Effects of low oxygen saturation limits on the ductus arteriosus in extremely low birth weight infants

Abstract

Objective: Postnatal increase in oxygen promotes constriction of the patent ductus arteriosus (PDA). According to the findings of prospective observational studies, the clinical practice of targeting lower fractional oxygen saturation between 70 and 90% has been associated with a reduced incidence of severe retinopathy of prematurity (ROP) without affecting survival or neurodevelopmental disability at 1 year of age. Our objective was to investigate the impact of the use of a lower oxygen saturation target range on the incidence of early hemodynamically significant PDA (hsPDA) and the need for ductal ligation in extremely low birth weight (ELBW, <1000 g) infants.Study Design: In this retrospective study, we analyzed data from 263 ELBW infants managed 4 years before (episode I: target oxygen saturation 89 to 94%) and after (episode II: target oxygen saturation 83 to 89%) implementation of the use of lower oxygen saturation limits in two neonatal intensive care units. Infants with a birth weight of 1000 to 1500 g were managed with the same oxygen saturation target range (89 to 94%) during both episodes, and they served as controls. Parametric and nonparametric tests were used as appropriate and multivariate logistic regression models were used to correct for confounders.Results: There was an increase in the incidence of hsPDA (63.2 vs 74.8%, P ¼ 0.043), without an increase in the need for surgical ligation (24.2 vs 29.9%, P ¼ 0.3) after implementation of the lower oxygen saturation target range policy. After adjusting for confounders, there was an increase in the odds of having an hsPDA (odds ratio (OR) 1.77, 95% confidence interval (CI) (1.03 to 3.06), P ¼ 0.04) but the odds for ductal ligation did not change in episode II (OR 1.25, 95% CI (0.70 to 2.25), P ¼ 0.4). The incidence of ROPXstage III (50.7 vs 15.7%; P<0.0001) and the need for laser ablation (33.8% vs 8.7%; P<0.0001) were significantly reduced. There was no change in the incidence of hsPDA or ductal ligation in the control group. Conclusion:Targeting lower oxygen saturation limits to minimize periods of hyperoxemia in ELBW infants reduced the incidence of severe ROP and the need for laser ablation. The incidence of early hsPDA was increased; however, final closure rate and the incidence of surgical ligation of the ductus arteriosus were not affected.

Graded oxygen saturation targets and retinopathy of prematurity in extremely preterm infants

“…We did not have a documentation of continuous SpO 2 monitoring to determine the percent of or actual time the patients spent in the desired oxygen saturation targets. However, we have previously shown improved outcomes after implementing potentially better practices such as use of lower oxygen saturations in our NICU (16,17). Data on neurodevelopmental outcomes in our patients are likewise not reported in this study.…”

“…One alternative hypothesis for this improved outcome could be improved adherence or compliance by the respiratory, nursing and medical staff to target oxygen saturations in these infants secondary to better education and careful attention to the SpO 2 . We have reported improved outcomes after implementing potentially better practices such as use of lower oxygen saturations in our NICU (16,17). In addition, there was no difference in mortality between the two groups, and there was a lower incidence of BPD with the use of graded SpO 2 targets.…”

Persistent Ductus Arteriosus in Critically Ill Preterm Infants

“…In the short term, PDA is associated with decreased blood pressure [5,8], decreased renal function [5], cardiac congestive failure [18,37,38], pulmonary haemorrhage [8,39], apnea and ventilator-dependency [6,38], bronchopulmonary dysplasia (BPD) [5,14,20,21,25,34,41,42], necrotizing enterocolitis (NEC) [8,9,11,19,20,34,39,43,44], intraventricular hemorrhage (IVH) [5,19,20,39,42,45,46], periventricular leukomalacia (PVL) [5], retinopathy of prematurity (ROP), cerebral palsy [24], delayed growth [11], and increased mortality rate [6,34,45,[47][48][49][50].…”

“…Multiple risk factors have been described in association with PDA such as lower GA and BW [14][15][16]21,22], chorioamnionitis and neonatal sepsis, [3,15,[22][23][24][25], maternal diabetes mellitus, [14,26] antepartum hemorrhage, multiple pregnancy, male gender [14], small for gestational age (SGA), [27] lower Apgar scores, need for resuscitation at birth, asphyxia [16], severe respiratory distress syndrome (RDS) [16,22,28,29], excessive fluid administration during the first days of life [30], Furosemide administration [31], decreased platelets number during the first day of life [22,32], oxygen administration [16], lower oxygen saturation targets [33,34], surfactant administration [16,28,35,36], increased duration of mechanical ventilation and respiratory support [22], metabolic acidosis [16], phototherapy [37], and high altitude [6].…”

Learning to live with patency of the ductus arteriosus in preterm infants

“…58 A recent retrospective analysis suggested that lower target saturation ranges increased the prevalence of early hemodynamically significant PDA, but not the ultimate closure rate or need for surgical ligations. 59 No differences in PDA or medical or surgical treatment for PDA were observed in a randomized trial comparing target ranges of oxygen saturation of 85 to 89% or 91 to 95% in preterm infants between 24 and 27 weeks' gestation. 36 Avoidance of unnecessary oxygen supplementation appears to be desirable 60 and does not increase the incidence of PDA.…”