Tuesday, June 9, 2009

Pulse Oximetry and Detection of Cardiac Abnormalities in Newborns

new lecture


Update2: to know about pulse oximetry

Update1: What are the take-home messages from this review?

Beliefs: I do believe that developing countries should develop through simple procedures. i.e. screening PHC, home visits,... etc.
To start screening you should apply the safest and cheapest procedure.

Applicability: This is so simple and should e applicable in any centre after birth. I know that each Nursery, labor department in any hospital has Pulse Oximetry. Alternatively, even, it could be applied from other departments or store. There is no cost at all. Furthermore, we need it to be documentary, routine, and obligatory in our FILE SYSTEM.

Manpower: The Obstetrician or paediatrician, or nurses will examine the newborn. They should check ALL PUSLES and PULSE OXIMETRY. It could be added as a routine item in checklist of newborn BEFORE DISCHARGE.


Pulse Oximetry and Detection of Cardiac Abnormalities in Newborns. (Review) By Dr Eman Altahawy 2009


· Neonatal screening started in the 1960s with the Guthrie bacterial inhibition test for detection of phenylketonuria.
· Screening test should reliably identified when asymptomatic, with a low false positive rate, and when treated early death or disability are prevented.


· Between 1 and 1.8 babies per 1,000 live births have duct dependent circulation.
· About 30% are not diagnosed before discharge. Duct-dependent cardiac lesions are especially difficult to diagnose before discharge now that most newborns are discharged before 72 hours of life, which is about when the ductus arteriosus closes.


· These babies return to the hospital in circulatory collapse, respiratory distress, metabolic acidosis, sudden death, or die at home. So, we need a Challenge .

· At first sight, universal pulse oximetry screening for this disease seems to contravene the above principles.


· Impact of pulse oximetry screening on the detection of duct dependent CHD: a Swedish prospective screening study in 39 821 newborns (BMJ 2009).
· Using a new generation pulse oximeter before discharge from well baby nurseries in West Götaland.
· Comparing with other regions not using pulse oximetry screening but only physical examinations.

Main outcomes

· It measures Sensitivity, specificity, positive and negative predictive values, and likelihood ratio for pulse oximetry screening and for neonatal physical examination alone.


· Nurses measured preductal oxygen saturation in the right hand and postductal oxygen saturation in either foot ( simple).
· total procedure time: 5 minutes (rapid).
· If both preductal and postductal oxygen saturation were <95%>3%, the screening was considered positive and the measurements were repeated.


· Infants with three positive measurements underwent echocardiography.

· Doctors were blinded to oximetry readings unless oxygen saturation was 90%; in these cases, the treating doctor was immediately notified and an echocardiogram was performed.

Results Sensitivity
• Adding pulse oximetry screening to a pre-discharge physical examination increased the sensitivity of detecting duct dependent circulation from 62.5% to 82.8%.
• It detected 100% of the babies with duct dependent lung circulation.


· The false-positive rate of 2.09% (low).
· Although pulse oximetry resulted in 69 false-positive cases, 44.9% of those had other conditions, some of which required immediate attention. (even it is good).
· Therefore, referring all babies with positive pulse oximetry results for echocardiography resulted in only 2.3 excess ECGs for each true-positive case.


· False positive rate with pulse oximetry was substantially lower than that with physical examination alone (0.17% vs. 1.90%, P<0.0001), color="#ff0000">False negative

· Five cases were missed (all with aortic arch obstruction).

· The risk for discharge with an undetected duct-dependent lesion was significantly higher in a cohort of infants from other regions in Sweden where pulse oximetry was not performed (relative risk, 3.4).


· The authors estimated that pulse oximetry screening would be at least cost-neutral in the short term and probably cost-effective in the long term due to reduced need for preoperative neonatal intensive care.


· Introducing pulse oximetry screening before discharge improved total detection rate of duct dependent circulation to 92%.
· High predictive value
· Low false-positive rate
· Cost-neutral in the short term
· Cost-effective in the long term.


· Routine pulse oximetry before hospital discharge in newborns.
· I suggest further similar work among Arab countries.

· Granelli A et al. Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: A Swedish prospective screening study in 39 821 newborns. BMJ 2009 Jan 8; 338:a3037.

· Pulse Oximetry Improves Detection of Cardiac Abnormalities in Newborns. Journal Watch Pediatrics and Adolescent Medicine February 11, 2009.

Thank you

I power

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