Pulse-Oximetry Congenital Heart Disease Screening Program :: Nationwide Children's Hospital

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Pulse-Oximetry Congenital Heart Disease Screening Program

Our goal is simple. We want all infants with critical congenital heart disease to be identified before leaving the nursery. Together, we can achieve this goal and save lives.

Congenital heart disease (CHD) is the most common birth defect. Infants with CHD have abnormal heart structure resulting in abnormal blood flow patterns. Approximately eight out of every 1,000 infants have a form of CHD. Some forms of CHD cause no, or very few, problems in the health, growth and development of the infant. In many cases, these forms of CHD do not require surgical repair or cardiac catheterization.

Critical CHD, however, can bring a significant risk of morbidity and mortality if not diagnosed in a timely manner. Failing to detect critical CHD while in the newborn nursery may lead to critical events, such as cardiogenic shock or death. Survivors who present late are at greater risk for neurologic injury and subsequent developmental delay.

Fortunately, a routine test exists that can help us identify most infants with critical CHD.

Overview of Pulse-Oximetry Congenital Heart Disease Screening Guidelines

It is recommended that pulse-oximetry screening be done in conjunction with other standard-of care newborn screening that requires the infant be at least 24 hours of age, such as metabolic or hearing screening.

If the newborn’s oxygen saturation is ≥95 percentage points in either extremity with a ≤3 percentage-point difference between the two, he or she will be considered to have passed the screening test and no additional evaluation will be required unless other signs or symptoms of CHD are present.

If the newborn’s oxygen saturation is <90 percentage points in either the hand or foot, he or she should be immediately referred for additional evaluation.

If the oxygen saturations are <95 percentage points in both the hand and foot or there is a >3 percentage-point difference between the hand and foot on three measures, each separated by one hour, the newborn should be referred for additional evaluation.

Performing Pulse Oximetry with the Infant Patient

Testing Dos

  1. If you are using disposable pulse-oximetry probes, use a new, clean probe for each infant. If you are using reusable pulse-oximetry probes, clean the probe with recommended disinfectant solution between each infant. Dirty probes can decrease the accuracy of your reading and can transmit infection. A disposable wrap should be used to secure the probe to the site.
  2. The best sites for performing pulse oximetry on infants are around the palm and the foot. An infant pulse-oximetry probe (not an adult pulse-oximetry clip) should always be used for infants.
  3. When placing the sensor on the infant’s skin, there should not be gaps between the sensor and the infant’s skin. The sides of the probe should be directly opposite each other.
  4. Nail polish dyes and substances with dark pigmentation (such as dried blood) can affect the pulse- oximetry reading. Assure that the skin is clean and dry before placing the probe on the infant. Skin color and jaundice do not affect the pulse-oximetry reading.
  5. Movement, shivering and crying can affect the accuracy of the pulse-oximetry reading. Ensure that the infant is calm and warm during the reading. Swaddle the infant and encourage family involvement to promote comfort while obtaining the reading. If possible, conduct screening while the infant is awake.
  6. Pulse oximeters have different confidence indicators to ensure that the pulse-oximetry reading is accurate. Determine the confidence indicators for the pulse-oximetry equipment that you are using.
  7. If an infant requires pulse-oximetry monitoring for an extended amount of time, assess the site where the probe is placed at least every two hours. Monitor for signs of irritation and burning of the skin.

Testing Don’ts

  1. Never use an adult pulse-oximetry clip when obtaining a reading for an infant. Using an adult clip on an infant will give an inaccurate reading.
  2. Blood flow is needed to obtain an accurate pulse-oximetry reading. Never attempt to obtain a reading on the same extremity that you have an automatic blood pressure cuff.
  3. Bright or infrared light, including bilirubin lamps and surgical lights, can affect the accuracy of the reading. Ensure that the infant is not placed in bright or infrared light while the test is being performed. You may cover the pulse-oximetry probe with a blanket to ensure that extraneous light does not affect the accuracy of your reading.
  4. Do not use tape to apply the pulse oximetry probe to the infant’s skin.

Testing Cautions

  1. The pulse is needed to determine the oximetry reading. Pulse oximetry is not accurate if the patient is coding or is having a cardiac arrhythmia. Remember: No pulse, no oximetry!
  2. Pulse-oximetry readings are not instantaneous. The oximetry reading that is displayed on the monitor is an average of readings over the past few seconds.

Pulse-Oximetry Congenital Heart Disease Screening Recommendations

  1. Pair pulse-oximetry screening with another standard-of-care screening performed following 24 hours of age, such as metabolic or hearing screening. If early discharge is planned, screening should occur as late as possible.
  2. Consider assigning one or two nursing assistants or registered nurses to pulse-oximetry screening on a daily basis. If possible, provide continuity by scheduling one screener to conduct screening on several continuous days.
  3. Conduct screening in a quiet area with parent present to soothe and comfort the infant.
  4. If possible, conduct screening while the infant is awake, quiet and calm.
  5. Do not attempt to perform pulse oximetry on an infant while he or she is sleeping, crying or cold as oxygen saturations may be affected.
  6. If using disposable pulse-oximetry probes, use one clean probe for each infant screened. If reusable probes are being used, clean probe as instructed by manufacturer prior to and following screening. Dirty probes may decrease the accuracy of a reading or transmit infection.
  7. Perform pulse oximetry on the right hand and one foot after 24 hours of age. Measurements should be taken in parallel or one after another. If infant was born prematurely, perform screening when medically appropriate.
  8. Ensure that all readings are accurate by using pulse-oximetry equipment confidence indicators.
  9. If the oxygen saturation is ≥95 percentage points in either extremity with a ≤3 percentagepoint difference between the two, the infant will “pass” the screening test and no additional evaluation will be required unless other signs or symptoms of CHD are present.
    • The physician or nurse practitioner caring for the infant does not need to be notified.
    • The infant does not require additional cardiac evaluation in the newborn nursery unless indicated.
  10. If the pulse-oximetry reading is <90 percentage points in either the hand or foot, the infant should be immediately referred to his or her physician for additional evaluation.
  11. If the oxygen saturations are <95 percentage points in both the hand and foot or there is a >3 percentage-point difference between the two or three measures, each separated by one hour, the newborn should be referred for additional evaluation.
    • The infant’s physician or nurse practitioner should be notified.
    • Infectious and pulmonary pathology should be excluded.
    • If cause of hypoxemia is not clear, an echocardiogram and cardiology consultation should be obtained if available to rule out congenital heart disease. If echocardiogram and/or cardiology consultation are not available, the infant should be transferred to Nationwide Children’s Hospital (or your local neonatal ICU consultation service) for further evaluation.
    • Further evaluation should be ordered at the discretion of the physician or nurse practitioner caring for the infant.

Reminder Algorithm for Screeners

  • Confirm that the infant is at least 24 hours of age and eligible for screening.
  • Help the parent to warm and calm the infant in a quiet and peaceful environment.
  • Describe the pulse-oximetry test to the parent.
  • Select a site on the right hand and one foot that is clean and dry.
  • Place the pulse-oximetry probe and perform the test.

Assessment of Babies with Failing Saturations

  1. Babies with saturation of <90 percentage points in RH or foot should have immediate assessment.
  2. Babies with failing saturations:
    • Perform clinical assessment.
    • Infectious and pulmonary pathology should be excluded.
    • Complete echocardiogram or transfer to Nationwide Children’s Hospital.

If screening fails, call the Physician Direct Connect Line at (614) 355-0221 or (877) 355-0221 and ask for Neonatology. If you have a local neonatology ICU resource, please contact your usual consultation service.

Copyright: Children’s National Medical Center. Congenital Heart Disease Screening Program Toolkit: A Toolkit for Implementing Screening. Washington, DC: Children’s National Medical Center; 2009.

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