNP or MD) remains at the infant's bedside until they are assured the infant is stable in this new FiO2

When infant's oxygen sats are stable at the new increased FiO2 for at least 1 hour this becomes the infant's "last stable FiO2"

If you are unable to return to the "last stable FiO2" and  it is necessary to keep the FiO2 increased greater than 5%..............notify the MD/NNP

The MD/NNP will reassess the infant