Pulse Oximetry Screening: UK Survey and BWH Experience

Quad Network Study DayAnju Singh, SV Rasiah, Andy Ewer

29/11/2012

Neonatal pulse oximetry screening: a national survey. Kang et al. Arch Dis Child Fetal Neonatal Ed 2011;96:F312

7% routine use of pulse oximetry to supplement postnatal examination

Pulse oximetry screening for critical congenital heart defectsin asymptomatic newborn babies: a systematic review andmeta-analysis.Shakila Thangaratinam, Kiritrea Brown, Javier Zamora, Khalid S Khan, Andrew K Ewer Lancet. 2012 Jun 30;379(9835):2459-64. doi: 10.1016/S0140-6736(12)60107-X. Epub 2012 May 2

13 eligible studiesSensitivity: 76.5% (95% CI 67·7–83·5)Specificity: 99·9% (99·7–99·9)False-positive rate of 0·14% (0·06–0·33)False-positive rate for critical CHD

Before 24 h 0·50 [0·29–0·86]After 24 h 0·05% [0·02–0·12] p=0·0017

Pulse oximetry is highly specifi c for detection of critical congenital heart defects with moderate sensitivity, that meets criteria for universal screening.

Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A

Who does the Routine Screening?Who intends to do it?Who doesn’t?Anticipated Barriers?

Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A

204/ 204 (100%) Units responded

Routine screening: 36 (18%) units

In process of introducing screening: 8 units

Considering routine screening: 111 (70%) units

Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A

Commonest ConcernsResource issues:

Cost : 63% Staff Time: 28% Availability of Echocardiography: 25% Staff Training: 24%

Lack of national and local guidelines: 36%Excess False Positives: 10%Delayed discharge: 5%Cross infection: 3%

Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A

Reasons for units not considering screening (49 units)Staffing: 57%False Positives: 55%Availability of echocardiography: 33%Cost: 31%Unconvinced by evidence: 22%Adequate current screening methods: 18%

Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A

Threshold Saturation for positive test: 90-97%

20/36: 95%Postductal Saturations Only: 18Screening Time:

Before discharge: 55%Within 48Hours: 4%Before 24 hours: 13/14After 24 hours: 1

Pulse Oximetry Screening for critical congenital heart defects: A UK national surveySingh A , Ewer A

Conclusion

Shift of opinion of among UK Neonatologists regarding pulse oximetry screening with a

significant majority now in favour, albeit with some reservations

The impact of pre- discharge pulse oximetry screening in a Regional Neonatal unit Singh A, Rasiah SV, Ewer A

To evaluate the impact of routine pulse oximetry screening on the rate of unexpected admissions and need for echocardiography.

To review the outcomes of babies admitted as a result of positive pulse oximetry screening.

Routine pre-discharge pulse oximetry screening at BWHPre and postductal SatsAbnormal Test: <95% or a difference of >2%Expedited Clinical ExaminationRepeat Pulse Ox in 1-2 hrsTest Positive

2 abnormal pulse ox readings1 abnormal pulse ox reading + abnormal

Clinical Exam

MethodsRetrospective review of all unexpected

admissions to the unit

April’10 –March’12

Review ofIndication for admissionClinical diagnosisManagement Outcome

Results Total admissions: 2137 Unexpected admissions: 1021

Test positive pulse oximetry: 123 (12%)

Congenital heart lesions: Critical CHD: 4 Serious CHD: 1 Significant CHD: 3

Critical - HLHS, PA/IVS, TGA or IAA or dying and/or intervention in 1st month with CoA, AS, PS, ToF, PA/VSD or TAPVD

Serious – Requiring intervention in 1st year

Significant - Requiring FU > 6 mths or drug Rx

CHD Classification

Congenital pneumonia: 33

Sepsis: 17

PPHN: 8

MAS: 3

TTN requiring oxygen: 21

Hyperinsulinaemia: 1

Pneumothorax: 1

Depressed skull fracture: 1

Early onset jaundice: 1

Congenital Pneumonia- ↑inflam markers ± +ve culture, X-Ray changes, O2 requirement, abs ≥ 5 days.

Sepsis - ↑ inflammatory markers ± culture +ve, abs ≥ 5 days

MAS – h/o meconium , respiratory distress, O2 requirement, X-Ray changes

TTN requiring oxygen: Tachypnoea with X-Ray changes of fluid retention, oxygen requirement, no rise in inflam markers or +ve culture

Other significant diagnosis

ResultsTransitional circulation: 29 (23%)

No collapse in the postnatal wards during study period

Echocardiograms performed for Test Postive pulse Ox: 39/123 (32%)

Abnormal ECHO’s: 16/39 (41%)

ConclusionsTest positive pulse oximetry resulted in

approx one admission per week

It leads to a modest increase in the number of echocardiograms performed.

Routine use of Pulse oximetry identifies babies with illnesses, which if not identified early could potentially lead to postnatal collapse

References

Ewer AK, et al. Pulse oximetry as a screening test for congenital heart defects in newborn infants: the PulseOx test accuracy study. The Lancet 2011 Aug 27;378(9793):785-94.

Kang et al. Neonatal pulse oximetry screening: a national survey. Arch Dis Child Fetal Neonatal Ed 2011;96:F312.