03 Transcutaneous Measurement of O2 and CO2 in Neonates Dr. Oliver Götz PDF

The information and statements presented
on the following slides reflect the personal

opinion of Dr. Oliver Götz.
medica 2018
Düsseldorf
SenTec-Symposium
Transcutaneous measurement of O2 and

CO2 in term and preterm neonates:
Basics and frequent questions
Oliver Götz, Leading senior physician, Department of Pediatrics and Neonatologie,
Kempten/Germany Nov 13, 2018 Seite 1
Perinatal Center Unit of Kempten
Intellectual property of Dr. Oliver Götz.

Nov 13, 2018 Seite 2
For internal use only! Do not distribute!
Perinatal Center Unit of Kempten:

Content
< Introduction
< Principles of treatment in neonatal patients
< Measurement of O2 and CO2 in the NICU
< Patients and neonatal therapie
< Equipement: Questions and Objections
< Conclusions

Perinatal Center Unit of Kempten:
< Kempten is a perinatal center level 1 (tertiary care center)
< Inborn deliveries 2017: 2000

< Deliveries in the region 2017: 600
< Inpatient treated newborn/preterm: ~350
< 75 preterm babys < 2200 g birthweight
< 60 Preterm babies < 1500 g birthweight

Definitions and limitations of
preterm deliveries

Distribution of preterm/newborn babys

Principles of treatment in neonatal patients
< First aim in the treatment of neonates: AVOID COMPLICATIONS
< Intraventricular hemmorhagie

< Bronchopulmonary dysplasie
< Necroticicing enterocolitis
< Retinophathia praematurorum
< Discharge from hospital in good condition and

furthermore normal neuro-motorical development
in the next years

< Close observation of all sick term or preterm babies
< Heart rate

< ECG
< Pulse rate with arterial line
< Saturation
< Saturation of peripheral oxigen (SP O2)
< Tc pO2 and pCO2
< Breathing rate
< ECG
< Trigger capsula
< Additional examinations
< Blood examinations (blood gas analysis, electrolytes, blood glucose,…)
< Ultrasound (Heart, brain, abdomen,…)
< X-ray

< Correct (?) treatment of phenomenas of premature birth and typical deseases
< Surfactant deficiancy desease: Oxygen, Surfactant, CPAP, Ventilation

< Apnoe-Bradycardie-Syndrom: Surveillance, Caffein, CPAP, NIV
< …
< …
< Avoid adverse effects and complications of treatment

< Lung damage
< Brain damage
< …
< Anemia

Nov 13, 2018 Seite 10
Measurement of pO2 and pCO2
< One essential function postnatal is breathing for

< A sufficiant oxygenation of the baby and
< A sufficiant ventilation
< Sufficiant oxygenation means normal pO2 levels in the arterial blood
< Levels are too low: Hypoxemia - give oxygen, treat problems
< Malfunction of organs (brain)
< Levels are too high: Hyperoxemia – reduce given oxygen

< Negative impact on cerebral blood flow
< Increasing risk for ROP

Nov 13, 2018 Seite 11
< Sufficiant ventilation means normal pCO2 levels in the arterial blood
< Levels are too high: Hypercapnia – increase breathing effort/ventilation

< Respiratory acidosis
< Levels are too low: Hypocapnia – reduce ventilation

< Respiratory alkalosis
< Cerebral vasoconstriction – reduced cerebral blood flow

Nov 13, 2018 Seite 12
< Arterial blood sample
< Exact results

< Needs an arterial line
< Needs an capillary or arterial punction
< Loss of blood
< Spot measurement
< Saturation of peripheral oxigen (SP O2)
< Routinely done, easy to do

< Measurement of O2-Saturation, not the pO2, not the pCO2
< Detection of hypoxemia
< No detection of hyperoxemia, hypercapnia, hypocapnia
< Contineous measurement

Nov 13, 2018 Seite 13
Measurement of pO2 and pCO2 –
SpO2 - the Oxyhemoglobin Dissociation Curve
Big change in paO2 despite a small

change in SaO2
Small change in paO2 with a small change in SaO2
Pulse oximetery
- can detect hypoxemia
- but cannot detect hyperoxemia

Nov 13, 2018 Seite 14
< Transcutaneos measurement of pO2 and pCO2
< Additional line necessary, routinely change of application site necessary

< Irritation of skin possible – depends on temperature (40 C – 43 C)
< Detection of hyperoxemia, hypoxemia, hypercapnia, hypocapnia

Nov 13, 2018 Seite 15

Nov 13, 2018 Seite 16
Measurement of pO2 and pCO2 - evidence

Nov 13, 2018 Seite 17
Govermental guidelines for perinatal centers!

Nov 13, 2018 Seite 18
< Preterm babys

< Regulation of invasive / noninvasive ventilation
< Prevention of damage by hyperoxemia and hypocapnia
„must have“
Equipement, not
< Sick term babys measurement in every case!
< Regulation of invasive ventilation
Level 1: 4 tc-monitors
Level 2: 2 tc-monitors
< Toddlers, infants

< Detection of sleep disorders due to breathing problems „nice to have“

Nov 13, 2018 Seite 19
Ø Perinatalcenter Level 1
Ø 2/3 of respirator places

need tc-capacity
https://www.g-ba.de/downloads/62-492-1646/QFR-RL_2018-05-17_iK-2018-08-25.pdf

Nov 13, 2018 Seite 20
< Limitations
< Skin leasions in ELBW preterms

< Reduce temperature, only pCO2-measurement
< Reduced skin and tissue perfusion

< Sepsis
< Use of catecholamines
< Hypothermia treatment
< ELBW below 500 g

< Skin regions may be too small for sensor!
< Healthy babies moving too much!

Nov 13, 2018 Seite 21
Which patients do need tc-measurement?
< Every baby with respiratory distress or failure (~70%)
< Distress (~60%):

< Tachydyspnoe
< Retractions of the chest
< Snorring / grunting
< Failure (40%):

< Partial failure vs global failure
< Hypoxemia or hypercapnia
< Every baby with mechanical respiratory support

Ø Number depends on gestational age!
Ø GA< 28 Weeks: 90%

Nov 13, 2018 Seite 22
Forms of respiratory support
< Non-invasive
< Oxygen: Nasal canula, oxygen in incubator air
< High flow nasal canula: CPAP „light“
< CPAP
< CPAP with backup-ventilation
< NIPPV (with external trigger capsula)
< Invasive
< CV: Pressure-controlled, volume-controlled,…
< HFO
< (CPAP)
Ø The not invasive-ventilated baby is often more unstable than

the intubated one!

Nov 13, 2018 Seite 23
Which patients do need tc-measurement?

Nov 13, 2018 Seite 24
Respiratory Monitoring under mechanical
respiratory support
< Non-invasive support:
< SPO2
< Respiratory rate, heart rate
< Blood gas analysis (capillary, venous, arterielle)
< Tc-measurement of CO2 and / or O2
< Invasive:
< SPO2
< Respiratory rate, heart rate
< Tidal volume Vt / minute volume MV (CV)
< DCO2 (HFO)
< Blood gas analysis (capillary, venous, arterielle)
< Tc-measurement of CO2 and / or O2
< ETCO2-measurement possible in patients > ~3 kg!
(dead space volume!)

Nov 13, 2018 Seite 25
Equipement – major problems
< Phycicians
< Selection of patients for tc-monitoring
< Grade of respiratory distress – art of respiratory support
< Newborn (50%) – preterm (50%) – LBW (80%) – ELBW (20%)
< Interpretation of differences in tc- and bloodgas-values of CO2/O2
< Wait and see – frequent blood gas controls
< Nurses
< Extra line to handle
< Technical knowledge
< Additional work in the same time
< Incecurity about measurement – alarm limits – consequences
< Concern about side effects of tc-measurement (i.e. skin burns)

Nov 13, 2018 Seite 26
Equipment
Accurate measurement

Nov 13, 2018 Seite 27
Equipment
Transportable:
- Use on NICU
- Use in the OR

Nov 13, 2018 Seite 28
Equipment
Integratable

Nov 13, 2018 Seite 29
Measurement of tc-pO2/pCO2 –
Benefits
< Easy and safe detection of hyperoxemia, hyper- and hypocapnia

< Prevention of additional damage:

< Lung by hyperoxemia (BPD)
< Brain by hyper- and hypocapnia (IVH, PVL)
< Eyes by hyperoxemia (ROP)
< Saving of blood and less frequent need for transfusion
< In absence of an arterial line less frequent taking of a blood sample by stiching the baby
< Legal security in case of a legal dispute

Nov 13, 2018 Seite 30
Practical procedure
< Optimal teaching bevor the „first trial“ – the importance of the first impression
< Standby support during the first use
< Start with new methode in children not so severely ill
< Severly ill babys are always complex and difficult to handle
< No one wants to practise in extreme situations
< The risk of a test failure is higher as in „normal patients“
< Start with a heading temperature of 43 C

< Calibration intervall every 8 hours
< Change application site every 4 hours
< Use the methode for

< Monitoring of the stable newborn/preterm with respiratory distress
< Monitoring of changes in ventilation mode and intensity
< Preparation of extubation – monitoring right after extubation

Nov 13, 2018 Seite 31
Questions and Objections –
Measurement and comparison to ABG
< Poor correlation to arterial blood gas analysis

< Continous measurement vs. spot measurement
< The trend is your friend
< Compare tc- measurement to control of respirator readings (VT, MV, DCO2)
< Learning by doing
< Limitations in ELBW preterms (as in nearly all other standard procedures!)
< Heading temperature 41 C
< Change application site every 3 hours
< Only one sensor ring possible
< Therapy methods with negative input (as in all therapies and monitored parameters!)
< Hypothermia - test the best
< Inotrope medicine – test the best

Nov 13, 2018 Seite 32
Measurement and comparison to ABG
< Real reduction of blood gas controls?
< Learning phase: No! Later: Yes! Learning by doing!

< Every blood loss is a blood loss (blood volume 80 ml/kg body weight!)
< Not every child has a arterial line – nedd to stich the baby
< The costs of blood gas controls are often unknown
< Changed therapy approach in neonatology: reduction of invasive ventilation
< The not invasive-ventilated baby is often more unstable than the intubated one
< Non-invasive methods of respiratory support needs the same accuracy in monitoring
as the invasive methods
< Especially the time bevor and after extubation is a vulnerable time

Nov 13, 2018 Seite 33
Application related
< Risk of skin burns

< Reduce temperature – risk of hypo-/hypercapnia
< Decision to forego in special cases
< Attachment ring is too big

< Only in ELBW
< Use only one site
< Ring do not stick well

< Well enough – reduced risk for skin injury
< Methode requires extre time for the nurses

< Best practise for the most vulnerable patients
< Less frequent need for stiches
< Timesaver when practiced users
< Everything is complicate bevor it is easy!

Nov 13, 2018 Seite 34
Frequent questions
Ø Know the limitations of the methode

Ø Every other therapie in neonatology has limitations and problems
Ø There is no absolutly best way to treat neonatal patients – in no field of problems
Ø In case of doubt it is correct and ofte used in neonatology to forego an act
<Convinve the phycicians!
<Win the heart of the nurses!

Nov 13, 2018 Seite 35
Conclusions
< Optimal observation is the base for an optimal treatment and outcome in sick term and
preterm babys
< Regarding oxygenation and ventilation, monitoring of SP O2 is not detecting relevant

abnormalities in pO2 and pCO2-levels
< Taking too much spot blood samples as gold standard methode is not helpful because of
the need for an arterial line, blood loss or pain and infection risk in case of stiching
< Transcutaneous measurement of pO2 and pCO2 is available for even ELBW preterm
babys

Nov 13, 2018 Seite 36
Conclusions
< The methode is safe and accurate
< The equipment is transportable and integreatable in PDM-systems
< The staff of the NICU in Kempten decided to work with the SenTec SDMS after testing
several devices

Nov 13, 2018 Seite 37
Thanks for your
attention!
oliver.goetz@klinikum-kempten.deetz@klinikum-kempten.de


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Copyright:

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The information and statements presented

on the following slides reflect the personal

Transcutaneous measurement of O2 and

Intellectual property of Dr. Oliver Götz.

Intellectual property of Dr. Oliver Götz.

< Principles of treatment in neonatal patients

< Measurement of O2 and CO2 in the NICU

< Patients and neonatal therapie

< Equipement: Questions and Objections

Intellectual property of Dr. Oliver Götz.

< Kempten is a perinatal center level 1 (tertiary care center)

< Inborn deliveries 2017: 2000

< Inpatient treated newborn/preterm: ~350

< 75 preterm babys < 2200 g birthweight

< 60 Preterm babies < 1500 g birthweight

Intellectual property of Dr. Oliver Götz.

Intellectual property of Dr. Oliver Götz.

Intellectual property of Dr. Oliver Götz.

< First aim in the treatment of neonates: AVOID COMPLICATIONS

< Intraventricular hemmorhagie

< Discharge from hospital in good condition and

Intellectual property of Dr. Oliver Götz.

< Close observation of all sick term or preterm babies

< Heart rate

Intellectual property of Dr. Oliver Götz.

< Surfactant deficiancy desease: Oxygen, Surfactant, CPAP, Ventilation

< Avoid adverse effects and complications of treatment

Intellectual property of Dr. Oliver Götz.

< One essential function postnatal is breathing for

< Levels are too high: Hyperoxemia – reduce given oxygen

Intellectual property of Dr. Oliver Götz.

< Levels are too high: Hypercapnia – increase breathing effort/ventilation

< Levels are too low: Hypocapnia – reduce ventilation

Intellectual property of Dr. Oliver Götz.

< Arterial blood sample

< Exact results

< Saturation of peripheral oxigen (SP O2)

< Routinely done, easy to do

Intellectual property of Dr. Oliver Götz.

Big change in paO2 despite a small

Small change in paO2 with a small change in SaO2

- can detect hypoxemia

- but cannot detect hyperoxemia

Intellectual property of Dr. Oliver Götz.

< Transcutaneos measurement of pO2 and pCO2

< Additional line necessary, routinely change of application site necessary

Intellectual property of Dr. Oliver Götz.

Intellectual property of Dr. Oliver Götz.

Intellectual property of Dr. Oliver Götz.

Govermental guidelines for perinatal centers!

Intellectual property of Dr. Oliver Götz.

< Preterm babys

< Toddlers, infants

Intellectual property of Dr. Oliver Götz.

Ø 2/3 of respirator places

Intellectual property of Dr. Oliver Götz.

< Skin leasions in ELBW preterms

< Reduced skin and tissue perfusion

< ELBW below 500 g

< Healthy babies moving too much!

Intellectual property of Dr. Oliver Götz.

< Every baby with respiratory distress or failure (~70%)

< Distress (~60%):