Running Head: NEAR-INFRARED SPECTROSCOPY NICU

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Near-Infrared Spectroscopy Monitoring in the Neonatal Intensive Care Unit: Changing provider
comfort and confidence
Danial Zepplin
Arizona State University College of Nursing and Health Innovation

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Abstract
Purpose: The purpose of this quality improvement (QI) project was to assess provider (MD and
Neonatal Nurse Practitioners (NNP)) comfort and confidence with Near-infrared Spectroscopy
(NIRS) monitoring on Newborn Intensive Care Unit (NICU) patients when provided with an
educational teaching session.
Background and Significance: NIRS data can be used in conjunction with standard vital sign
monitoring to help clinicians understand blood flow and metabolic demands of organ systems,
particularly cerebral, renal, and mesenteric blood flow patterns. A NICU unit in the
northwestern US adopted NIRS use on their patients in 2008, however, NIRS monitoring usage
decreased over the past 5 years, citing a lack of continued education and comfort interpreting and
managing NIRS monitored patients. One patient was monitored with NIRS in the year prior to
the QI project.
Methods: A 5 point Likert-Type survey was designed to examine provider comfort and
confidence using and interpreting NIRS on NICU patients. No Croanbach’s alpha value exists
for the survey as it was purposefully designed for the QI project. An educational presentation on
the use and interpretation of NIRS on NICU patients was created and delivered during a formal
provider staff meeting. Pre and Post education surveys were distributed electronically to
participants and were presented 1 week prior to educational session and 1 month after
educational session. IBM SPSS version 23 was used for descriptive statistics, paired t tests, and
Wilcoxon test. Significance set to p<0.05.
Results: In total, 18 providers (N=18) were surveyed, and 13 paired survey results (n=13) were
received (8 MD and 5 NNP). Paired-samples t tests were calculated to compare the mean total
score (TS) for pre/post comfort and pre/post confidence. This was a significant improvement for
both comfort (t(11) = -3.13, p=0.010) and confidence (t(11) = -3.37, p=0.006). Wilcoxon test
showed a significant increase in the times a provider managed a patient with NIRS (z=-2.762,
p=0.006). The number NIRS monitored patients increased from one in the previous year to 15
patients in the 5 months of data tracking, a clinically significant increase.
Conclusions: Providing educational session on previously utilized clinical applications can
improve providers comfort and confidence and influence their usage in clinical practice. Future
continuing education sessions could be designed for different clinical applications in order to
keep clinicians abreast of the current evidenced based applications of advanced clinical monitors.
Keywords: NIRS, NICU, Comfort, Confidence, Likert-type survey, Quality Improvement

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Neonatal intensive care units help to provide care and support to infants born both prematurely
and those with illness or infection. Complex vital sign monitoring is required to maintain
homeostasis and indicate times for needed interventions. Routine vital sign monitors may be
inadequate at capturing end organ demands in vulnerable neonatal populations. Current
noninvasive blood pressure monitoring gives a momentary picture of hemodynamic stability and
does not provide continuous moment to moment feedback that a dynamic critically ill neonate
can require (Greison, Leung, & Wolf, 2011). Near-infrared spectroscopy monitoring may
provide practitioners with additional information to better care for at risk neonatal populations.
Problem Statement
Preterm and vulnerable term infants in neonatal intensive care units (NICU) are at risk for
cerebral, renal, and mesenteric hypotension making them susceptible to intraventricular
hemorrhage (IVH), feeding intolerance, necrotizing entrocolitis (NEC) and acute renal failure.
Current monitoring of standard vital signs may not be capable of accurately identifying this end
organ hypoperfusion. Regional saturation monitors, also known as near-infrared spectroscopy
monitors (NIRS), are currently available within NICUs to monitor regional saturations across
time (Sood, McLaughlin, & Cortez, 2015), however, the medical team in a northwestern city
cites a lack of education related to the use and benefits of the monitors preventing them from
using them on high-risk NICU patients. Centers across the nation caring for similar acuity
infants utilize NIRS monitors on patient populations that are at higher risk for systemic
hypotenison/hypoxia such as infants with congenital cardiac defects (Chock, Rose, Mante, &
Punn, 2016, & Gillam-Krakauer et al., 2013). The SafeBoosC clinical trials established
treatment guidelines for the use of NIRS in NICU patients for monitoring cerebral tissue
oxygenation (Pellicer et al., 2013) and have been able to show reductions in cerebral oxygen debt

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associated with hypoperfusion (Hyttel-Sorensen, et al., 2013 ). Though exact numbers of infants
who experience hypotension is not known given our current monitoring systems, data regarding
infants who require blood pressure medications has been researched. Laughon et al. (2010)
examined extremely low birth weight infants showed that 90% of 23 week infants and 89% of 27
week infants required some form of blood pressure supportive measures within the first 24 hrs of
life. Review of the electronic medical record at the northwestern NICU showed there have been
zero prescribed uses of the NIRS monitor for the previous year.
Purpose and Rationale
Currently, a level 4 non-complex cardiac care, non-ECMO NICU in the northwestern
United States has NIRS monitors available, however, does not use them because of lack of
practitioner education about the benefits and data output generated when monitoring cerebral,
renal, and mesenteric regional saturations. The NICU site cares for infants from 22 weeks
through post term and utilizes multiple monitors beyond standard vital sign monitoring including
amplitude electroencephalogram and transcutaneous carbon dioxide monitoring. Sood,
McLaughlin, and Cortex (2015) cited ten different NICU patient groups that use NIRS
monitoring including neonates with complex heart disease, preterm infants at risk for patient
ductus arterosis (PDA), and infants at high risk for IVH. Investigating the use of NIRS in the
NICU may provide additional data to better support infants at risk for systemic end organ hypo
perfusion and guide earlier interventions.
Background/Significance
There are groups of preterm and term infants that are at high risk for shunting blood flow
preferentially causing end organ hypo perfusion and hypoxia. The highest risk populations
include preterm (infants born less than 35 weeks), infants with cardiac defects, infants who have

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experienced intrauterine growth restriction (IUGR) and infants who have experienced hypoxic
ischemic events (HIE) (Blackburn, 2013; Gleason & Devaskar, 2012; Lin, Hagan, Fenoglio,
Grant, & Franceschini, 2016). These groups of infants could benefit from advanced vital sign
monitoring beyond the standard vital signs monitoring done on routine patients in neonatal
intensive care units (NICU). Current vital sign monitoring includes heart rate, respiratory rate,
oxygen saturation, temperature, blood pressure and pain. Near-infrared spectroscopy offers
additional vital sign monitoring by providing regional oxygen saturation data thus giving
information on both the blood flow and the metabolic needs of the end organ systems. Liu,
Chalak, and Lu (2014) cited that not being able to meet an end organs metabolic demands or a
states of end organ hypotension places infants at higher risk for IVH and long-term neurologic
deficits. Bozzetti et al. (2016) utilized NIRS to show that IUGR infants continued to shunt blood
flow preferentially to their brain over their GI tracts even after birth, a phenomenon not visible to
practitioners utilizing routine vital sign monitoring.
In current NICU practice, hypotension is defined as a mean blood pressure less than the
infant's gestational age in weeks. This is measured on a peripheral limb with a cuff or centrally
with an invasive blood pressure monitoring device such as an umbilical artery catheter. The
presence however of a hemodynamically significant patient ductus arteriosus (hsPDA) has the
potential to cause decreased the mean blood pressure downstream causing the blood pressure at
the level of the kidney to be less than the measured upper limb cuff blood pressure. Blood flow
to the end organ systems such as the kidneys cannot be measured by this technique and current
practice is to assume that if an infant is making urine then there is adequate blood flow to the
kidneys. Similarly, there is no direct measure of cerebral blood flow or cerebral oxygen
requirements. Preterm infants are at high risk for intracranial bleeding due to an inability to

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autoregulate their cerebral blood pressure as well as the presence of a highly vascular structure
known as the germinal matrix (Gleason & Devaskar, 2012). The germinal matrix exists in
preterm infants and is often the site for most intracranial bleeds where as in term infants this
structure has matured and is much less likely to be at risk for bleeding (Blackburn, 2013).
Near-infrared spectroscopy monitoring has been used in NICU patients as far back as
1985 (Greison, Leung, &Wolf, 2011), however, not until recent SafeBoosC Phase II clinical
trials (Riera, et al., 2016) and 2-center randomized controlled pilot study (Pichler et al, 2013)
were reference ranges established for infants. NIRS monitors provide real time end organ
saturation data allowing practitioners the ability to visualize the impact of interventions on end
organ blood flow (Greison, Leung, & Wolf, 2011). Regional saturation information is
determined by examining the difference between the arterial and venous oxygenated hemoglobin
molecules and the end organ uptake of oxygen also known as metabolic demand (Liao & Culver,
2014). There has been a surge in publications in the last five years pertaining to the use of NIRS
monitoring in NICU patients to help better guide both the resuscitation of preterm infants and
interventions to protect against end organ hypoprofusion including Pellicer, et al. (2013), Pichler,
et al. (2015), and Plomgaard, et al. (2016). Alderliestin et al. (2016) published NIRS reference
ranges for both term and preterm infants for the first three days of life enhancing practitioners
understanding of how the cerebral oxygen saturation changes overtime in infants. Kenosi et al.
(2015) provides an overview of current NIRS research and use in NICU patients as well as
suggesting future research regarding cerebral monitoring during the birth process.
Problem Statement
This inquiry has lead to the clinically relevant PICO question, "In Neonatologists and
Neonatal Nurse Practitioners, does providing education on the use and interpretation of Near-

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Infrared Spectroscopy monitoring on Newborn Intensive Care Unit patients affect their comfort
and confidence using and ordering NIRS and the frequency of ordering the intervention
compared to no formal education"?
Search Strategy
Searches were conducted utilizing Cumulative index of nursing and allied health
literature (CINAHL), PubMed, and the Cochrane Library. Keywords of NICU, Newborn, infant,
neonate, NIRS, near infrared spectroscopy, INVOS, monitoring, intervention, and education
were used. Initial CINAHL results (Appendix A) for search terms Infant or neonate and INVOS
or NIRS or near infrared spectroscopy produced 1,675 results and PubMed (Appendix B)
provided 55 results. Cochrane library (Appendix C) initial search for infant produced 40,087
results and was further narrowed using infant and NIRS or INVOS to 47 results. No initial
limiters were placed on the search results and no publication data limit. Further combining
search terms together produced 46 results through CINHAL (Appendix A), 55 results through
PubMed (Appendix B), and 47 results through Cochrane Library (Appendix C). One hundred
and forty eight studies were identified and duplicates were removed. Elimination criteria were
implemented including publication within the last 10 years, available in English, and full text
available. Thirty-nine studies were then selected for review.
Primary preference was given to studies of either systematic reviews or randomized
controlled trials. One systematic review and three randomized controlled trials are included in
the evaluation table (Appendix D). Multiple non-systematic reviews of the current use of NIRS
in the NICU were excluded though they provided background to the current uses and
implantation of NIRS protocols in neonatal care. The table (Appendix D) discusses the purpose
and significant findings of 10 of the 39 reviewed studies. The findings help establish how NIRS

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monitoring is currently utilized in NICU patients and additional research being done with NIRS
monitoring.
Critical Appraisal and Synthesis
Ten studies were included in this literature review; all studies were evaluated using the
rapid clinical appraisal tool from Melnyk and Fine-Overhold (2015) and their results are
presented in an evidence table for analysis (Appendix D). Included are two randomized
controlled trials (RCT), one extension of data gathered during an RCT, one systematic review
(SR), one prospective observational trial (POT), one non-aprori retrospective study (NPRS), two
observational cohort studies (OCS), one prospective observational study (POS), one case control
(CS), and one prospective case-control study (PCCS). The levels of evidence include one level
one, three level two, three level three, two level four and one level six, based on Melnyk and
Fine-Overhold (2015) classification of evidence, providing a range of study designs. Sample
sizes varied from 3 to 999 participants and the SR examined 229 studies. The ten studies
provided a good representation of current use of NIRS in NICU patients and provide reference
curves for the use NIRS on both term and preterm infants. The studies provide the clinical
background for addressing the PICO question explored in this examination. A synthesis table
(Appendix E) was created to illustrate the pertinent findings noted in the evidence table
(Appendix D).
All ten studies were published in the last five years and all completed within the NICU
setting. Most studies were published in Europe, with two studies being multicenter trials.
Homogeneity was noted in the demographics across studies with participants being both term
and preterm infants with similar ranging birth weights. APGAR scores assigned to patients at
both one and five minutes were homogenous across the sample.

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The study findings included establishing rScO2 reference plots for both term and preterm
infants from birth through transition and birth through first 72 hrs of life, a reduction in overall
oxygen debt (cerebral), the ability to monitor for hsPDA, and visualization of the physiologic
response of the mesenteric artery velocity in relation to feeding. Prior to rScO2 reference plots
being created clinicians interpreted NIRS data from unpublished reference ranges that were
established on well term infants. Cerebral oxygen debt, defined as the time spent outside of
expected rScO2 saturations ranges during newborn transition, was shown to be reduced when
resuscitation team members were able to view the real time NIRS monitoring data. The
hemodynamic status of an infant's PDA was shown to be able to be monitored with NIRS by
utilizing a ratio between simultaneously measured rScO2 and rSmO2 values. Lastly, rSmO2
monitoring was able to show the physiologic response feeding had on the blood flow to an
infant's gastrointestinal tract by monitoring the regional saturation and ultrasound velocity of the
mesenteric artery.
The primary variables measured included measurement of three different NIRS values,
rScO2, rSrO2, and rSmO2, the time domain, and detection of hemodynamically significant PDA.
Moderate homogeneity exits between the period analyzed across studies ranging from birth to
transition through birth to 72 hrs. All nine studies utilized INVOS monitors for data
measurement making for consistent comparison across studies. No validity or reliability was
stated for the INVOS measurements.
Conclusions about Evidence
Evaluation of the synthesis table (Appendix E) shows that NIRS monitoring provides
actionable data for clinicians when used on a variety of NICU patients. NIRS can be utilized to
monitor infants during birth transition, prompting clinicians to add or remove respiratory support

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in response to cerebral saturations. This can help reduce oxygen debt, an important concept for
preterm infants with reduced cerebral auto-regulation of blood flow and blood pressure.
Reducing the oxygen debt has the potential to then reduce IVH rates leading to better overall
neurologic outcomes though this potential has not yet been fully studied by utilizing the NIRS
monitor.
NIRS provides clinicians the ability to monitor physiologic parameters including the
status of an infant’s PDA, potentially saving the patient financially by reducing the frequency of
screening echocardiograms. The PDA status is monitored by measuring a ratio of the rScO2 and
rSmO2, giving medical providers’ additional information on cerebral oxygen debt and abdominal
blood flow patterns.
The creation of gestational age specific reference plots for expected rScO2 values over
time provides guidance to both medical staff and nursing for managing patients and
interventions. The SafeBoosC clinical trial (Riera, et al., 2016) established intervention
guidelines for saturations outside of the reference values and has been shown to reduce overall
oxygen debt and improve outcomes.
Though these highlighted clinical applications do not directly answer the PICO question
they provide the fundamental background for the current usefulness of NIRS in NICU patients.
Providing this NIRS background data, in conjunction with education on NIRS management, to
the medical team in the Northwestern NICU should assist in making a change in clinical practice
and ordering of NIRS monitoring.
Theoretical Framework
Near-infrared spectroscopy monitoring is a measure of a physiologic response to
changing conditions within the body, however, Kurt Lewin’s Change theory was chosen as a

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conceptual framework to guide this project as the focus is on changing the behaviors of the
participants. For this project, the participants are the medical team in the Northwestern NICU
and the behavior is the utilization of NIRS monitoring on their patients.
Change theory is a three-step process involving unfreezing, moving, and refreezing to
change behaviors and three major concepts driving forces, restraining forces and equilibrium
(Polt & Beck, 2015). Lewin discussed driving forces that influence organizations towards
change and restraining forces to remain the same, keeping the organization in a state of
equilibrium (Polt & Beck, 2015 & Lewin’s Change theory, n.d.). Unfreezing of a behavior must
first take place in which a new solution is found, then the influencing forces must be addressed,
before movement can happen on the behavior. Refreezing takes place when the new behavior is
integrated into practice creating a new state of equilibrium in the system.
The current state of equilibrium in the Northwestern NICU is one of little to no use of
NIRS on high risk neonates. To shift this to the goal of increased utilization the staff will need to
be willing to unfreeze, accept the education, and refreeze by integrating NIRS into their practice.
Key stake holders have been identified and have assisted in creating buy-in from the rest of
medical staff to overcome increase the driving force to moving. An educational intervention is
being proposed with a goal of decreasing the restraining forces that can negatively affect the
movement. Assessing the refreezing process and establish the use of NIRS in the NICU will be
done by a pre-and post-educational session surveying to assess the providers change in comfort
and behavior prescribing the use of NIRS.
Evidence Based Practice Model
Rosswurm and Larrabee (1999) evidenced based practice (EBP) model was chosen to
guide the implementation of the evidence. The model (Appendix F) involves six steps from

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exploring a clinical gap to maintenance of the intervention. Rosswurm and Larrabee EBP model
was chosen primarily for its focus on integration and maintenance of change beyond the initial
change process. Review of the Northwestern NICU's electronic medical record (EMR) shows no
orders for the use of NIRS monitoring, even with three dedicated monitors available for NICU
patients, showing the gap in clinical practice. The lack of education was cited as the problem
leading to the practice gap that linking the problem to the intervention laid out in step two of the
EBP model. Buy in from the medical team has been established, and best evidence was
reviewed and synthesized (Appendix E) relating to the use of the NIRS in NICU patients. Going
forward education will be designed and presented to the medical staff and the bedside RNs on
use and management of NIRS for at risk NICU patients.
Purpose Statement
The purpose of this quality improvement (QI) project was to increase provider (doctors
and neonatal nurse practitioners) comfort and confidence using, interpretering, and ordering
near-infrared spectroscopy (NIRS) monitoring on neonatal intensive care (NICU) patients. The
providers will benefit from the project by gaining improved knowledge leading to potentially
improved health outcomes for the patients in their care. The goal of the project is to see an
increase in the providers comfort and confidence and see an increase in the utilization of NIRS in
the NICU.
Methods
Intuitional review board (IRB) approval was applied for and granted from Arizona State
University and the northwestern NICU hospital to conduct the QI project. The QI project was
conducted at a single NICU site that cares for infants from 22 weeks through post term with a
wide range of children's specialty services. The NICU has a max census of 64 patients and an

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average daily census of 30-35 patients. The NICU had adopted the use of NIRS ~10 years ago
and the QI project required no financial budget as the NICU already owns the NIRS monitors to
be utilized for patient monitoring.
Eighteen doctors and NNPs were recruited for the project. The project design was an
interventional education session with a pre and post intervention survey and usage tracking of
clinical orders for a 3 month period, however, the tracking phase was extended to 5 months. The
primary investigator was the only team member supporting the project and was available to
support the providers by phone and in person.
An educational session was designed and delivered to the providers by the primary
investigator. The session consisted of a PowerPoint, handouts, and question and answer period.
The educational session was delivered during a medical staff meeting and the materials used
were then distributed to the staff for review via their work emails.
A 5-point Likert-type survey was created and then distributed to the NICU providers
using a Google form (Appendix F). The survey contained consent to participate in the project, a
unique reproducible identifier for the provider to fill out for pairing pre and post surveys,
demographics questions (job role, years in role, years at northwestern NICU), and 13 questions
on the use and interpretation of NIRS. The same survey was used pre and post educational
session to measure the change in the providers. Two primary concepts were explored were
comfort and confidence using, ordering, and interpreting NIRS data. No Croanbach's alpha
value exists for the survey as it was specifically designed to assess the providers comfort and
confidence using NIRS. No established survey tool was found specifically designed for the
content examined in this QI project.

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Surveys were distributed to the participants through their work email accounts via a web
link to the survey. The primary investigator was the only person with access to the online survey
results. The results were then converted to an Excel spreadsheet and printed to be stored by the
primary investigator. No provider identifiers were collected beyond the unique reproducible
identifier used to pair pre and post educational surveys in order to maintain participant
anonymity and each participant provided their consent to participate in the project with each
survey they filled out.
The pre survey was distributed 7 days prior to the educational session and responses were
accepted until the day of the educational session. The post survey was distributed to the
participants one month after the educational session and responses were accepted for a 10 day
period.
The one month period following the educational session was noted to have a lower than
normal census in the NICU prompting the investigator to modify the original QI plan. The lower
than normal census period resulted in no NICU patients being considered for monitoring causing
there to be no potenital change to be measured by some of the survey questions. To account for
this period of low census the tracking period was extended from 3 months to 5 months and an
abbreviated survey was created to revaluate three survey questions. The abbreviated survey was
distributed 4 months after the educational session and responses were accepted for 2 weeks.
The survey results were validated and entered into IBM SSPS version 23 for analysis.
Demographic data was analyzed with descriptive statistics. NIRS frequency survey questions
were analyzed using a Wilcoxon analysis. The comfort and confidence concepts were analyzed
using mean total score paired t tests. The significance was set to p<0.05.

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The usage data tracked included the gestational age of the NICU patient at birth and at
time of NIRS ordering, the sites monitored with NIRS, and the length of time the patient was
monitored. This information was gathered from the electronic medical record and was recorded
in an Excel spreadsheet and printed to be stored by the primary investigator. The pre
intervention data was examined for the 1 year period before the project and the post intervention
data was tracked for a 5 month period. No patient identifiers were collected during the project in
order to protect the identity of the patients monitored with NIRS.
Outcomes
Eighteen NICU providers completed the initial pre survey (8 MD/10 NNP) and 13
providers completed the post education survey (7 MD/8 NNP). The samples were paired using a
unique reproducible identifier made by the provider at the time the survey for a total of 13 paired
surveys. Additionally 16 providers completed the abbreviated surveys and those results were
then paired to the pre educational survey results.
Descriptive statistics on the providers including their role in the NICU (MD or NNP), the
years they have been in that role and the number of years they have been with the Northwestern
NICU. The 13 providers (61% MD/ 39% NNP) had worked in their role on average 11.25 years
(sd=5.8) with a range of 0.1-20 years. Significance for parametric and non-parametric statistics
was set to p<0.05.
A Wilcoxon test examined the results of three survey questions; how frequently providers
ordered NIRS, how frequently providers managed NIRS and how frequently providers managed
NIRS ordered by another provider. A significant difference was found in the results for the how
frequently providers managed patients with NIRS with the result of (z= -2.762, p=0.006)
between the pre intervention survey results and the abbreviated survey results given at 4 months.

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Providers stated that they managed patients more frequently after the educational session with
NIRS in place. No significant difference was found the providers response to the frequency
which they ordered NIRS (z=1.51, p=0.132) and how frequently they managed NIRS ordered by
another provider (z=-1.01 , p=0.314).
Paired-samples t test was calculated to compare the mean total score for pre survey for
both comfort and confidence to the mean total score post survey. The pre education mean total
score for comfort was 8.77 (sd=2.62) and the mean total score post education was 12.85
(sd=4.52). The pre education mean total score for confidence was 12.33 (sd= 4.54) and the mean
total score post education was 16.42 (sd=5.38). A significant increase was noted for both
comfort (t(11)=-3.13, p=0.010) and confidence (t(11)=3.37, p=0.006) at one month after
educational session.
The clinical use of NIRS in the NICU changed considerably from the 1 year prior to
educational session with one patient monitored in that time and 15 patients monitored during the
5 months of data tracking.

Patients who NIRS was used on during the 5 months of data

tracking ranged from 24 weeks to 36 weeks with 10 of 15 patients monitored less than 27 weeks
gestation. Cerebral and Renal monitoring was used in 13 of 15 patients and renal monitoring
only in 2 of 15 patients. Patients were monitored from 1 day to 15 days with one patient actively
being monitored at the time data tracking was completed.
Discussion
The QI project did result in a statistically significant improvement in the providers
comfort and understanding using, interpreting, and ordering NIRS on NICU patients as measured
by the pre/post survey results. These findings, however, should factor in that they survey was
purposefully created for this project and does not have an established Cronbach’s alpha

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coefficient for validation. The survey questions were designed to assess the providers on topics
related to NIRS use and interpretation and reviewed by the primary investigator and DNP
mentor. The post education survey was given 1 month after the teaching session in order to
allow the providers time to review the material covered and use the NIRS on patients they felt
could be monitored. Of far greater importance than the statistical significance was the change in
clinical practice with 15 patients monitored with NIRS during the 5 months of data tracking, an
increase from 1 patient monitored in the previous year. Additionally the patient population being
monitored was a significant shift from historical use in the Northwestern NICU with 10 of 15
patients being less 27 weeks or less gestation. Previously only term infants with mature skin
were monitored and now the use of Mepitel skin barrier product between the sensor and the
infant’s skin. The Mepitel barrier has helped alleviate some of the concern from providers
regarding how tacky the sensors are when using them on preterm infants with fragile skin
(McNeil, Gatenby, McElroy, & Engelhardt, 2010).
Though specific diagnoses were not tracked on patients who NIRS was ordered on, the
investigator did notice three particular patient groups that were being monitored. This was based
on interactions with the ordering providers as well as the questions being asked about patient
conditions and NIRS probe site selection. The three groups were patients who were being
observed for the presence of a hemodynamically significant PDA (hPDA), patients nearing red
blood cell (RBC) transfusion criteria established by the unit specific transfusion algorithm, and
preterm infants during the initial transition to extrauterine life. These are three groups that are
found in the current literature and in NIRS clinical trials. Chock, Rose, Mante, and Punn (2016)
published their findings related to the use of NIRS to monitor an infant for hPDA and cited a
81% sensitivity and 77% specificity for infants with hPDA when the infants rSO2 was less than

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66%. This is valuable to the clinical setting as pediatric echocardiograms are a costly
intervention not available at all hospital settings, however, clinical judgments on treating a hPDA
should not be made on the rSO2 NIRS alone. The SafeBoosc clinical guideline by Plomgaard et
al. (2016) discusses different interventions for when cerebral NIRS values are less than the
expected range and this was given to the medical staff during the educational teaching session.
One of the interventions discussed was examining a patient’s hematocrit and considering a RBC
transfusion if the values were consistently lower than expected (Plomgaard et al., 2016). The
improvement in the cRSO2 values when noted by the providers was often discussed with the
investigator when reviewing the patient’s time with NIRS in place.
Prospectively, only time will tell if the increased utilization of NIRS in the Northwestern
NICU will continue or if it was a direct result of the QI project and support being provided to the
medical providers. The NICU has a history of increased utilization of NIRS monitoring
following educational presentations, however, their utilization decreased overtime. Lewin’s
Change Theory was chosen with the hopes of being able to change the clinical practice and then
refreeze it into place. Additional educational “check in’s” may help the providers with questions
and allow for further discussion on the current research on NIRS use in NICUs, helping to
sustain the change long term (Silver et al., 2016). The health information technology (HIT)
department working within the NICU is currently working with the electronic medical record
(EMR) to have data flow directly from the NIRS monitor into the patients record, eliminating the
bedside nurses from having to enter the values hourly. This advance with aid in decreasing data
being missed and allow the providers to see remotely what the min to min graphically
representation of NIRS data looks like. This will decrease the frequency in which providers will
have to come to the patient’s bedside to review the NIRS trends.

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Limitations
The limitations of this QI project include its single site design with a provider group that
had previous history using the NIRS monitors. The survey used to assess for change in the
providers comfort and confidence was designed specifically for this project and does not have a
Cronbach’s alpha coefficient to report for validity of the survey findings. Lastly the investigator
does work in the NICU as a bedside RN and was responsible for providing care to some of the
patients being monitored with NIRS, however, while working as the bedside RN refrained from
suggesting or discussing NIRS monitoring on other patients with the providers unless asked by
the provider specifically, as to prevent creating bias in the frequency of NIRS orders.
Conclusion
This QI project focused on educating the providers on the current evidence and research
into NIRS use on NICU patients while also supporting the clinicians when managing patients
with NIRS monitoring in place. The Northwestern US NICU had already invested capital budget
into the purchase of three NIRS monitors, however, was not utilizing them for their patients.
The educational session provided did show a significant change in the providers comfort and
confidence on NIRS and a significant increase in the clinical utilization of NIRS monitoring was
noted. This project highlighted how revising previously abandoned clinical tools and monitors
with new evidence can change provider practice, a very good reason for providers to attend
continuing education seminars and conferences. Just as Kenosi, Naulaers, Ryan, and Dempsey
(2014) titled their article, the future looks brighter for cerebral oxygenation monitoring in
preterm infants.
Dissemination of Project Plan

NEAR-INFRARED SPECTROSCOPY NICU

20

The project results were presented in poster format at ASU to DNP nursing faculty and
students. Completed DNP project poster was shared with the Northwestern NICU department
staff with a review of the project results. There is no further presentation or publication plan at
this time.
Moving forward, alerts have been set for NIRS and NICU on PubMed, Cochrane Library,
and CINAHL in order to keep abreast of the new research published on NIRS use. The
publications will be reviewed and additional teaching sessions

NEAR-INFRARED SPECTROSCOPY NICU

21

References
Alderliesten, T., Dix, L., Baerts, W., Caicedo, A., van Huffel, S., Naulaers, G., et al. (2016).
Reference values of regional cerebral oxygen saturation during the first 3 days of life in
preterm neonates. Pediatric Research, 79(1-1), 55-64.
Blackburn, S. (2013). Maternal, fetal, & neonatal physiology: A clinical perspective. Elsevier
Saunders, Maryland Heights MO.
Bozzetti, V., Paterlini, G., Bel, F. v., Visser, G. H. A., Tosetti, L., Gazzolo, D., et al. (2016).
Cerebral and somatic NIRS-determined oxygenation in IUGR preterm infants during
transition. Journal of Maternal-Fetal & Neonatal Medicine, 29(3), 443-446.
Cerbo, R. M., Cabano, R., Di Comite, A., Longo, S., Maragliano, R., & Stronati, M. (2012).
Cerebral and somatic rSO2 in sick preterm infants. The Journal of Maternal-Fetal &
Neonatal Medicine 25 Suppl 4, 97-100.
Chock, V. Y., Rose, L. A., Mante, J. V., & Punn, R. (2016). Near-infrared spectroscopy for
detection of a significant patent ductus arteriosus. Pediatric Research, 80(5), 675-680.
Gillam-Krakauer, M., Cochran, C. M., Slaughter, J. C., Polavarapu, S., McElroy, S. J., HernanzSchulman, M., et al. (2013). Correlation of abdominal rSO2 with superior mesenteric
artery velocities in preterm infants. Journal of Perinatology, 33(8), 609-612.
Gleason, C. & Devaskar, S. (2012). Avery's diseases of the Newborn. Elsevierr Suanders,
Phillidelphia PA.
Greisen, G., Leung, T., & Wolf, M. (2011). Has the time come to use near-infrared spectroscopy
as a routine clinical tool in preterm infants undergoing intensive care? Philosophical
Transactions.Series A, Mathematical, Physical, and Engineering Sciences, 369(1955),
4440-4451.

NEAR-INFRARED SPECTROSCOPY NICU

22

Hyttel-Sorensen, S., Pellicer, A., Alderliesten, T., Austin, T., van Bel, F., Benders, M., et al.
(2015). Cerebral near infrared spectroscopy oximetry in extremely preterm infants: Phase II
randomised clinical trial. BMJ (Clinical Research Ed.), 350, g7635.
Kenosi, M., Naulaers, G., Ryan, C., Dempsey, E., Ryan, C. A., & Dempsey, E. M. (2015).
Current research suggests that the future looks brighter for cerebral oxygenation monitoring
in preterm infants. Acta Paediatrica, 104(3), 225-231.
Laughon, M., Bose, C., Allred, E., O'Shea, T., Van Marter, L., Bednarek, F., & Leviton, A.
(2007). Factors Associated With Treatment for Hypotension in Extremely Low Gestational
Age Newborns During the First Postnatal Week. Pediatrics, 119(2), 273–280.
Lewin’s Change Theory. (n.d.). Nursing Theory. Retrieved from: http://www.nursingtheory.org/theories-and-models/Lewin-Change-Theory.php
Liao, S. M., & Culver, J. P. (2014). Near infrared optical technologies to illuminate the status of
the neonatal brain. Current Pediatric Reviews, 10(1), 73-86.
Lin, P. Y., Hagan, K., Fenoglio, A., Grant, P. E., & Franceschini, M. A. (2016). Reduced
cerebral blood flow and oxygen metabolism in extremely preterm neonates with low-grade
germinal matrix- intraventricular hemorrhage. Scientific Reports, 6, 25903.
Liu, P., Chalak, L. F., & Lu, H. (2014). Non-invasive assessment of neonatal brain oxygen
metabolism: A review of newly available techniques. Early Human Development, 90(10),
695-701.
McNeill, S., Gatenby, J., McElroy, S., & Engelhardt, S. (2010). Normal cerebral, renal, and
abdominal regional oxygen saturations using near-infrared spectroscopy in preterm
infants. Journal of Perinatology 31(1). 51-57.
Melnyk, B. & Fineout-Overholt, E. (2015). Evidence-based Practice in Nursing and

NEAR-INFRARED SPECTROSCOPY NICU

23

Healthcare: A Guide to Best Practice (3rd ed.). Lippincott, Williams & Wilkins.
Pellicer, A., Greisen, G., Benders, M., Claris, O., Dempsey, E., Fumagalli, M., et al. (2013). The
SafeBoosC phase II randomised clinical trial: A treatment guideline for targeted nearinfrared-derived cerebral tissue oxygenation versus standard treatment in extremely preterm
infants. Neonatology, 104(3), 171-178.
Pichler, G., Avian, A., Binder, C., Zotter, H., Schmölzer, G. M., Morris, N., et al. (2013). aEEG
and NIRS during transition and resuscitation after birth: Promising additional tools; an
observational study. Resuscitation, 84(7), 974-978.
Pichler, G., Urlesberger, B., Baik, N., Schwaberger, B., Binder-Heschl, C., Avian, A., et al.
(2016). Cerebral oxygen saturation to guide oxygen delivery in preterm neonates for the
immediate transition after birth: A 2-center randomized controlled pilot feasibility
trial. Journal of Pediatrics, 170, 73-78.e4.
Plomgaard, A. M., van Oeveren, W., Petersen, T. H., Alderliesten, T., Austin, T., van Bel, F., et
al. (2016). The SafeBoosC II randomized trial: Treatment guided by near-infrared
spectroscopy reduces cerebral hypoxia without changing early biomarkers of brain
injury. Pediatric Research, 79(4), 528-535.
Polt, D. & Beck, C. (2012). Nursing research: Generating and assessing evidence for nursing
practice, 9th edition. Philadelphia, PA. Lippincott Williams & Wilkins.
Riera, J., Hyttel-Sorensen, S., Bravo, M. C., Cabanas, F., Lopez-Ortego, P., Sanchez, L., et al.
(2016). The SafeBoosC phase II clinical trial: An analysis of the interventions related with
the oximeter readings. Archives of Disease in Childhood.Fetal and Neonatal
Edition, 101(4), F333-8.
Rosswurm, M. & Larrabee, J. (1999). A model for change to Evidence-Based practice. Journal
of Nursing Scholarship.31:4, 317-322.

NEAR-INFRARED SPECTROSCOPY NICU

24

Silver, S., McQuillan, R., Harel, Z., Weizman, A., Thomas, A., Nesrallah, G., … Chertow, G.
(2016). How to sustain change and support continuous quality improvement. Clinical
Journal of American Society of Nephrology. 11(5), 916-924. DOI: 10.2215/CJN.11501015

Sood, B. G., McLaughlin, K., & Cortez, J. (2015). Near-infrared spectroscopy: Applications in
neonates. Seminars in Fetal & Neonatal Medicine, 20(3), 164-172.

NEAR-INFRARED SPECTROSCOPY NICU
Appendix A
Database Search Strategy
CINHAL Plus with full text

25

NEAR-INFRARED SPECTROSCOPY NICU
Appendix B
Database Search Strategy
PubMed

26

NEAR-INFRARED SPECTROSCOPY NICU
Appendix C
Database Search Strategy
Cochrane Library

27

28

NEAR-INFRARED SPECTROSCOPY NICU
Appendix D
Evaluation Table
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Data
Instrumentation Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Alderliesten,
Dix, 2015,
Reference
values of
rScO2 during
first 3 days of
life in preterm
neonates.

Physiologic
Framework

Quantitative

n= 999 preterm
infants (M 539 /
F 460)
GA <32 weeks
Mean 28.7 SD
1.96
IC - born < 32
weeks with PC
between 1/2005 9/2013
EC - CM/SGA or
severe congenital
malformations,
missing data sets
DD - BW,
APGAR score,
hsPDA, presence
of IVH, Mortality

Variable of
interest: rScO2
over time
Measured for
first 72 hrs
after birth

INVOS 4100 or
5100 with small
adult electrode
Data collected
from birth through
first 72 hrs.
Sensor on
forehead with
elastic bandage.
Mean value for 1
hr periods were
analyzed. Small
sample (n=16)
with neonatal
sensor for
conversion data

Creation of
reference curves
for GA in 2 week
increments for
both rScO2 and
cFTOE for first
72 hr of life

Level IV

Similar results to
other similar
studies for
reference ranges

Weakness: Use
of adult sensor,
only <32 week
infants

Country: The
Netherlands
Wilhelmina
Children's
Hospital Level
III NICU
Funding:
Fellowship
from RFF,
ERC
COI- None
disclosed

Observational
cohort Study
Purpose:
Establish rScO2
reference
values/tables for
preterm infants
for first 3 days of
life

Linear, squared,
and polinominal
models to find
best fit for both
rScO2 and
cFTOE.

Strength: Large
sample size,
establish, similar
results to other
studies

Highly
applicable to
practice,
education on
normal expected
ranges for given
GA and time.
Conclusion:
Good references
for use of NIRS
in practice on
preterm infants
through

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

29

NEAR-INFRARED SPECTROSCOPY NICU
transition

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Data
Instrumentation Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Bozzetti
(2016), rScO2
and rSmO2 in
IGUR preterm
infants

Physiologic
Framework

Quantitative

n=20, 10 IUGR
preterm infants
10 AGA preterm
infants (GA 2933 weeks)

IV1- rScO2 for
IUGR infants
IV2- rSmO2
for IUGR
infants
IV3- rScO2 for
non-IUGR
infants
IV4- rSmO2
for non-IUGR
infants
DV1- T0 (12.3
hr ±4.4 hr)
DV2- T1 (62.7
hr ± 4.0 hr)

NIRS data from
INVOS 5100
placed infraumbilical and
forehead.
Measured in first
24 hrs and again at
48-72 hrs

CSOR of IV1
and IV2 at DV1
(p<0.001)

Level of
evidence: Level 4

Country: Italy,
San Gerardo
Hospital
Funding: None
COI: None
stated

Prospective
Case-control
Study
Purpose:
Examine BS in
IGUR infants by
measuring
regional
saturations

DD: GA, Gender,
BW, APGAR,
Prenatal steroids,
hsPDA, IVH
(BW only
significant
difference
between groups
(p=0.05)
EC: CM/SGA,
Perinatal
asphyxia with
multi-organ
failure, skin
disease at probe
site

Student's t-test
for continuous
variables, ManWhitney U two
sided, KuskalWallis, and
fisher's exact /
chi-squared

IV1 > at DV1
than DV2
(p<0.001)
cFTOE for IV1
at DV1 and DV2
(p<0.001), no
difference in
mFTOE (p not
reported)
CSOR for IV3
and IV4 at DV1
and DV2
(p<0.001)
IV2 and IV4 at
DV1 and DV2
(p<0.001) for
both rSmO2 and
mFTOE

Strengths:
preselected
infants for study
based on
ultrasound data.
Two paired
groups reflective
of population
difference in
question
Weakness: Small
sample size and
limited
timeframe of
measurement
Application to
practice: Good
for monitoring
differences in
IUGR patients
blood flow
patterns to not
push feeds to
quickly post birth
Conclusion:

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

30

NEAR-INFRARED SPECTROSCOPY NICU
Helps establish
awareness of
continued BS
post birth and
feeding
considerations
with continued
BS effect

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Measurement/
Discussion
Variables & Instrumentation of case
interventions
studies
studied

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Cerbo (2012).
rScO2 and
rSmO2 in sick
preterm infants

Physiologic
framework

Quantitative

n= 3
GA #1= 24 week
M infant
GA #2= 28 week
F infant
GA #3= 30 week
M infant
DD: HR, BP,
pulse ox, rScO2
and rSmO2
Single center
findings

Variables:
rScO2 and
rSmO2

Discussion of
NIRS data
findings prior to,
during, and after
PDA ligation
with overall
increase in rScO2
noted when duct
was closed
NIRS data
trended to show
worsening
hsPDA and
changes during
surgical closure
Discussion of
rSmO2 response
with abdominal
infiltration of
umbilical
catheter

Level of
evidence: Level
VI
Strengths: Shows
use of NIRS in
different disease
process

Country: Italy,
Fondazione
IRCCS, San
Matteo
Funding: No
funding stated
COI: No
conflict of
interest stated

Case review of 3
preterm infants
and use of NIRS
monitoring
Purpose: review
of use of NIRS in
clinical practice
with different
patient diagnosis

Treatments:
PDA ligation,
UVC
extravasations
monitoring

NIRS
measurement of
rScO2 and rSmO2
with INVOS 5100

Case #1:
Preterm infant
noted to have
CSOR
difference
suggestive of
PDA, required
ligation
Case #2:
Preterm infant
with atrial
tachyarrhythmia
shown to have
PDA requiring
ligation
Case #3: Infant
with UVC
infiltrate noted
with change in
rSmO2

Weakness: Small
number of cases,
not easily
reproducible
Application to
practice:
Additional ways
NIRS can be
used to monitor
disease processes
Conclusion:
Limited
generalizability
to populations

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

31

NEAR-INFRARED SPECTROSCOPY NICU
without
reproducibility of
case study results

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Data
Instrumentation Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Chock (2016)
NIRS for
Detection of
hsPDA.

Physiologic
framework

Quantitative

n= 47 (M 15 / F
32)
GA <29 weeks
with NIRS
monitoring
between 9/20138/2015, Normal
routine
monitoring of
rScO2 and rSrO2
done on patients
of this GA

IV- rScO2 and
rSrO2 values
measured at 6
days of life

NIRS monitoring
of both rScO2 and
rSrO2 with
INVOS 5100
Cardiac Echos
performed on any
suspected infant
with hsPDA
without influence
of rScO2 or rSrO2
data and read by
Peds Cardiology
without
knowledge of any
rScO2 or rSrO2
data

rSrO2 less an
66% correlated
with hsPDA
(p=0.03), rScO2
was not
significantly
different between
confirmed
hsPDA and non
hsPDA (p=0.24),
rScO2 to rSrO2
ratio higher with
hsPDA
(p=0.007)

Level IV

Non a-priori
retrospective
study

Country: USA,
Stanford
University
Medical center,
Luciel Packard
Children's
Hospital

Purpose:
Determine if
NIRS monitoring
can show the
presence of
hsPDA with
confirmation by
Cardiac Echo

Funding: no
support
COI - None
stated

DV- Presence
of hsPDA by
cardiac Echo

DD - GA, BW,
Race, PNA, use
of vasopressors,
MV

Fisher's exact
test w/Freeman-Halton
extension,
Kruskal-Wallis
for
nonparametric
with Bonferroni
correction

Strength:
Measured when
hsPDA plays a
physiologic role
Weakness: Small
sample size
Applicable to
clinical practice
as a non invasive
tool to monitor
for hsPDA
without added
cost of Cardiac
Echo
Conclusion:
Small study size,
good consistent
result when
confirmed by
Echo

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Data
Instrumentation Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

32

NEAR-INFRARED SPECTROSCOPY NICU
practice/
application to
practice
GillamKrakauer
(2013).
Correlation of
rSmO2 with
Superior
mesenteric
artery velocity

Physiologic
framework

Quantitative
Prospective
Observational
single-center trial
Purpose:
Determine if
variations in
rSmO2 measured
by NIRS
correlated with
measured
variations in
superior
mesenteric artery
velocities.

Country: USA,
Vanderbilt
Children’s
Hospital
Funding:
Grand from
Vanderbilt
Institute for
clinical and
translational
research,
unrestricted
technology
grant from
Somanetics,
NIH grant

n=18 (M 9, F 9)
GA: 25 – 31
weeks
Attrition: 28%
(18/25)
IC: GA 23 6/7 to
30 6/7 weeks, <
1500 g, < 14 days
of age, tolerating
enteral feeds 1020 ml/kg/day
EC: CM/SGA,
IUGR,
Gastrointestinal
anomalies,
pressor support
within 24 hrs,
severe jaundice,
hx necrotizing
enterocolitis

rSmO2 data
and the
corresponding
superior
mesenteric
artery velocity
in three
intervals
around feeding
for three
consecutive
days
Higher superior
mesenteric
artery velocity
would correlate
with increased
blood flow to
the abdominal
viscera

DD: GA, BW,
Gender, Race,
APGAR, PNA,
Days to full feeds

COI:
Unrestricted
Somanetics
grant

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

rSmO2 with
INVOS 5100 with
neonatal sensor
placed midline
below the
umbilicus,
measured just
prior to starting
feeding, 10 mins
after feeding, and
60-120 mins after
feeding
completed.

Spearman’s
rank
correlation,
Wilcoxon test,
and KruskalWallis

Doppler
ultrasound of
SMAV (systolic,
diastolic and
mean) by Siemans
Acuson Sequoia
measured just
prior to starting
feeding, 10 mins
after feeding, and
60-120 mins after
feeding
completed. Total
of 9 ultrasound
measurements,
around 3 different
feedings

Measurement/
Data
Instrumentation Analysis
(stats used)

Kruskal-Wallis
on rSmO2 and
Dopplar flow
measures were
not significantly
different from
day 1 to day 3.
Not significant in
pre feeding or
60-120 mins post
feeding
(p=0.068, 0.062,
and 0.53 for
systolic,
diastolic, and
mean pre
feeding)
Significant
difference in 10
mins post feed in
all SMAV
(p=0.013, 0.015,
and 0.005)

Level of
evidence:

Findings/
Results

Level/Quality
of Evidence;
Decision for

Strengths:
Weakness: Small
sample size,
Application to
practice: Limited
beyond
continued focus
on variability in
NIRS data being
more clinically
important
Conclusion:
Provides jumping
off point for
further research

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

33

NEAR-INFRARED SPECTROSCOPY NICU
practice/
application to
practice
HyttelSorensen
(2015). rScO2
in Phase II
clinical trial
Country: 8
European
countries
(retrieved from
British medical
journal)
Funding:
Unrestricted
grand from
Danish
Council for
Strategic
research
COI: None
stated

Physiologic
Framework

Quantitative
Phase II
randomised,
blinded,
feasibility trial
Randomization
by computer
generated
allocation
sequence
Purpose: test the
SafeBoosc
recommendations
for reduction in
rScO2 burden in
multiple centers

n= 166 infants
Intervention
group: 86 (M 44,
F 51)
Control group: 80
(M 34, F 43)
DD: BW, GA,
Sex, prenatal
steriods, length
(time) of rupture
of membranes,
presence of
chorioamnionitis,
APGAR,
Umbilical artery
pH
IC: At least 12
weeks preterm,
establish rScO2
within 3 hrs of
birth with PC
EC: Inability to
place rScO2
within 3 hrs, no
NIRS monitor
available, no PC,
decision for no
life support
measures
Power of 95%
with sample size
of 166 estimated
Attrition: 4%
(6/166)

IV1- rScO2
data visible to
medical staff
IV2- rScO2 not
visible to
medical staff
DV- Cerebral
oxygen burden
(hypoxia or
hyperoxia)

NIRS data from
INVOS 5100c
with adult sensor
measuring rScO2
from 3 hrs through
72 hrs after birth.
INVOS were
blinded by being
placed in a box or
in a research
specific screen
mode

Specific
statistical
analysis tests
were not
discussed.
Cited as
utilizing two
sided tests with
P of 0.05 and
mixed modeling
for continuous
variables and
ordinary
logistic
regression for
binary and
ordinal
outcomes

IV1 to DV
(p<0.001) when
compared to IV2
to DV, primary
reduction in
hypoxia
DD were not
significant
between IV1 and
IV2
No secondary
measures were
significant
between IV1 and
IV2

Level of
evidence: Level
II
Strengths: Large
multicenter RCT
utilizing
established
interventional
guidelines
Weakness: First
study of its kind
with infants, no
discussion of
stats analyzed
Application to
practice: shows
the importance of
utilizing
interventions to
reduce rScO2
oxygen debt
when monitoring
with NIRS
Conclusion:
Good evidence
for the use of
NIRS to reduce
potential harmful
oxygen debt and
use of clinical
treatement
recomendations

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

34

NEAR-INFRARED SPECTROSCOPY NICU
from SafeBoosc

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Interventions Measurement/
Impact on
used during Instrumentation practice
RCT

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Pellicer
(2013),
SafeBoosC
Phase II RCT
treatment
guideline

Physiologic
Framework

Quantitative

N= 229 initial
studies, 61
directly relevant
to treatment
guideline and 9
RCT's

Cardiovascular
status review

All
recommendations
have at least a
Level II study
supporting and a
minimum of
small to
substantial net
benefit

Level of
evidence: Level I

Country: Spain
(La Paz
University
Hospital)
Funding:
Danish
Council for
Strategic
Research
COI: None
stated

Systematic
Review
Purpose:
Describe the
rational for the
treatment
guideline and the
algorithm for the
interventions per
SafeBoosC

SafeBoosC is a
randomized
clinical trial
involving
premature infants
from birth
through the first
72 hrs of life
examining rScO2
values measured
by NIRS

Oxygen
Transportation
Respiratory
Status
Blood Glucose
management

Recommendations
based on level of
evidence from I to
III with Level I
being from RCT
and Level III
being opinions
from respected
authorities
Recommendations
based on quality
of evidence from
good to fair to
poor and net
benefit to health
outcomes from
substantial to
zero/negative.
MeSH terms
searched through
PubMed: Neonate,
NIRS,
cerebrovascular
circulation, BP,
hypotension,
dopamine,
dobutabmine,
epinepherine,
anesmia, blood

Provides
background for
interventions
recommended
by SafeBoosC
RCT

Strengths:
Provided rational
for clinical
interventions
Weakness: Some
recommendations
are only weakly
supported by
research
Application to
practice: Highly
applicable if
monitoring
rScO2 in preterm
infants
Conclusion:
Good for basis of
interventions
used to correct
rScO2 outside of
expected ranges

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

35

NEAR-INFRARED SPECTROSCOPY NICU
transfusion, CO2,
RDS, PDA, and
treatment

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Data
Instrumentation Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Pichler, Binder
(2013)
Reference
ranges for
rScO2 and
cFTOE during
neonatal
transition

Physiologic
framework

Quantitative

n= 381 neonates
(82 Term vaginal
delivered, 272
term Cesarean
delivered, 27
preterm Cesarean
delivered)
DD: BW, GA,
Apgars, SpO2,
HR
EC: Vacuum
assisted or
forceps assisted
delivery,
Respiratory
support during
transition

IV1- rScO2
IV2- cFTOE
DV- Time
Birth through
15 mins

Invos 5100
monitor with
neonatal sensor
placed on left
frontoparietal
forehead, secured
with strap

Stats for HR and
SpO2 differences
min by min for
three population
groups
rScO2 at 4 and 5
mins for vag
term deliveries
was higher than
Ceserean term (p
= 0.003)

Level of
evidence: Level
IV
Strengths: Large
sample size,
Multiple
gestations,
Establish normal
transition data set

Country:
Austria, Royal
Alexandra
Hospital
Funding:
Jubilaumfsond,
Osterreichische
National-Bank
COI: No
conflict stated

Prospective
Observational
Study
Purpose:
determine range
values for rScO2
during neonatal
transition using
NIRS

Setting: Medical
university of
Graz between
1/2009 - 8/2012
Attrition: none,
analysis done for
only those who
had complete data
sets

Measurements
started at 2 mins
of age and
continued for 15
mins during
transition

Least mean
squares for
rScO2 and
cFTOE and
linear mixed
modeling with
first order
autoregressives
covariance
structure for
ovarall effects
and differenced
between groups
P value set to
0.05

Four rScO2 vs
time graphs and
four cFTOE vs
time graphs

Weakness:
Limited to 15
mins of
transition,
minimal vaginal
preterm infants,

Two tables with
10th, 50th, and
90th percentile
for rScO2 and
cFTOE

Application to
practice: Assist
with guiding
normal transition
in delivery room
Conclusion:
Helps establish
base knowledge
of use during
transition and
expected data

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

36

NEAR-INFRARED SPECTROSCOPY NICU
points/goals for
normal transition

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Data
Instrumentation Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Pichler (2016),
rScO2 to guide
oxygen
delivery 2
center RCPT

Physiologic
Framework

Quantitative

Two sites: Graz,
Austria and
Edmonton,
Alberta CA
n= 60, 30 at each
site, 15 in Control
group and 15 in
intervention
group, (M - 32, F
- 28)
DD: GA, BW,
APGAR, Sex,
Mortality, IVH
rates, NEC rates,
ROP, BPD
IC: PC, < 34
weeks, choice to
provide life
support
EC: Congenital
malformation or
no life support

IV 1-rScO2
visible to
resuscitation
team
IV 2 - rScO2
not visible to
resuscitation
team
DV- Oxygen
debt defined as
hypoxia or
hyperoxia
during
resuscitation as
measured by
cerebral NIRS

IVOS 5100 with
cerebral monitor
placed on Left
forehead and
covered with hat.
Continuous data
was recorded and
means for each
min were
calculated for HR,
Saturation, and
rScO2. Delayed
cord clamping was
done between 30
to 60 seconds for
eligible infants.

No significant
DD differences

Level of
evidence: Level
II

Country:
Austria,
Medical
University of
Graz
Funding: None
stated
COI: No
conflicts stated

Multicenter
Randomized
controlled Pilot
Feasibility trial
Randomized by
sealed envelope
opened just
before birth
Neonatology
staff in NICU
was blinded to
whether NIRS
was visible to
resuscitation
team on delivery
of infant

Attrition: 0/60

Data was collected
for the first 15
mins after birth

Chi Squared,
Fisher exact test
for discrete
variables, t test
or MannWhitneyU for
continuous
variables.
Group
differences with
Mann-Whitney
U
Mean values
expressed in
models and
P<.05 for
statistical
significance

IV1 vs IV2 on
DV Reduction in
cerebral oxygen
debt (p=.028) for
patients who had
complete data
sets available for
analysis

Strengths:
Showed
reduction in
oxygen debt
during
resuscitation,
multiple centers

IV1 vs IV2 on
DV for all
patients not
significant
(p=.107)

Weakness: Small
sample size, Not
significant result
on whole of data
set

Teams with
visible NIRS
were able to
add/wean resp
support reducing
cerebral hypoxia
quicker

Application to
practice: Could
help guide
resuscitation of
known NICU
admits
Conclusion:
Good application
of NIRS similar
to SafeBoosC
clinical trial

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

NEAR-INFRARED SPECTROSCOPY NICU
Citation
Theory/
Design/
Conceptual Method
Framework

Plomgaard
(2016)
SafeBoosC II
RCT:
treatment
guided by
NIRS reduces
cerebral
hypoxia
Country: 6
European
countries
(retreieved
from Pediatric
RESEARCH)
Funding:
Danish
Council for
Strategic
Research
COI: No
authors cite
conflicts

Physiologic
framework

Quantitative
Extension of
original RCT
Purpose: Extend
the findings of
initial RCT to
examine the
effect on cerebral
hypoxia by EEG

37

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Data
Instrumentation Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

n= 158 in RCT,
133 for analysis
in subgroup of
EEG recording,
123 for blood
biomarker
analysis

IV1- NIRS
visible
IV2- Control
group without
NIRS
DV1- EEG
DV2- Blood
Biomarker

EEG at 64 hrs of
age by amplitudeintegrated EEG at
P3 and P4
locations with 120
mins of recording
time

EEG examined
for normality,
multiple
regression
modeling of
estimated
means

No significant
changes noted
between IV1and
IV2 on DV1 or
DV2

Level of
evidence: Level
II

Blood biomarkers
at 6 hrs and 64
hrs, 1 ml per
collection,
markers S100β,
BFABP, and
Neuroketal
examined

Biomarkers
with
logarithmic
transformation,
linear mixed
modeling
analysis and
unstructured
covariance
matrix. Mann
Whittney U for
non normal
distributed data

DD: BW, GA,
Twin delivery,
APGAR,
Antinatal
steriods,
Setting: NICU in
6 different
European
countries

Attrition: 16/158
(10%), 8 died
before 64 hr
mark, 8 did not
have EEG

The use of
cerebral NIRS
did not have an
effect on the
EEG or blood
biomarkers for
cerebral damage

Strengths: Data
found during
RCT, well
designed
multicenter trial,
multiple data
variables
analyzed
Weakness: EEG
and biomarkers
are not
established
markers for brain
injury
Application to
practice:
Additional
justification for
use of clinical
guideline
Conclusion: The
SafeBoosC
treatment
guideline did not
have a negative

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

38

NEAR-INFRARED SPECTROSCOPY NICU
effect on EEG of
preterm infants

Key: AGA – Appropriate for Gestational age, BP - Blood pressure, BPD - Bronchopulmonary displasia BS – Brain sparring, BW - Birth weight, cFTOE - cerebral fractional tissue oxygen extraction, CM/SGA - Cardiac malformation
or severe chromosomal abnormalities, COI - Conflicts of interest, CSOR – cerebral / splanchnic oxygenation ratio, DD - Demographic data, DV-dependent variable, EC - Exclusion criteria, EEG - Electroencephalographic, ERC European Research Council, F - Female, GA - Gestational Age, HR - Heart rate, hsPDA - hemodynamically significant patent ductus arteriosus, IC - Inclusion criteria, IUGR – Intrauterine Growth Restricted, IV- independent variable,
IVH - Intraventricular hemorrhage, M - Male, mFTOE – Mesenteric fractional tissue oxygen extraction, MV - Mechanical ventilation, N-number of studies, n- number of participants, NEC - Necrotizing Enterocolitus, NIH – National
Institutes of health, NIRS - Near infrared Spectroscopy, PC - Parental Consent, PNA - Post natal age, RDS - Respiratory distress syndrome, REF - Research Foundation Flanders, ROP - Retinopathy of Prematurity rScO2 - regional
cerebral oxygen saturation, rSrO2 - regional renal oxygen saturation, rSmO2 – Regional mesenteric oxygen saturation, SD - Standard Deviation, SMAV - Superior Mesenteric artery velocity, T - Time,

39

NEAR-INFRARED SPECTROSCOPY NICU
Appendix E
Synthesis Table
Alderliesten

Bozzetti

Cerbo

Chock

Year
RCT
NPRS
POT
SR
OCS
POS
PCCS
CS
N
Ns
Demographics
GA range, (Mn)
BW range, (Mn)

2015

2016

2012

2016

24-31 (28.7)
0.770-1.375

29-33 (31 1/7)
1.157

Mn APGAR at 1,5 mins
Setting
NICU
United States
Spain
Europe

7, 8

-, 9

X

X

Austria
Italy
Netherlands
Findings
Creation of reference ranges
Reduction in oxygen debt
No negative impact to infant
Able to monitor for hsPDA
Physiologic response
Measurement Interval
Birth - Transition
Birth - 72 hrs
Measurement device
Invos used
Independent variables
rScO2
rSrO2
rSmO2
cFTOE

GillamKrakauer
2013

HyttelSorensen
2015
X

Pellicer
2013

Pichler,
Binder
2013

Pichler

Plomgaard

2016
X

2016
X (Extension)

381

60

158

34-40
2.2593.386
9, 10

(29.5)
(1.35)

(24.4-27.6)
0.41-1.33

X

X

X
X
X
X
X
X
999

20

X
3

47

18

166
229

25-28
0.66-1.038

25-31 (28)
(1.203)

25-27 (26)
0.410-1.33

7,8
X

X
X

X
X

X

X

6, 8
X

X
X (8
countries)

X (6 countries)
X

X

X

X

X
X

X

X
X

X
X

X

X
↓ post feed

X
X

X

X

X

X

X

X

X

X

X
X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X
X

C- country, CS- Case study, hsPDA - hemodianamicly significant patient ductus arterousis, IUGR - Intra Uterine Growth Restricted, Mn- mean, N- number of subjects,NPRS- Non a-priori retrospective study, Ns - Number of studies,
NICU- neonatal intensive care unit, OCS- Observational cohort study, RCT - Randomized controlled trial, PCCS - Prospective case-control study, POT - Prospective Observational Trial, POS - Prospective Observational Study, Rrange, rScO2 - regional cereberal oxygen saturation, rSmO2 - regional mesenteric oxygen saturation, rSrO2 - regional renal oxygen saturation, SMAV - Superior mesenteric artery velocity, SR- systematic review

40

NEAR-INFRARED SPECTROSCOPY NICU
Alderliesten

Independent variables
Cont.
IUGR
Non-IUGR
Dependent variables
Oxygen Debt
hsPDA presence
SMAV
Time (post birth)
EEG variance
Blood Biomarkers

Bozzetti

Cerbo

Chock

GillamKrakauer

HyttelSorensen

Pellicer

Pichler,
Binder

Pichler

Plomgaard

X
X
X

X

X
X
X

X

X
X
X

C- country, CS- Case study, hsPDA - hemodianamicly significant patient ductus arterousis, IUGR - Intra Uterine Growth Restricted, Mn- mean, N- number of subjects,NPRS- Non a-priori retrospective study, Ns - Number of studies,
NICU- neonatal intensive care unit, OCS- Observational cohort study, RCT - Randomized controlled trial, PCCS - Prospective case-control study, POT - Prospective Observational Trial, POS - Prospective Observational Study, Rrange, rScO2 - regional cereberal oxygen saturation, rSmO2 - regional mesenteric oxygen saturation, rSrO2 - regional renal oxygen saturation, SMAV - Superior mesenteric artery velocity, SR- systematic review

41

NEAR-INFRARED SPECTROSCOPY NICU
Appendix F
Rosswurn and Larrabee EBP model

Figure 1. From Rosswurm, M. & Larrabee, J. (1999). A model for change to Evidence-Based
practice. Journal of Nursing Scholarship.31:4, 317-322.

42

NEAR-INFRARED SPECTROSCOPY NICU
Appendix G
Survey to assess Provider Comfort and Confidence

NEAR-INFRARED SPECTROSCOPY NICU

43

NEAR-INFRARED SPECTROSCOPY NICU

44

NEAR-INFRARED SPECTROSCOPY NICU

45