In PIR’s September 2016 In Brief column, Philip Roth, MD, PhD, of Staten Island University Hospital, in New York, presents a thorough and crisp paper regarding the now mandated pulse oximetry usage in the newborn nursery. He nicely dissects the various newborn problems that it can help uncover.As a pediatric cardiologist, I have seen this technique save lives through early screening and referral, especially of arterial duct-dependent lesions, such as hypoplastic left heart syndrome, pulmonary atresia, and transposition of the great arteries.
Figure 1. Aside from its use in the early evaluation of cyanotic CHD, pulse oximetry can also play a key role in the detection of critical congenital heart disease (CCHD) in asymptomatic infants. Photo courtesy of the University of Mississippi Medical Center, Jackson, MS, www.umc.edu.
I would offer some suggestions to you who are in the front lines in the nursery when confronted with an infant who fails the pulse oximetry test.First, refer to a center that has pediatric cardiology expertise and first-rate neonatal cardiac surgery capability.
I have had two experiences where the patient was referred quickly, but to the wrong place, one with near disaster resulting. The nursery physician was quick and appropriate to transport the infant, but in rather an “out of sight, out of mind” manner.
This child was sent to a satellite center with no heart catheterization, cardiac surgery and only minimal pediatric cardiology presence. (The cardiologist was in a clinic remote from the emergency room where the patient was transported). He left the clinic, arranged a helicopter transport, and started prostaglandin for the infant who had transposition and needed a balloon septostomy. Much time was lost when the original transport could have gFigure 2. Be sure to measure oximetry in upper and lower extremities. A differential value may portend congenital heart disease. Photo courtesy of the Textbook of Neonatal Resuscitation, 7th Edition.one another 30 minutes to our center.
The other was an infant who had pulmonary atresia and intact atrial septum. The child was 4 months old, stable and gaining weight. The pulse oximetry in the office showed 78% saturation. This is an entirely different circumstance that could have been handled electively. Instead, the pediatrician panicked and sent the child to an adult emergency room where the provider had no idea of what was going on. He contacted us, and the child is now postoperative and doing well.
Last, please, please, please, do not get an echo at your institution unless you have a qualified pediatric cardiologist there and present in the nursery (not showing up the next morning). Time is lost, and when echocardiographers are not familiar with congenital heart disease, disastrous mistakes can be and have been made. (I should not and do not care for patients with acquired coronary disease either).
As an example, I recall one patient with tetralogy who was said to have critical aortic stenosis. If the interpretation had been followed the patient would have faced disaster. The fact is that interpreters with little experience with congenital heart disease should not interpret echoes done in children.The bottom line is not to panic, but to refer quickly and with proper information to a pediatric cardiac center and avoid unnecessary testing. You will have served your patient well in so doing.