1. Controversies & Oxygen DR Resuscitation Premature Infants

2. Living In Utero -- On the cliff

3. PaO 2 20 40 60 80 100 120 mean 12-14 minutes 2 (Range of 2-55 minutes)

4. NRP Position on Resuscitation zClear the airway zStimulate and Dry zProvide PPV with 100% oxygen zGradually withdraw oxygen, maintaining pink

5. Why 100% Oxygen ? zRestore oxygen for metabolism of lactate and to restore aerobic metabolism zReduce Pulmonary Vascular Resistance zHelp to prevent PPHN

6. Why NOT 100% Oxygen? zYou may not have Oxygen zExpensive if you don’t need it z If ischemic, there is reperfusion injury. More oxygen might make that worse. zMight it be harmful? Does an infant need time to transition? zAsphyxiated piglets resuscitate fine with RA

7. Animal Studies zPiglets: (earlier adult pigs) y8% oxygen until hypotensive & Base XS - 20 zRabbits: yMaternal hypoxia for fetal hypoxia zGerbils y15 min cerebral ischemia zLambs yhypopneic with water zDogs (adult) y9 min. cardiac arrest y RESULTS

8. The Question in Babies z1993*Ramji 82 odd, even, unblinded z1998* Saugstad 609 odd,even, unblinded z2000Vento 537 z2003*Vento 106 RCT, blinded zsubmitted Ramji 354 zSo 1,688 infants have been studied z(?)

9. Outcome Mortality z1993 z1998 z2000 z2003 zpending zTOTAL 7.1% 9.5% 15 % 20 % --- 0 0 --- 6% 11% OR 0.63, [0.42-0.97] MORTALITY Room Air 100% Oxygen

10. Other Outcomes In Room Air as vs 100% zTime to first cry about 1/2 min. sooner zTime to established Resp about 1 min. sooner z 1 min. APGARs higher (4 v 5) z 5 min. APGARs not Different z Diagnoses of HIE not significantly different, but favors RA

11. So What Will You Do ? zSaturday when you see the next depressed baby? zPosition on a Policy Committee y(Remember the RLF Experience) zAction at the National Level as an NRP instructor?

12. What about Preterms? Win Tin: 50 Years of Uncertainty in the NICU

13. A Request (pick up pen) zDoes your NICU have a policy on Oxygen Saturation Targets? zDo you write orders for Saturation Targets? zAssume an infant of 26 weeks, 800 grams in the first 3 days after birth yWhat saturation target orders would you write?

14. Stated Pulse Oximetry Goals NICU A 88-98% 70-90% NICU B Tin et al, Arch Dis Child Fetal Neonatal, 2001;84:F106-10 Results from Differing Pulse Oximetry Guidelines -- UK

15. Infants <28 weeks 1990-1994 Tin et al, Arch Dis Child Fetal Neonatal, 2001;84:F106

16. Duration of ventilation (weeks) Proportion still being ventilated( %) 100 75 50 25 0 2 4 6 8 1210 88-98% 75-93% Proportion Still Being Ventilated 88-98% Target 75-93% Target Duration of Ventilation (Days) Percent

17. Reduction in Rates of ROP An Historical Comparison --- USA Chow et al zBW 500-1500g zRates of stage 3 or worse ROP zPre-intervention 1997 zIntervention 1998 forward yDelivery Room: blender and saturation monitor yNICU: proportional response, prompt weans yTarget saturations: 85-93% zOutcomes of births from 1997-2001 zAnnually about 70 infants in this BW range

18. Laser Treatment of ROP Chow et al. Pediatrics 2003; 111:339

19. Incidence: Stage 3 or Worse ROP Chow et al. Pediatrics 2003; 111:339

20. The POST-ROP Study zPremature Oxygen Saturation Targeting for the prevention of Retinopathy of Prematurity zPlanning Stages zEditorial Forthcoming in Pediatrics zMulticenter, double blinded, 5 year follow- up zCurrently considering 85-90% v 91-96%

21. Thank you !