Sage Journals: Discover world-class research

Abstract

In hospitals, oxygen is the most frequently administered medication to pediatric in-patients. Too much oxygen in arterial blood is not a natural occurrence, consequently hyperoxia can be caused by healthcare providers. The aim of this scoping study was to synthesize evidence that could contribute to safe and appropriate oxygen treatment in children 0–3 years of age. The method was in line with Arksey and O’Malley’s framework, and 11 research articles regarding oxygen treatment were included. The main results are presented as three key findings: 1) overview of assessing the need for oxygen based on the use of pulse oximetry, 2) overview of oxygen treatment, and 3) overview of the need for educational intervention. In conclusion, there is a shortage of research literature to guide nurses in assessment of oxygen requirements, and administration of oxygen treatment in critically ill children. Consensus and guidelines are needed, as there are variations in practice regarding oxygen treatment.

Keywords

nursing assessment oxygen assessment oxygen therapy pediatric intensive care scoping study

Introduction

Oxygen was discovered in the late 17th century and is considered to be the molecule of greatest importance for human beings.¹ In hospitals, oxygen is the most frequently administered medication to children in-patients^2,3 and it is considered a potent and potentially toxic drug.^4,5 It is a fact that the toxic nature of oxygen has been a cause for concern for more than 200 years, and that too much oxygen in arterial blood, hyperoxia, is caused by healthcare professionals, as it does not occur in nature.⁶ Healthcare professionals need to be aware that too much oxygen supplementation may cause hyperoxia,⁷ and that excessive oxygen is the only cause for hyperoxia in critically ill infants.⁸ In clinical practice, uncritical usage of supplemental oxygen and limited knowledge regarding hyperoxia have both been observed. Oxygen should be administered according to the patient’s requirements, but this is not always done in practice.³

Challenges related to hyperoxia

In neonates at birth the normal limit for arterial pressure of oxygen (PaO₂) is 8.0–10.7 kPa and in children it is 10.7–13.3 kPa.⁹ Thus, hyperoxia is defined as arterial oxygen tension above 10.7 kPa in full-term newborns,¹⁰ and above 13.3 kPa among children.^9,11 Oxygen toxicity can result from high levels of the fraction of inspired oxygen (FiO₂), which increases the risk of absorption atelectasis¹² and may lead to vasoconstriction, lower heart rate and increased blood pressure.^1,13 Hyperoxia leads to free oxygen radicals as a result of more oxygen molecules being added than each hemoglobin molecule can carry.^4,14 This may lead to oxidative stress, defined as an imbalance between prooxidant and antioxidant forces in the body.¹⁵ Oxidative stress is associated with both tissue damage and DNA damage, and cell death is a prominent feature of hyperoxia-induced lung injury.^4,16,17 Additionally, hyperoxia may lead to the release of a cascade of harmful chemicals in certain parts of the brain, possibly influencing central nervous functions.¹³ Research indicates a possible association between administering high levels of FiO₂ and increased hospital mortality in critically ill patients.¹⁸ However, there seems to be more awareness about the risk of hyperoxia in premature newborns and less attention is paid to full-term newborns.¹⁹

Assessing the oxygen treatment

Physicians have a legal responsibility for oxygen treatment,⁷ but nurses are responsible for titrating oxygen within prescribed limits of oxygen saturation.^20,21 Both theoretical and practical knowledge of pulse oximetry are necessary during assessment of oxygen requirements in pediatric patients.²² In addition, the placement of the oximetry probe is important.^23–25 Pulse oximetry alone has its limitations,²² therefore the best method to both assess oxygen requirements, and detect hyperoxia or hypoxia is by assessing the arterial blood gases.²⁶ The accuracy even of newer generations of pulse oximeters is poor when used on newborn infants.²⁷ Clinical conditions such as low perfusion, patient motion artifacts, cardiac arrhythmias and shivering could also result in poor signal quality of the pulse oximeter.²⁸ In order to assess oxygenation correctly, an understanding of the hemoglobin–oxygen dissociation curve (Hb–O₂ curve) and of the relationship between PaO₂ and oxygen saturation (SpO₂) is required.²¹ The dynamic of the Hb–O₂ curve will depend on pH, arterial pressure of carbon dioxide (PaCO₂), PaO₂, temperature, hemoglobin and the enzyme 2,3-diphosphoglycerate.²⁹ As the Hb–O₂ curve refers to the hemoglobin affinity for oxygen, the hemoglobin will bind oxygen more strongly if PaO₂ is low, which results in less oxygen released to the tissue.²¹ Clinical observations and the patient’s condition may affect the results as well.³⁰ Nurses also need to be aware that changes to the child’s position could make a difference in the oxygenation status, as children have less ‘surface of gas exchange’ than adults.³¹

In addition, if nurses add oxygen without knowing that SpO₂ > 95% may lead to high levels of PaO_2, the child could be exposed to potential danger.³ Exposure to pure oxygen, even briefly when SpO₂ > 95%, is not recommended, and use of blenders could enable healthcare professionals to achieve FiO₂ control and avoid unnecessary use of 100% oxygen.⁴ The British National Formulary for Children recommends that SpO₂ is maintained at >92% among most critically ill children, but also points out that some clinicians may aim for a target of 94–98%.³² Appropriate oxygenation in ventilated children could be achieved by titrating FiO₂ and regulating the mean airway pressure (MAP). To regulate MAP, the physician may use peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP) or inspiratory time (TI).^7,19 Since physicians have the legal responsibility for decision-making in patient treatment and the opportunity to delegate responsibility to nurses, interprofessional collaboration is a necessity.⁷

To summarize, there is a great deal of information available about the significance and risks of using oxygen in premature newborns. We also know that the use of pulse oximetry to assess patients’ need for oxygen has its limitations. In children aged 0–3 years, however, we see that there is uncritical usage of supplemental oxygen and limited knowledge regarding hyperoxia. The aim of this study was therefore to synthesize evidence that could contribute to safe and appropriate oxygen treatment in children 0–3 years of age. The research questions were:

What is known from existing literature about oxygen treatment in children aged 0–3 years receiving supplemental oxygen?

What does the evidence tell us about how to improve nurses’ knowledge of assessing children’s need for oxygen?

Method

This article is based on a scoping study of current research literature. A scoping study is used to explore gaps, and map key concepts and types of evidence in research related to a defined field or area by systematically searching for, selecting and synthesizing existing knowledge.³³ This methodology is appropriate to synthesize evidence that can influence guidelines and practice,³³ in this case in pediatric intensive care units (PICUs). Scoping studies also tend to focus on the breadth rather than the depth of literature,³⁴ and many different study designs might be applicable.³⁵ When searching for literature, the methodological framework outlined in Arksey and O’Malley was adapted, which means a five-stage approach: 1) identifying the research question, 2) identifying relevant studies, 3) study selection, 4) charting data, 5) collating, summarizing and reporting the results.³⁵

Eligibility criteria

Articles were included if they contained information about oxygen treatment of children aged 0–3 years, between 2004 and February 2016. Also included were articles with information about how to improve nurses’ knowledge of assessing patients need for oxygen. Studies conducted on premature children were included if they covered nursing assessment in oxygen treatment directly transferable to full-term newborns (0 years of age).

Articles were excluded if they lacked relevance from a nursing perspective, such as manikin, in vitro studies and animal studies. Furthermore, articles that focused on oxygen therapy and different medical conditions such as acute respiratory failure and congenital heart disease, or articles that compared different pulse oximeters, were excluded. The searches were also limited to articles in English or Scandinavian languages.

Literature search to identify relevant studies

Eligible articles were identified using electronic health research databases: Medline, EMBASE and CINAHL. Search terms included both medical subject headings (MeSH) and keywords, and Boolean operators (OR, AND) were used to expand and narrow searches. The truncated search terms child*, oxygen* and assess* were also used. Systematic searches, including single and combined search terms, through various databases were conducted, both with and without a librarian present. Relevant studies were also identified by checking reference lists as recommended in the framework in Arksey and O’Malley.³⁵ The literature searches were carried out during the period October 2015 to February 2016, and the search terms are listed in Table 1.

Table 1.

Single and combined search terms.

• Pediatric/intensive care units • Pediatric nursing/pediatric intensive care nursing • Intensive care/newborn intensive care • Emergency nursing/intensive care/critical care • Child/infant/neonate/newborn/preschool/toddler • Oxygen/oxygen inhalation therapy • Respiration, artificial • Pulse oximetry/blood gas analysis/blood gas monitoring, transcutaneous • Oxidative stress

• Respiratory physiological phenomena/respiratory physiological processes/pulmonary ventilation • Decision making/choice behavior • Professional competence/clinical competence • Nursing assessment • Nursing diagnosis • Nurse’s role/nursing role • Nurse/nurses/nursing

Study selection

The literature search produced a total of 1653 articles. We performed the first-level selection of literature by reading through all the titles, and also abstracts where the title did not clearly state the content of the article. At this step, we excluded comments, letters, conference notes and editorial articles, thus narrowing down the selection of articles to 40. Articles were only included if they addressed any aspect that could contribute to awareness of how nurses may evaluate safe and appropriate oxygen treatment in children. At the second-level selection, we discarded 10 duplicate articles. The remaining 30 articles were then read thoroughly, and after this third-level selection we were left with 11 research articles to include in our scoping study. The included literature was read thoroughly by the first author, judged using standard Norwegian checklists for research articles, following their recommendations regarding aim, research questions, research design and data collection.³⁶ The checklists have been developed by the national Public Health Institute’s Centre of Knowledge for the Health Service to evaluate the methodological quality and the reliability of results within research articles.³⁶ The 11 articles were deemed of high enough quality to include in the study.

Collating, summarizing and reporting the results

This stage involved mapping key items of information obtained from research literature as recommended in the scoping study framework.³⁵ We took a narrative approach during the reading process, to identify key themes. In order to present an overview of existing literature, we needed some thematic categories,^35,37 and so we organized the included literature according to their key findings. Subsequently we collated and summarized all information in tables, including author(s), aim, design and methodology, study population, and key findings based on the framework’s approach.³⁵

Results

The main finding is that only five articles have been published regarding oxygen treatment in children 0–3 years of age (Table 2).^{23–25,38,39} All of these articles address the use of pulse oximetry. In addition we included three articles related to Neonatal Intensive Care Units (NICUs) because they answered our research question about assessment of oxygen treatment in newborns (Table 3).^19,21,40 We also included three articles that highlighted how to improve nurses’ knowledge of assessing critically ill patients’ oxygen requirements (Table 4).^41–43 The results are reported in two ways: first in tables, which summarize the key findings from each article, followed by a description of the findings.

Table 2.

Overview of assessing the need for oxygen based on the use of pulse oximetry.

Author(s)	Aim	Design and method	Key findings
Popovich, Richiuso and Danek, 2004	To measure the knowledge in pediatric healthcare professionals regarding pulse oximetry and clinical interpretation of the data given.	Survey design including multiple choice (MCQ) and open-ended questions. N = 66 pediatric healthcare professionals (15 physicians, 42 nurses, 9 respiratory practitioners).	There is a lack of knowledge of basic principles in assessing the need for oxygen. The healthcare professionals need education about pulse oximetry technology and an understanding of the Hb–O₂ curve.
Sedaghat-Yazdi, Torres, Fortuna et al., 2008	To assess the effect of sensor location on pulse oximeter accuracy in critically ill children.	Prospective, observational study design with consecutive sampling. N = 50 children (0–2 years of age) admitted to PICU.	In critically ill children with SaO₂ <90% healthcare professionals need to know that SpO₂ measurements on toes or fingers are more accurate than on the sole of the foot, or the palm of the hand.
Bilan, Behbahan, Abdinia et al., 2010	To find the most reliable placement of the pulse oximeter probe.	Cross-sectional comparative study design. Measurements from ear, thumb and big toe were compared with arterial blood gas (ABG). N = 200 pediatric patients (90 aged <1 month and 110 aged >1 months).	Healthcare professionals need to know that SpO₂ measurements from the ear are the most reliable, with thumb measurements second, and measurements from the big toe the least reliable compared to SaO₂ and arterial blood gases.
Fouzas, Politis, Skylogianni et al., 2010	To assess knowledge of pulse oximetry among pediatric healthcare providers.	A multicenter survey design based on MCQ. N = 505 pediatric healthcare professionals from 19 hospitals.	There was a lack of knowledge about the use and limitations of pulse oximetry.
Safar and El-dash, 2015	To investigate if wrist and ankle could be alternative placement sites during pulse oximetry measuring of critical ill children.	A prospective observational study design. N = 94 children admitted to NICU or PICU, aged 1–8 months.	In critically ill children, healthcare professionals need to know that wrists and ankles can be alternative placement sites for measurement of SpO₂ instead of the routinely used palm or sole.

Table 3.

Overview of oxygen treatment.

Author(s)	Aim	Design and method	Key findings
Solberg, Hansen and Bjørk, 2011	To explore nurses’ opinions on how they assess oxygen requirement in ventilated infants receiving supplemental oxygen.	Survey design with descriptive statistics. N = 111 nurses working at NICUs.	There was a gap between the literature criteria versus the criteria nurses perceived they were using during assessment of oxygen treatment.
Solberg, Bjørk and Hansen, 2013	To assess the quality of current care regarding oxygenation and ventilation parameters in newborns receiving mechanical ventilation.	Single center, retrospective chart review design. N = The intensive care charts of 138 newborns where study was based on a target range of charted oxygenation and ventilation parameters.	There is a low prevalence of high PaO₂ values in premature newborn children, which increased significantly with gestational age. There was no significant correlation between MAP variability and PEEP, suggesting that PEEP was not used to improve oxygenation.
Tan, Mulder, Lopriore et al., 2015	To evaluate the practice in oxygenation and gas exchange monitoring.	An online survey-based questionnaire design. N = 47 healthcare professionals from 10 different NICU centers.	All healthcare professionals indicated a lack of guidelines concerning oxygenation monitoring. SpO₂, PaO₂ and SaO₂ were used by respectively, 100, 80 and 27% for monitoring oxygenation, and 76% considered pulse oximetry, 22% pO₂ and 2% SaO₂ as the best parameter to assess the need for oxygen.

Table 4.

Overview of the need for educational intervention.

Author(s)	Aim	Design and method	Key findings
Considine, Botti and Thomas, 2005	To examine the effect of education intervention related to oxygen administration decisions.	A pre-test/post-test, controlled, quasi-experimental design, including MCQ and self-directed learning package. N = 88 emergency nurses (37 participants in the control group and 51 in the experimental group).	There was a significant correlation between educational interventions and increased understanding and knowledge about assessment of oxygenation and use of supplemental oxygen.
Considine, Botti and Thomas, 2007	To examine the effect of education intervention related to oxygen administration decisions.	A controlled pre-test/post-test quasi-experimental design, MCQ. N = 88 emergency nurses, control group n = 37 and experimental group n = 51. Subgroups also participated in the patient scenarios (n = 20) and clinical practice observation (n = 10).	To make decisions regarding oxygen administration, the nurses need factual knowledge developed through educational intervention about the therapeutic use of supplemental oxygen.
Pirret, 2007	To assess the level of knowledge of respiratory physiology among ICU nurses and their ability to provide rationale for their clinical decision-making.	Evaluation methodology design based on multiple methods. Quantitative analysis, including interviews based on semi-structured questionnaire. N = 27 ICU nurses.	There is a lack of knowledge regarding respiratory physiology. Nurses rely heavily on experience-based knowledge instead of an analytic approach. Closer cooperation between the education sector and the clinical field is required in order to improve nurses’ theoretical knowledge and clinical decision-making.

The main findings from this scoping study are articles which present pulse oximetry as a noninvasive tool to assess the need for oxygen in children.^22–24,38 In order to rely on the monitored saturation, the authors emphasize the impact of correct probe placement.^22,23,25 In addition, both theoretical and practical knowledge of pulse oximetry are needed during assessment of oxygenation in pediatric patients.^24,38 There seems to be a gap between literature recommendations and existing knowledge among pediatric healthcare professionals regarding the use of pulse oximetry^22,38 and correct understanding of the Hb–O₂ curve.^21,38 This highlights the necessity of an adequate knowledge base for nurses, enabling them to make appropriate assessments during oxygen treatment of critically ill children.

Assessment of oxygen requirement in children is based on insufficient information among nurses.²¹ In order to improve oxygenation in newborns, one study found that there was no significant correlation between MAP variability and PEEP, which suggests that changing PEEP was not used as a strategy to adjust MAP.¹⁹ Furthermore, newborns at term were at higher risk for hyperoxia than preterm, as low prevalence of high PaO₂ values in premature infants increased significantly with gestational age.¹⁹ This could indicate greater knowledge and awareness of the toxic effect of high oxygen concentrations on the prematurely newborn, with less attention being paid to full-term newborns. But a wide variation in preference in oxygenation monitoring exists both within and between units.²⁶

The scoping study found that educational interventions contribute to an increased understanding and knowledge of the complexity of the respiratory system.^41–43 There is a need for an analytical approach to nurses’ assessment in order to contribute to professionally sound decision-making.⁴³ In addition, a closer relationship between the clinical field and the education programs in developing nurses in intensive care units (ICUs) is found to be important.⁴³

Discussion

Assessing oxygenation based on the use of pulse oximetry

We found that one characteristic of assessing oxygenation is a high reliance on the use of pulse oximetry^21,26 and that the placement of the probe influences the result (Tables 2 and 3).^23-25 Taking SpO₂ measurements on toes or fingers might be more accurate than on the sole of the foot, or palm of the hand.²⁴ Furthermore, SpO₂ measurements on the ear appear to be the most reliable, with thumb measurements second, and measurements on the big toe the least reliable compared to saturation in arterial blood gases (SaO₂).²³ Nurses also need to be aware that wrists and ankles can be alternative placement sites for measurement of SpO₂.²⁵ When faced with a range of different recommendations, it can be difficult for the nurse to know which results can be relied upon. A study indicates that educated ICU nurses seem to have more basic SpO₂ knowledge based on their ability to correctly assess pulse oximetry values within the context of technological limitations.²⁸ As pulse oximetry alone has its limitations²² arterial blood gas analysis is the most important and reliable way to assess oxygen requirements in critically ill patients.^26,44,45 It is worrying that, despite the known limitations of using pulse oximetry, the majority of the articles we found on children had this as their main focus. This highlights the need for more articles about the more reliable methods of assessing oxygen requirements.

When assessing blood gases together with the SpO₂, nurses in PICUs also need to be familiar with the dynamic of the Hb–O₂ curve.^4,46 For example, if a newborn has no clothes on during procedures and therefore gets cold, there may be metabolic consequences for the child, such as increased oxygen consumption.⁴⁷ Since newborns have a lot of fetal hemoglobin, the oxygen will have a stronger binding to the hemoglobin,⁴⁸ and when coinciding with hypothermia this leads to a curve tilted leftward, which could lead to quickly reduced SpO₂ levels.^4,21 In clinical practice, nurses have been observed adding or increasing FiO₂ without checking the child’s temperature and the dynamic of the Hb–O₂ curve. If oxygen is added without increasing the body temperature, the oxygen treatment may be inappropriate. Thus, the challenge becomes titrating correct FiO₂ by considering the Hb–O₂ curve together with the clinical condition of the child to prevent hypoxia as well as hyperoxia. It is also necessary to avoid fluctuations of SpO_2, therefore titration should be performed with caution³ and if an increase of 10% is much more than needed, hyperoxia occurs in seconds.⁴⁹ According to legislation, nurses should prevent patients being harmed by the treatment provided,⁵⁰ and by considering all aspects of respiratory physiology, the child’s position, state of illness and clinical condition, one will practice nursing based on an analytical approach at a high cognitive level.

Oxygen assessment, and the need for educational intervention

We discovered that lack of knowledge was a consistent finding from this scoping study, including of respiratory physiology,⁴³ basic principles in assessing oxygenation,³⁸ the use and limitations of pulse oximetry,²² criteria regarding blood gases sampling,⁴⁴ assessing criteria from the literature^21,26 and the use of PEEP to improve oxygenation in pediatric patients.¹⁹ We also identified a lack of guidelines concerning oxygenation monitoring,²⁶ and found that educational interventions that increase knowledge will further improve clinical decision-making regarding oxygenation assessment and use of supplemental oxygen (Table 4).^41,42

Knowledge of respiratory physiology and pathophysiology that increases professional expertise contributes to improved patient outcomes.⁴³ Furthermore, the ability to articulate analytical decision-making processes may enhance the clinical credibility of ICU nurses.⁴³ The understanding that prolonged oxygen treatment could be harmful to premature infants dates back over 60 years, but recently we have come to realize that even brief exposure to oxygen causes damage to full-term newborns as well.⁵¹ Since few studies have been conducted regarding oxygen requirements in children 0–3 years of age, it is challenging to assess children given supplemental oxygen. Nevertheless, it has been possible to detect the toxic effects of oxygen in adults for over 40 years,⁵² and Saugstad has documented the adverse effects of oxygen in premature and sick newborns between the same decade and the present date.¹⁷ Therefore, nurses may be able to assess safe and appropriate oxygen treatment according to need based on literature recommendations and an analytical approach rather than experience-based judgment alone.

Findings from this scoping study indicate a wide variety of preferences in oxygenation monitoring both within and between units, and a lack of guidelines (Table 3).²⁶ Although clear guidelines combined with the development of clinical judgment are recommended on a general basis,⁵³ and despite the toxic nature of oxygen, it is a paradox that no consensus exists, nor evidence to guide nurses during administration of oxygen in full-term newborns.¹⁹ Sola et al. argue that if oxygen had been discovered today, national and international drug agencies would have prepared stricter guidelines for the use of supplemental oxygen.⁴ Developing guidelines that are evidence-based as well as practical, can contribute to establishing consensus regarding administration and titration of oxygen treatment in critically ill children.²⁶ In order to ensure the quality of oxygen treatment, established criteria are needed.⁵⁴ Additionally, increased knowledge gained through educational interventions seems to be necessary.^41,42 Researchers also emphasize that clinical practice should be based on empirical data instead of old traditions.⁵³

There are limitations to this study. Only the first author has performed the selection of included articles, and gone through checklists in order to judge the included articles’ aim, research questions, research design, and data collection. Nevertheless, tables 2 –4 show that the included articles present a specific aim, sample size and important key findings.

Conclusion

Based on the findings of the articles included in this scoping study, nurses need factual knowledge developed through educational intervention in order to safely administer supplemental oxygen. When assessing oxygen treatment, an analytical approach is preferred, using pulse oximetry, arterial blood gases analysis, the dynamic of the Hb–O₂ curve, respiratory physiology and the patient’s clinical condition. This study concludes that there is a shortage of research literature to guide nurses in assessment of oxygen requirements, and administration of oxygen treatment in critically ill children. Consensus and guidelines are needed, as there are variations in practice regarding oxygen treatment.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare that there is no conflict of interest.

References

Rousseau

Sjöberg

. The time of uncritical oxygen treatment is over. Läkartidningen 2006; 103: 1100–1104.

Pease

. Oxygen administration: is practice based on evidence? Paediatr Nursing 2006; 18: 14–8.

Sola

Saldeno

Favareto

. Clinical practices in neonatal oxygenation: where have we failed? What can we do? J Perinatol 2008; 28(Suppl 1): S28–34.

Sola

Rogido

Deulofeut

. Oxygen as a neonatal health hazard: call for detente in clinical practice. Acta Paediatr 2007; 96: 801–812.

Vento

. Oxygen supplementation in the neonatal period: changing the paradigm. Neonatology 2014; 105: 323–331.

Sola

Golombek

Montes Bueno

et al.

Safe oxygen saturation targeting and monitoring in preterm infants: can we avoid hypoxia and hyperoxia?

Acta Paediatr 2014; 103: 1009–1018.

Solberg

. Interprofessional collaboration in management of ventilated premature and sick newborns: perspectives on ventilator treatment practices, Oslo: Institute of Health and Society, Faculty of Medicine, University of Oslo, 2015.

Bancalari

Claure

. Control of oxygenation during mechanical ventilation in the premature infant. Clin Perinatol 2012; 39: 563–572.

Kline-Tilford

Sorce

Levin

et al.

Pulmonary disorders. In: MF

Hazinski

(ed). Nursing care of the critically ill child, St Louis, MO: Elsevier, 2013, pp. 483–561.

10.

Randolph

. Management of acute lung injury and acute respiratory distress syndrome in children. Crit Care Med 2009; 37: 2448–2454.

11.

Merenstein

Gardner

. Merenstein & Gardner’s handbook of neonatal intensive care, Maryland Heights, MO: Mosby Elsevier, 2016.

12.

Slota

Bioinstrumentation: principles and techniques. In: MF

Hazinski

(ed). Nursing care of the critically ill child, St Louis, MO: Elsevier, 2013, pp. 961–1042.

13.

Macey

Woo

Harper

. Hyperoxic brain effects are normalized by addition of CO₂. PLoS Med 2007; 4: e173.

14.

Guerra-Wallace

Casey

3rd Bell

et al.

Hyperoxia and hypoxia in children resuscitated from cardiac arrest. Pediatr Crit Care Med 2013; 14: e143–148.

15.

Walsh

Brooks

Grenier

. Oxygen therapy in the neonatal care environment. Respir Care 2009; 54: 1193–1202.

16.

Altemeier

Sinclair

. Hyperoxia in the intensive care unit: why more is not always better. Curr Opin Crit Care 2007; 13: 73–78.

17.

Saugstad

. Oxidative stress in the newborn: a 30-year perspective. Biol Neonate 2005; 88: 228–236.

18.

de Jonge

Peelen

Keijzers

et al.

Association between administered oxygen, arterial partial oxygen pressure and mortality in mechanically ventilated intensive care unit patients. Crit Care 2008; 12: R156.

19.

Solberg

Bjørk

Hansen

. Adherence to oxygenation and ventilation targets in mechanically ventilated premature and sick newborns: a retrospective study. BMC Pediatr 2013; 13: 126.

20.

Johnson

Scott

Fraser

. Oxygen use for preterm infants: factors that may influence clinical decisions surrounding oxygen titration. Adv Neonatal Care 2011; 11: 8–14. quiz 5–6.

21.

Solberg

Hansen

Bjørk

. Nursing assessment during oxygen administration in ventilated preterm infants. Acta Paediatr 2011; 100: 193–197.

22.

Fouzas

Politis

Skylogianni

et al.

Knowledge on pulse oximetry among pediatric health care professionals: a multicenter survey. Pediatrics 2010; 126: e657–662.

23.

Bilan

Behbahan

Abdinia

et al.

Validity of pulse oximetry in detection of hypoxaemia in children: comparison of ear, thumb and toe probe placements. Eastern Mediterr Health J 2010; 16: 218–222.

24.

Sedaghat-Yazdi

Torres

Jr Fortuna

et al.

Pulse oximeter accuracy and precision affected by sensor location in cyanotic children. Pediatr Crit Care Med 2008; 9: 393–397.

25.

Safar

El-dash

. Pulse oximetry: could wrist and ankle be alternative placement sites? Clin Pediatr (Phila) 2015; 54: 1375–1379.

26.

Tan

Mulder

Lopriore

et al.

Monitoring oxygenation and gas exchange in neonatal intensive care units: current practice in the Netherlands. Front Pediatr 2015; 3: 94.

27.

Solevag

Solberg

Saltyte-Benth

. Pulse oximetry performance in mechanically ventilated newborn infants. Early Hum Dev 2015; 91: 471–473.

28.

Giuliano

Liu

. Knowledge of pulse oximetry among critical care nurses. Dimens Crit Care Nurs 2006; 25: 44–49.

29.

Solberg MT. Utfører sykepleiere faglig forsvarlig vurdering av premature barns oksygenbehov? (MA thesis). Oslo: University of Oslo, 2008.

30.

Bakkelund

Thorsen

Pulmonal monitorering. In: Gulbrandsen

Stubberud

(eds). Intensivsykepleie, Oslo, Norway: Akribe, 2010, pp. 281–269.

31.

Bradshaw

Turner

Pierce

Physiologic monitoring. In: G

Merenstein

Gardner

Carter

et al. (eds). Merenstein & Gardner’s handbook of neonatal intensive care, Maryland Heights, MO: Moseby Elsevier, 2016.

32.

BNF for children. Oxygen, https://www.medicinescomplete.com/mc/bnfc/current/PHP78543-oxygenhtm?q=oxygen&t=search&ss=text&p=1#_hit (2016, accessed 1 February 2016).

33.

Colquhoun

Levac

O’Brien

et al.

Scoping reviews: time for clarity in definition, methods, and reporting. J Clinic Epidemiol 2014; 67: 1291–1294.

34.

Rumrill

Fitzgerald

Merchant

. Using scoping literature reviews as a means of understanding and interpreting existing literature. Work 2010; 35: 399–404.

35.

Arksey

O’Malley

. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005; 8: 19–32.

36.

Nasjonalt Kunnskapsenter for helsetjenesten. Sjekklister for vurdering av forskningsartikler, http://www.kunnskapssenteret.no/verktoy/sjekklister-for-vurdering-av-forskningsartikler (2014, accessed 1 February 2016).

37.

Levac

Colquhoun

O’Brien

. Scoping studies: advancing the methodology. Implement Sci 2010; 5: 69.

38.

Popovich

Richiuso

Danek

. Pediatric health care providers’ knowledge of pulse oximetry. Pediatr Nurs 2004; 30: 14–20.

39.

Fouzas

Politis

Skylogianni

et al.

Knowledge on pulse oximetry among pediatric health care professionals: a multicenter survey. Pediatrics 2010; 126: e657–662.

40.

Tan

Mulder

Lopriore

et al.

Monitoring oxygenation and gas exchange in neonatal intensive care units: current practice in the Netherlands. Front Pediatr 2015; 3: 94.

41.

Considine

Botti

Thomas

. The effect of education on hypothetical and actual oxygen administration decisions. Nurse Educ Today 2007; 27: 651–660.

42.

Considine

Botti

Thomas

. Effect of a self-directed learning package on emergency nurses’ knowledge of assessment of oxygenation and use of supplemental oxygen. Nurs Health Sci 2005; 7: 199–208.

43.

Pirret

. The level of knowledge of respiratory physiology articulated by intensive care nurses to provide rationale for their clinical decision-making. Intens Crit Care Nurs 2007; 23: 145–155.

44.

Andrews

Waterman

. What factors influence arterial blood gas sampling patterns? Nurs Crit Care 2008; 13: 132–137.

45.

Lynch

. Arterial blood gas analysis: implications for nursing. Paediatr Nurs 2009; 21: 41–44.

46.

Saugstad

. Take a breath: but do not add oxygen (if not needed). Acta Paediatr 2007; 96: 798–800.

47.

Steinnes

Hovde

Det akutt kritisk syke barnet. In: BS

Tandberg

Steinnes

(eds). Nyfødtsykepleie 2: syke nyfødte og premature barn, Oslo, Norway: Cappelen Damm AS, 2009, pp. 190–223.

48.

Haaland

Medisinske problemer knyttet til umodenhet. In: BS

Tandberg

Steinnes

(eds). Nyfødtsykepleie 2: Syke nyfødte og premature barn, Oslo, Norway: Cappelen Damm AS, 2009, pp. 15–26.

49.

Sola

. Oxygen in neonatal anesthesia: friend or foe? Curr Opin Anaesthesiol 2008; 21: 332–339.

50.

Norwegian Ministry of Health and Care Service. LOV-1999-07-02-64: Lov om Helsepersonell [Health personnel act], Oslo, Norway: Norwegian Ministery of Healt and Care Service, 1999.

51.

Saugstad

. Kronikk – Oksygen til nyfødte? Tidsskr Nor Laegeforen 2011; 131: 2488.

52.

Nash

Blennerhassett

Pontoppidan

. Pulmonary lesions associated with oxygen therapy and artifical ventilation. N Engl J Med 1967; 276: 368–374.

53.

Flynn

Sinclair

. Exploring the relationship between nursing protocols and nursing practice in an Irish intensive care unit. Int J Nurs Pract 2005; 11: 142–149.

54.

Mellingen

Langeland

Graue

. Oksygenbehandling til barn på sykehus. Sykepleien Forskning 2016; 2: 127–133.

Oxygen treatment of critically ill children: A lack of evidence

Abstract

Keywords

Introduction

Challenges related to hyperoxia

Assessing the oxygen treatment

Method

Eligibility criteria

Literature search to identify relevant studies

Study selection

Collating, summarizing and reporting the results

Results

Discussion

Assessing oxygenation based on the use of pulse oximetry

Oxygen assessment, and the need for educational intervention

Conclusion

Footnotes

Funding

Conflict of interest

References