Oxygen prescription. Dr Julian Forton. Consultant in paediatric respiratory medicine Noah s Ark Children s Hospital for Wales
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1 Oxygen prescription Dr Julian Forton. Consultant in paediatric respiratory medicine Noah s Ark Children s Hospital for Wales
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4 Oxygen prescription chart
5 EXCEPTION: Oxygen may be given without a prescription in any emergency Prescribe it as soon as possible
6 Example scenario 9 month child; bronchiolitis
7 Doctor s prescription 11 July 2014 Jforton 1234 Jf 11/7/14 Jf 11/7/14
8 Nurse documentation July 2014 Jforton 1234 Jf 11/7/14 Jf 11/7/14
9 Clinical deterioration day 3 Nurse contacts doctor July 2014 Jforton 1234 Jf 11/7/14 Jf 11/7/14
10 Doctor makes clinical assessment & increases oxygen prescription July 2014 Jforton 1234 Jf 11/7/14 PK 13/7/2014 Jf 11/7/14 PK 13/7/2014
11 Clinical deterioration overnight Nurse increases oxygen as needed Nurse contacts doctor July 2014 Jforton 1234 Jf 11/7/14 PK 13/7/2014 Jf 11/7/14 PK 13/7/2014
12 Doctor makes clinical assessment & increases oxygen prescription July 2014 Jforton 1234 Jf 11/7/14 PK 13/7/2014 Jf 11/7/14 PK 13/7/2014 EZ 14/7/2014
13 Child transferred to HDU & started on ncpap with 10L/min O July 2014 Jf 11/7/14 PK 13/7/2014 Jf 11/7/14 PK 13/7/2014 Jforton 1234 Nasal CPAP 10L/minute EZ 14/7/2014 PE 14/7/2014 GW/TY
14 Is oxygen dangerous? In adults with chronic respiratory disease and CO 2 retention, respiratory drive may be dependant on hypoxia Giving oxygen to these patients may cause CO 2 narcosis. These adult patients are managed with regular blood gases and lower target oxygen saturations
15 Is oxygen dangerous in children? In theory, children with chronic respiratory disease may also have CO 2 retention CO 2 narcosis is rare in the paediatric population However, Pay particular attention to children with chronic lung disease of prematurity, end stage cystic fibrosis, neuromuscular weakness and obesity If in doubt talk to your consultant
16 Monitoring oxygen (nurse) Observation chart 4 hourly observations RR oxygen saturations Level of oxygen delivered mode of oxygen delivery Drug Chart Double signing of oxygen prescription at each drug round
17 Titrating oxygen (nurse) If sats are lower than target threshold on chart 0 2 If sats are higher than target threshold on chart 0 2 Always give the minimum oxygen possible Monitor sats for 5 mins at every change Document sats after 5 mins on chart If oxygen delivered reaches upper extreme of range, call for medical review
18 Stopping oxygen (nurse /doctor) When Patient stable on minimal oxygen Sats are within range on 2 consecutive observations How Stop oxygen & monitor sats for 5mins. If stable, continue to monitor in air for 1 hour If saturation falls, then re-start oxygen If saturation remain stable at one hour, stay in air Document the changes you make Oxygen may still be required at night and with feeding
19 Responsibilities DOCTORS Prescribe oxygen Target saturations Device Oxygen delivery limits Sign drug chart Review withdrawal of oxygen Cross off oxygen on drug chart NURSES Start oxygen achieve target straight away Monitor oxygen minimum 4 hourly. Titrate and wean off oxygen Always give the minimum oxygen required Record O 2 Sats, RR, O 2 delivery, delivery device Sign drug chart every drug round Document all changes in oxygen requirement Inform doctors If limits to oxygen prescription are reached
20 EMERGENCY OXYGEN PRESCRIBING PAEDIATRIC GUIDELINES IN SECONDARY CARE Is the patient critically ill? No Yes APLS Reservoir mask Oxygen 15L/min or bag-valve mask Discuss target O 2 sats with cardiology Yes Does the child have congenital heart disease? No Does the child have chronic lung disease of prematurity? Target O 2 sats >92% Yes Patient has or is at risk of pulmonary hypertension No Patient has or is at risk of pulmonary hypertension No Yes Yes No Target O 2 sats 91-94% Target O 2 sats >95% Could the patient have chronic CO 2 retention? (see orange box below) Yes No Discuss with consultant or SpR Consider capillary blood gas Breathing in patients who have chronic CO 2 retention may be dependant on hypoxic drive Take care with oxygen in the following patients Chronic lung disease of prematurity Neuromuscular disease Obesity End stage cystic fibrosis Oxygen must be prescribed in the drug chart using the paediatric oxygen sticker In an emergency, oxygen can be given without a prescription
21 Guidance on oxygen delivery interfaces in children DEVICE/FiO 2 INDICATIONS ADVANTAGES LIMITATIONS Headbox Humidified and warmed O % Suitable for infants and small children with acute episodes of respiratory illness eg bronchiolitis Controlled oxygen delivery Well tolerated in infants Easy delivery of humidified O2 CO 2 build up may occur if flow <7l/min OR outflow from box is obstructed. O 2 needs to be warmed for smaller infants as the environment inside can become cold Access to give care can cause significant fall in oxygen delivered Nasal cannulae Maximum flow rate 2l/min Estimated oxygen delivery 24-40% Long Term Oxygen Therapy (LTOT). Minimal oxygen requirement Recovery phase from acute episodes Low cost and easy for patient to eat and talk well tolerated No re-breathing. Uncontrolled oxygen delivery Oxygen delivery is affected by flow setting, respiratory rate, depth of breathing and geometry of nose. Dries the nose, can cause headaches. Facemask 5-15 litres/min Estimated oxygen delivery 40-60% Use for patients who need high oxygen delivery Useful in children who are mouth breathers have nasal irritation have epistaxis Minimum delivery 5litres/min to avoid rebreathing of expired CO 2. Oxygen delivery is affected by flow setting, mask fitting, mask leak and patient s breathing pattern. Non re-breathe mask 26/6/ litres/min Estimated oxygen delivery % Often used in APLS setting (trauma, shock, severe asthma, convulsions, reduced level of consciousness) Delivers very high concentrations of oxygen Dr Julian Forton. Consultant in paediatric respiratory medicine Minimum delivery 6 litres/min to avoid rebreathing of expired CO 2. Oxygen delivery is affected by mask fitting and mask leak
22 Paediatric oxygen working group Dr Julian Forton Anthony Lewis Rowena McArtney Avril Gowman Mary Glover Janice Gracie Louise Williams Consultant in paediatric respiratory medicine Directorate Pharmacist, Child Health Senior information pharmacist Lead nurse, Child Health Senior nurse. Neonatal Unit Sister Ocean and Land wards Nurse Advisor - Medicines Management
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