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Wright CJ, Glaser K, Speer CP, Härtel C, Roehr CC. Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools? J Pediatr 2022; 247:138-146. [PMID: 35429507 DOI: 10.1016/j.jpeds.2022.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/27/2021] [Accepted: 04/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Charles C Roehr
- Southmead Hospital, North Bristol NHS Trust, University of Bristol, Dept. Pediatrics, Faculty of Health Science, Bristol, UK; National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford Oxfordshire, UK.
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Glaser K, Wright CJ. Indications for and Risks of Noninvasive Respiratory Support. Neonatology 2021; 118:235-243. [PMID: 33902052 PMCID: PMC8178193 DOI: 10.1159/000515818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 01/20/2023]
Abstract
Within the last decades, therapeutic advances have significantly improved the survival of extremely preterm infants. In contrast, the incidence of major neonatal morbidities, including bronchopulmonary dysplasia, has not declined. Given the well-established relationship between exposure to invasive mechanical ventilation and neonatal lung injury, neonatologists have sought for effective strategies of noninvasive respiratory support in high-risk infants. Continuous positive airway pressure has replaced invasive mechanical ventilation for the initial stabilization and the treatment of respiratory distress syndrome. Today, noninvasive respiratory support has been adopted even in the tiniest babies with the highest risk of lung injury. Moreover, different modes of noninvasive respiratory support supplemented by a number of adjunctive measures and rescue strategies have entered clinical practice with the goal of preventing intubation or reintubation. However, does this unquestionably important paradigm shift to strategies focused on noninvasive support lull us into a false sense of security? Can we do better in (i) identifying those very immature preterm infants best equipped for noninvasive stabilization, can we improve (ii) determinants of failure of noninvasive respiratory support in the individual infant and underlying etiology, and can we enhance (iii) success of noninvasive respiratory support and (iv) better prevent ultimate harm to the developing lung? With increased survival of infants at the highest risk of developing lung injury and an unchanging burden of bronchopulmonary dysplasia, we should question indiscriminate use of noninvasive respiratory support and address the above issues.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
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Glaser K, Speer CP, Wright CJ. Fine Tuning Non-invasive Respiratory Support to Prevent Lung Injury in the Extremely Premature Infant. Front Pediatr 2020; 7:544. [PMID: 31998672 PMCID: PMC6966957 DOI: 10.3389/fped.2019.00544] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/13/2019] [Indexed: 12/31/2022] Open
Abstract
Within the last decades, therapeutic advances, such as antenatal corticosteroids, surfactant replacement, monitored administration of supplemental oxygen, and sophisticated ventilatory support have significantly improved the survival of extremely premature infants. In contrast, the incidence of some neonatal morbidities has not declined. Rates of bronchopulmonary dysplasia (BPD) remain high and have prompted neonatologists to seek effective strategies of non-invasive respiratory support in high risk infants in order to avoid harmful effects associated with invasive mechanical ventilation. There has been a stepwise replacement of invasive mechanical ventilation by early continuous positive airway pressure (CPAP) as the preferred strategy for initial stabilization and for early respiratory support of the premature infant and management of respiratory distress syndrome. However, the vast majority of high risk babies are mechanically ventilated at least once during their NICU stay. Adjunctive therapies aiming at the prevention of CPAP failure and the support of functional residual capacity have been introduced into clinical practice, including alternative techniques of administering surfactant as well as non-invasive ventilation approaches. In contrast, the strategy of applying sustained lung inflations in the delivery room has recently been abandoned due to evidence of higher rates of death within the first 48 h of life.
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Affiliation(s)
- Kirsten Glaser
- University Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Christian P. Speer
- University Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
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Stritzke A, Mohammad K, Shah PS, Ye XY, Bhandari V, Akierman A, Harrison A, Bertelle V, Lodha A. Use and timing of surfactant administration: impact on neonatal outcomes in extremely low gestational age infants born in Canadian Neonatal Intensive Care Units. J Matern Fetal Neonatal Med 2017; 31:2862-2869. [PMID: 28724325 DOI: 10.1080/14767058.2017.1358266] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Use, timing and doses of surfactant in preterm infants are variable in practice in modern NICUs. OBJECTIVE The objective of this study is to explore the association between use and timing of surfactant administration and common neonatal adverse outcomes in preterm infants with gestational age (GA) < 28 weeks. MATERIAL AND METHODS Neonates admitted to a participating Canadian Neonatal Network NICU between 2013 and 2015 were studied. Infants were divided into three groups based on surfactant administration: none, early (within 30 min of life), and late surfactant (>30 min). The primary outcome was a composite of ≥2 predefined outcomes: bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP) and severe neurological injury (intraventricular hemorrhage or intraventricular hemorrhage (IVH) grade III/IV ± periventricular leukomalacia). RESULTS Of 2512 eligible neonates, 430 were in the early, and 1228 were in the late surfactant group. There was no difference in the primary outcome (p = .88). There was a slightly lower risk of late onset sepsis [25% versus 29%, adjusted odds ratio (aOR): 0.8; 95% CI: 0.6-0.9] and ROP (12.4 versus 15%, aOR: 0.7; 95% CI: 0.5-0.9) in the early surfactant group. CONCLUSIONS In preterm neonates, early administration of surfactant within 30 min of life was not associated with an increased risk of the primary composite outcome, but did have decreased rates of late onset sepsis and ROP.
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Affiliation(s)
- Amelie Stritzke
- a Department of Pediatrics, Section of Neonatology, Foothills Medical Centre , Cumming School of Medicine, University of Calgary , Calgary , Canada
| | - Khorshid Mohammad
- a Department of Pediatrics, Section of Neonatology, Foothills Medical Centre , Cumming School of Medicine, University of Calgary , Calgary , Canada
| | - Prakesh S Shah
- b Department of Paediatrics , Institute of HPME, University of Toronto, Mount Sinai Hospital , Toronto , Canada
| | - Xiang Y Ye
- c Samuel Lunenfeld-Tanenbaum Research Institute , Mount Sinai Hospital , Toronto , Canada
| | - Vineet Bhandari
- d Section of Neonatal-Perinatal Medicine, Drexel University College of Medicine, St. Christopher's Hospital for Children , Philadelphia , PA , USA
| | - Albert Akierman
- a Department of Pediatrics, Section of Neonatology, Foothills Medical Centre , Cumming School of Medicine, University of Calgary , Calgary , Canada
| | - Adele Harrison
- e Victoria General Hospital , Victoria , British Columbia , Canada
| | - Valerie Bertelle
- f Faculté de Médecine de l'Université de Sherbrooke CIUSS Estrie-CHUS , Sherbrooke, Québec , Canada
| | - Abhay Lodha
- a Department of Pediatrics, Section of Neonatology, Foothills Medical Centre , Cumming School of Medicine, University of Calgary , Calgary , Canada.,g Department of Pediatrics & Community Health Sciences , University of Calgary, Alberta Children's Hospital Research Institute , Calgary , Canada
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Freitas RJ, Munhoz TN, Santos IDSD, Chiuchetta FS, Barros F, Coletto A, Matijasevich A. Providers' compliance with practice guidelines of prenatal and neonatal care to reduce neonatal mortality: 2004 versus 2012. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2017; 19:702-712. [PMID: 28146161 DOI: 10.1590/1980-5497201600040002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 08/09/2016] [Indexed: 11/22/2022] Open
Abstract
Objective: To evaluate providers' compliance with practice guidelines of prenatal and neonatal care in order to reduce neonatal mortality. Methods: Uncontrolled before-and-after study designed to evaluate changes that occurred between 2004 and 2012, after the interventions proposed by the Municipality Committee of Research on Child Deaths, Foetal and Maternal Death (COMAI) on the frequency of the process indicators for perinatal assistance improvement. A total of 254 patients were studied in 2004 and 259 patients in 2012. Results: During the study period, there was an increase of 65% in the use of prenatal corticosteroids among pregnant women in preterm labor with gestational age of ≤ 34 weeks (rate of use of 38.0 and 62.8% in 2004 and 2012, respectively; p < 0.001), 35% of increase in the use of surfactant among newborns with ≤ 34 weeks of gestational age (41.3 and 55.6% in 2004 and 2012, respectively; p = 0.025) and a reduction of 16% in the prevalence of hypothermia (70.8 and 59.4% in 2004 and 2012, respectively; p = 0.009) at the neonatal intensive care unit admission. Conclusions: Prenatal and neonatal care practices improved between 2004 and 2012. At the end of the study period, rates of use of antenatal steroids and surfactant were lower than figures reported internationally. Similarly, the frequency of hypothermia at the neonatal intensive care unit admission was higher than the occurrence observed in developed countries.
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Affiliation(s)
- Renata Jaccottet Freitas
- Programa de Pós-graduação em Epidemiologia, Universidade Federal de Pelotas - Pelotas (RS), Brasil
| | - Tiago Neuenfeld Munhoz
- Programa de Pós-graduação em Epidemiologia, Universidade Federal de Pelotas - Pelotas (RS), Brasil
| | - Iná da Silva Dos Santos
- Programa de Pós-graduação em Epidemiologia, Universidade Federal de Pelotas - Pelotas (RS), Brasil
| | - Flávio Sérgio Chiuchetta
- Programa de Pós-graduação em Epidemiologia, Universidade Federal de Pelotas - Pelotas (RS), Brasil
| | - Fernando Barros
- Programa de Pós-graduação em Saúde e Comportamento, Universidade Católica de Pelotas - Pelotas (RS), Brasil
| | - Aline Coletto
- Faculdade de Medicina, Universidade Católica de Pelotas - Pelotas (RS), Brasil
| | - Alicia Matijasevich
- Programa de Pós-graduação em Epidemiologia, Universidade Federal de Pelotas - Pelotas (RS), Brasil.,Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Wright CJ, Polin RA. Noninvasive Support: Does It Really Decrease Bronchopulmonary Dysplasia? Clin Perinatol 2016; 43:783-798. [PMID: 27837759 DOI: 10.1016/j.clp.2016.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Noninvasive support of preterm infants with respiratory distress is an evidenced-based strategy to decrease the incidence of bronchopulmonary dysplasia. Continuous positive airway pressure (CPAP) is the only noninvasive strategy with sufficient evidence to support its use in acute respiratory distress syndrome. It is unclear if one method for delivering CPAP is superior to another. Future research will focus on strategies (eg, sustained lung inflation, and administration of surfactant using a thin plastic catheter) that increase the likelihood of success with CPAP, especially in infants with a gestational age of less than 26 weeks.
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Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Perinatal Research Center, Children's Hospital Colorado, University of Colorado School of Medicine, Mail Stop F441, 13243 East 23rd Avenue, Aurora, CO 80045, USA.
| | - Richard A Polin
- Department of Pediatrics, Morgan Stanley Children's Hospital, 3959 Broadway, New York, NY 10032, USA
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Wright CJ, Polin RA, Kirpalani H. Continuous Positive Airway Pressure to Prevent Neonatal Lung Injury: How Did We Get Here, and How Do We Improve? J Pediatr 2016; 173:17-24.e2. [PMID: 27025910 DOI: 10.1016/j.jpeds.2016.02.059] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/25/2016] [Accepted: 02/24/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Richard A Polin
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Haresh Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia at the University of Pennsylvania, Philadelphia, PA
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Kong X, Cui Q, Hu Y, Huang W, Ju R, Li W, Wang R, Xia S, Yu J, Zhu T, Feng Z. Bovine Surfactant Replacement Therapy in Neonates of Less than 32 Weeks' Gestation: A Multicenter Controlled Trial of Prophylaxis versus Early Treatment in China--a Pilot Study. Pediatr Neonatol 2016; 57:19-26. [PMID: 26059103 DOI: 10.1016/j.pedneo.2015.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/31/2015] [Accepted: 03/05/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND A domestic surfactant preparation has been used in China for a number of years. However, as for other surfactant preparations, there is debate among neonatologists regarding the optimal dose, mode of administration, and the best time of intervention. OBJECTIVE To evaluate whether prophylactic administration of surfactant is superior to early treatment in preterm infants < 32 weeks with a high risk of respiratory distress syndrome (RDS). METHODS We prospectively compared small premature infants (< 32 weeks) receiving 70 mg/kg bovine surfactant within 30 minutes after birth (prophylactic group, N = 116) with infants who received surfactant therapy for established RDS (early treatment group, N = 91). The primary outcome assessed was the incidence of RDS. The secondary outcomes assessed were severity of RDS, mortality, and bronchopulmonary dysplasia morbidity. RESULTS Compared with the early treatment group, the prophylactic group had a significantly better PaO2 (at 1 hour, 4 hours, and 12 hours postdose, respectively), better a/APO2 (at 1 hour, 4 hours, 12 hours, and 24 hours postdose, respectively), lower PaCO2 (at 1 hour postdose), and a significantly decreased need for mean airway pressure (MAP) and FiO2 on ventilation (p < 0.05). The prophylactic group had shorter durations for mechanical ventilation and supplemental oxygen compared with the early treatment group (p < 0.01 and p < 0.05, respectively). The incidence of RDS was comparable between the groups; however, the prophylactic group had a significantly lower incidence of severe RDS and significantly lower rate of repeated doses of surfactant than the early treatment group (p < 0.05). The incidences of bronchopulmonary dysplasia and patent ductus arteriosus were also lower in the prophylactic group than the early treatment group (p < 0.05). The two groups were comparable in mortality rate. CONCLUSION In preterm infants under 32 weeks' gestation, prophylactic use of a domestic surfactant preparation is better than early surfactant treatment in improving pulmonary status and in decreasing the incidence of severe RDS and duration on mechanical ventilation.
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Affiliation(s)
- Xiangyong Kong
- Newborn Care Center, Bayi Children's Hospital, the Military General Hospital of Beijing P.L.A., Beijing, China
| | - Qiliang Cui
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuhua Hu
- Department of Pediatrics, Jiangsu Province Hospital, Nanjing, China
| | - Weimin Huang
- Department of Pediatrics, Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - Rong Ju
- Newborn Care Center, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Wen Li
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Ruijuan Wang
- Newborn Care Center, Bayi Children's Hospital, the Military General Hospital of Beijing P.L.A., Beijing, China
| | - Shiwen Xia
- Department of Pediatrics, Hospital of Hubei Province, Wuhan, China
| | - Jialin Yu
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Tian Zhu
- Department of Neonatology, Daping Hospital, The Third Military Medical University, Chongqing, China
| | - Zhichun Feng
- Newborn Care Center, Bayi Children's Hospital, the Military General Hospital of Beijing P.L.A., Beijing, China.
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Abstract
The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.
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Affiliation(s)
- Kevin Fiscella
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York 14620;
| | - Mechelle R Sanders
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York 14620;
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Abstract
Worldwide, neonatal networks have been formed to address both the research and quality improvement agenda of neonatal-perinatal medicine. Neonatal research networks have led the way in conducting many of the most important clinical trials of the last 25 years, including studies of cooling for hypoxic-ischemic encephalopathy, delivery room management with less invasive support, and oxygen saturation targeting. As we move into the future, increasing numbers of these networks are tackling quality improvement initiatives as a priority of their collaboration. Neonatal quality improvement networks have been in the forefront of the quality movement in medicine and, in the 21st century, have contributed to many of the reported improvements in care. In the coming years, building and maintaining this community of care is critical to the success of neonatal-perinatal medicine.
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Affiliation(s)
- Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA; California Perinatal Quality Care Collaborative, Palo Alto, CA, USA.
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT, USA; Department of Pediatrics, University of Vermont College of Medicine, Burlington, VT, USA
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Chavatte-Palmer P, Lévy R, Boileau P. [Reproduction without a uterus? State of the art of ectogenesis]. ACTA ACUST UNITED AC 2012; 40:695-7. [PMID: 23084738 DOI: 10.1016/j.gyobfe.2012.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 09/10/2012] [Indexed: 10/27/2022]
Abstract
The concept of reproduction without uterus, or ectogenesis, has long been considered a myth. Nowadays, however, the in vitro conception (IVF) and embryo culture before implantation are largely used in humans with more than 50,000 IVF and ICSI procedures yearly in France, but also in ruminants where about 400,000 bovine embryos are produced in vitro worldwide each year. In order to proceed with gestation, a 3D structure enabling implantation is needed. Ex-vivo implantation of human embryos was obtained both in a perfused ex-vivo uterus and in a 3 dimensional culture of endometrial cells, but these experiments were stopped because of ethical concerns. The implantation of a mouse embryo in a similar 3D structure has been reported but did not lead to the production of a live pup. Another interest for an artificial uterus or placenta would be to use it for ex-vivo maturation of very premature fetuses. Extra-corporal membrane oxygenation (ECMO) was developed for many years but its use remains disappointing in preterm infants when compared to the important progress made with more classical clinical care. In any case, goat fetuses have been maintained alive up to 9 days in an artificial amniotic pouch, being oxygenated via ECMO.
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Affiliation(s)
- P Chavatte-Palmer
- Inra, UMR1198 biologie du développement et reproduction, 78350 Jouy-en-Josas, France.
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Oyetunji TA, Thomas A, Moon TD, Fisher MA, Wong E, Short BL, Qureshi FG. The impact of ethnic population dynamics on neonatal ECMO outcomes: a single urban institutional study. J Surg Res 2012; 181:199-203. [PMID: 22831562 DOI: 10.1016/j.jss.2012.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 06/08/2012] [Accepted: 07/02/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Neonatal extracorporeal membrane oxygenation ECMO has been clinically used for the last 25 y. It has been an effective tool for both cardiac and non cardiac conditions. The impact of ethno-demographic changes on ECMO outcomes however remains unknown. We evaluated a single institution's experience with non cardiac neonatal ECMO over a 28-y period. METHODS A retrospective review of all neonates undergoing noncardiac ECMO between the y 1984 and 2011 was conducted and stratified into year groups I, II, III (≤1990, 1991-2000, and ≥2001). Demographic, clinical, and outcome data were collected. The patient specifics, ECMO type, ECMO length, blood use, complications, and outcomes were analyzed. Univariate, bivariate, and multivariate analyses were then performed. RESULTS Data was available for 827 patients. The number of African-American and Hispanic patients increased over the last 27 y (27.5% versus 45.0% and 3.3% versus 21.5%, year group I versus year group III, respectively). The proportion of congenital diaphragmatic hernia (CDH) patients by ethnicity also increased for African-Americans and Hispanics between the two year groups (22.0% to 33.0% and 4.9% to 33.0%, respectively). Similar pattern was noted for non-CDH diagnoses. Low birth weight, low APGAR scores, CDH, primary pulmonary hypertension, central nervous system hemorrhage, and ECMO were independent predictors of mortality. Ethnicity, in itself however, was not associated with mortality on adjusted analysis. CONCLUSION More African-Americans and Hispanics have required ECMO over the years with a concurrent decrease in the number of Caucasians. While ethnicity was not an independent predictor of mortality, it appears to be a surrogate for fatal but sometime preventable diagnoses among minorities. Further investigations are needed to better delineate the reason behind this disparity.
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Affiliation(s)
- Tolulope A Oyetunji
- Department of Surgery, Howard University College of Medicine, Washington, District of Columbia, USA
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Survival rates in extremely low birthweight infants depend on the denominator: avoiding potential for bias by specifying denominators. Am J Obstet Gynecol 2011; 205:329.e1-7. [PMID: 21741613 DOI: 10.1016/j.ajog.2011.05.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 04/20/2011] [Accepted: 05/12/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of the study was to assess whether recent data reporting survival of preterm infants introduce a bias from the use of varying denominators. STUDY DESIGN We performed a systematic review of hospital survival of infants less than 1000 g or less than 28 weeks. Included publications specified the denominator used to calculate survival rates. RESULTS Of 111 eligible publications only 51 (46%) specified the denominators used to calculate survival rates: 6 used all births, 25 used live births, and 20 used neonatal intensive care unit admissions. Overall rates of survival to hospital discharge ranged widely: from 26.5% to 87.8%. Mean survival varied significantly by denominator: 45.0% (±11.6) using a denominator of all births, 60.7% (±13.2) using live births, or 71.6% (±12.1) using used neonatal intensive care unit admissions (P ≤ .009 or less for each of 3 comparisons). CONCLUSION Variations in reported rates of survival to discharge for extremely low-birthweight (<1000 g) and extremely low-gestational-age (<28 weeks) infants reflect in part a denominator bias that dramatically affects reported data.
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Thomas J. The Circle of Caring Model for Neonatal Transport. Neonatal Netw 2011; 30:14-20. [PMID: 21317093 DOI: 10.1891/0730-0832.30.1.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Circle of Caring Model serves as a guide that superimposes nursing and medical practice models. This transformative template was formulated for advanced practice nursing in all health care settings, including neonatal care. This article proposes an extension of this model specific to neonatal transport. It also shows how the Circle of Caring Model for Neonatal Transport functions within the framework of a hypothetical patient case.
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Shah S. Exogenous surfactant: intubated present, nebulized future? World J Pediatr 2011; 7:11-5. [PMID: 20549420 DOI: 10.1007/s12519-010-0201-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 05/25/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND exogenous surfactant is currently administered via intra-tracheal instillation, a method which can increase the possibility of clinical instability in the peri-surfactant administration period. Since its introduction, there has been an increase in understanding of the pathology of respiratory distress syndrome and surfactant biology. This includes development of a potential nebulized surfactant which has the potential to increase the number, safety and timely administration of the medication in preterm infants. DATA SOURCES based on recent original publications in the field of surfactant biology, we reviewed our experience with surfactant administration and discussed the available evidence on nebulized surfactant and outlined potential barriers toward widespread introduction of this therapy. RESULTS surfactant has revolutionized modern neonatal management and nebulized surfactant is attractive and a vector for administration. However, issues regarding costeffectiveness, development of nebulizer devices capable of administration, deposition of medication in the airway and dosing strategies remain unresolved. CONCLUSIONS nebulized surfactant has the potential to be a therapeutic breakthrough by eliminating the potent volu-and-baro-traumatic effects of mechanical ventilation in the peri-surfactant period. Nebulization would likely lead to increased administration immediately after birth and more emphasis on noninvasive ventilator strategies. These features will aid clinical implementation of nebulized surfactant as a standard of treatment after introduction.
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Affiliation(s)
- Shetal Shah
- Department of Pediatrics, State University of New York at Stony Brook, Stony Brook, New York 11791, USA.
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Kaplan HC, Lorch SA, Pinto-Martin J, Putt M, Silber JH. Assessment of surfactant use in preterm infants as a marker of neonatal intensive care unit quality. BMC Health Serv Res 2011; 11:22. [PMID: 21281485 PMCID: PMC3045285 DOI: 10.1186/1472-6963-11-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 01/31/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proposed neonatal quality measures have included structural measures such as average daily census, and outcome measures such as mortality and rates of complications of prematurity. However, process measures have remained largely unexamined. The objective of this research was to examine variation in surfactant use as a possible process measure of neonatal quality. METHODS We obtained data on infants 30 to 34 weeks gestation admitted with respiratory distress syndrome (RDS) within 48 hours of birth to 16 hospitals participating in the Pediatric Health Information Systems database from 2001-2006. Models were developed to describe hospital variation in surfactant use and identify patient and hospital predictors of use. Another cohort of all infants admitted within 24 hours of birth was used to obtain adjusted neonatal intensive care unit (NICU) mortality rates. To assess the construct validity of surfactant use as a quality metric, adjusted hospital rates of mortality and surfactant use were compared using Kendall's tau. RESULTS Of 3,633 infants, 46% received surfactant. For individual hospitals, the adjusted odds of surfactant use varied from 2.2 times greater to 5.9 times less than the hospital with the median adjusted odds of surfactant use. Increased annual admissions of extremely low birth weight infants to the NICU were associated with greater surfactant use (OR 1.80, 95% CI 1.02-3.19). The correlation between adjusted hospital rates of surfactant use and in-hospital mortality was 0.37 (Kendall's tau p = 0.051). CONCLUSIONS Though results were encouraging, efforts to examine surfactant use in infants with RDS as a process measure reflecting quality of care revealed significant challenges. Difficulties related to adequate measurement including defining RDS using administrative data, accounting for care received prior to transfer, and adjusting for severity of illness will need to be addressed to improve the utility of this measure.
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Affiliation(s)
- Heather C Kaplan
- Perinatal Institute and James M, Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA.
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Howell EA, Holzman I, Kleinman LC, Wang J, Chassin MR. Surfactant use for premature infants with respiratory distress syndrome in three New York city hospitals: discordance of practice from a community clinician consensus standard. J Perinatol 2010; 30:590-5. [PMID: 20182436 PMCID: PMC2888640 DOI: 10.1038/jp.2010.6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess concordance with a locally developed standard of care for premature infants with respiratory distress syndrome (RDS) for whom the standard recommends surfactant treatment within 2 h of birth, and to examine the association between clinical, demographic, and hospital characteristics with discordance from the standard. STUDY DESIGN Retrospective cohort study of 773 infants weighing < or =1750 g born in any of the three New York City hospitals between 1999 and 2002. RESULT 227 of the 773 infants (29%) met criteria for treatment according to the standard. Of these, 37% received surfactant by 2 h. By 4 h, 70% of infants who met the standard received surfactant. White infants were more likely to receive surfactant by 4 h (85%) than African American (61%) or Latino infants (67%). Multivariable logistic regression revealed significant odds ratios predicting discordance from the relaxed criteria (4 h) for African American race (4.10, 95% confidence interval: 1.30 to 13.00), 100 g of birth weight (odds ratio: 1.22, 95% confidence interval: 1.10 to 1.34), and hospital of birth. CONCLUSION Many infants with RDS failed to receive surfactant replacement therapy at 2 and 4 h after birth. African Americans and those born larger were less likely to receive surfactant. If these data can be generalized, there is a large opportunity to reduce infant morbidity from RDS and to reduce racial/ethnic disparities in birth outcomes by increasing the rate and speed with which surfactant is delivered to these infants.
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Affiliation(s)
- Elizabeth A. Howell
- Department of Health Policy, Mount Sinai School of Medicine, New York City, New York,Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai School of Medicine, New York City, New York
| | - Ian Holzman
- Department of Pediatrics, Mount Sinai School of Medicine, New York City, New York
| | - Lawrence C. Kleinman
- Department of Health Policy, Mount Sinai School of Medicine, New York City, New York,Department of Pediatrics, Mount Sinai School of Medicine, New York City, New York
| | - Jason Wang
- Department of Health Policy, Mount Sinai School of Medicine, New York City, New York
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Saianda A, Fernandes RM, Saldanha J. Uso do método INSURE versus CPAP nasal isolado em recém-nascidos de muito baixo peso com 30 ou menos semanas de gestação. REVISTA PORTUGUESA DE PNEUMOLOGIA 2010. [DOI: 10.1016/s0873-2159(15)30071-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kaplan HC, Tabangin ME, McClendon D, Meinzen-Derr J, Margolis PA, Donovan EF. Understanding variation in vitamin A supplementation among NICUs. Pediatrics 2010; 126:e367-73. [PMID: 20603256 DOI: 10.1542/peds.2009-3085] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We examined and characterized variation among NICUs in the use of vitamin A supplementation for the prevention of bronchopulmonary dysplasia in extremely low birth weight infants. METHODS An historical cohort study of extremely low birth weight infants admitted within 7 days after birth to NICUs participating in the Pediatric Health Information System database, between January 1, 2005, and March 31, 2008, was performed. NICU medical directors were surveyed to determine attitudes and decision-making regarding adoption of vitamin A supplementation. The proportion of infants receiving vitamin A at each center was measured over time. Patient and hospital characteristics associated with vitamin A use were examined. RESULTS Among 4184 eligible infants cared for in 30 NICUs, 1005 infants (24%) received vitamin A. Eighteen centers (60%) used vitamin A for some patients. Infants discharged in 2007 (odds ratio: 2.7 [95% confidence interval: 1.4-5.3]) and 2008 (odds ratio: 2.8 [95% confidence interval: 1.4-5.8]), compared with 2005, were more likely to receive vitamin A. NICU medical directors from centers using vitamin A, compared with centers that did not adopt vitamin A supplementation, reported stronger beliefs in the efficacy of vitamin A to reduce the incidence of bronchopulmonary dysplasia (83% vs 33%; P = .03) and in the ease with which vitamin A could be implemented (75% vs 22%; P = .02). CONCLUSIONS Although the use of vitamin A is increasing, marked variation across NICUs remains. Provider attitudes and system characteristics seem to influence vitamin A adoption.
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Affiliation(s)
- Heather C Kaplan
- Divisions of Neonatology, Cincinnati Children's Hospital Medical Center, Division of Neonatology, ML 7009, Cincinnati, OH 45229, USA.
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Koch L, Frommhold D, Beedgen B, Ruef P, Poeschl J. Prophylactic administration of surfactant in extremely premature infants. Crit Care Res Pract 2010; 2010:235894. [PMID: 20948885 PMCID: PMC2951078 DOI: 10.1155/2010/235894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 01/21/2010] [Accepted: 03/24/2010] [Indexed: 11/17/2022] Open
Abstract
Objective. To investigate whether prophylactic surfactant administration is superior over selective treatment in preterm infants with respiratory distress syndrome (RDS). Methods. In our retrospective analysis, we compared premature infants (23 + 0 to 26 + 6 weeks) receiving 200 mg/kg surfactant (curosurf(®)) within five minutes after birth (prophylactic group, N = 31) with those infants who received surfactant therapy for established RDS (selective group, N = 34). Results. Prophylactic therapy significantly decreased the need for mechanical ventilation (74 hours per patient versus 171 hours per patient, resp.). We observed a reduced incidence of interstitial emphysema (0% versus 9%, resp.), pneumothoraces (3% versus 9%, resp.), chronic lung disease (26% versus 38%, resp.), and surfactant doses per patient (1.3 versus 1.8, resp.), although those variables did not reach significance. Conclusion. We conclude that infants under 27 weeks' gestation profit from prophylactic surfactant administration by reducing the time of mechanical ventilation. This in turn could contribute to reduce the risk for mechanical ventilation associated complications, without any detrimental short-term side effects.
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Affiliation(s)
- Lutz Koch
- Division of Neonatology, Department of Pediatrics, University of Heidelberg Medical School, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - David Frommhold
- Division of Neonatology, Department of Pediatrics, University of Heidelberg Medical School, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Bernd Beedgen
- Division of Neonatology, Department of Pediatrics, University of Heidelberg Medical School, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Peter Ruef
- Division of Neonatology, Department of Pediatrics, University of Heidelberg Medical School, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Johannes Poeschl
- Division of Neonatology, Department of Pediatrics, University of Heidelberg Medical School, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
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O'Donnell CPF, Kamlin COF, Davis PG, Morley CJ. Crying and breathing by extremely preterm infants immediately after birth. J Pediatr 2010; 156:846-7. [PMID: 20236659 DOI: 10.1016/j.jpeds.2010.01.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Revised: 11/24/2009] [Accepted: 01/06/2010] [Indexed: 12/21/2022]
Abstract
We reviewed videos of 61 extremely preterm infants taken immediately after birth. The majority cried (69%) and breathed (80%) without intervention. Most preterm infants are not apneic at birth.
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Abstract
The "Quality Chasm" exists in neonatal intensive care. Despite years of clinical research in neonatology, therapies continue to be underused, overused, or misused. A key concept in crossing the quality chasm is system redesign. The unpredictability of human factors and the dynamic complexity of the neonatal ICU are not amenable to rigid reductionist control and redesign. Change is best accomplished in this complex adaptive system by use of simple rules: (1) general direction pointing, (2) prohibitions, (3) resource or permission providing. These rules create conditions for purposeful self-organizing behavior, allowing widespread natural experimentation, all focused on generating the desired outcome.
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Affiliation(s)
- Dan L Ellsbury
- The Center for Research, Education, and Quality, Pediatrix Medical Group, 1301 Concord Terrace, Sunrise, FL 33323, USA.
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Abstract
The Vermont Oxford Network is a not-for-profit organization established in the late 1980s with the goals of improving the quality and safety of medical care for newborn infants and their families through a coordinated program of research, education, and quality improvement. In this paper the authors discuss the activities and programs sponsored by the Network to achieve those goals.
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Affiliation(s)
- Jeffrey D Horbar
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, VT, USA.
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Reynolds RD, Pilcher J, Ring A, Johnson R, McKinley P. The Golden Hour: care of the LBW infant during the first hour of life one unit's experience. Neonatal Netw 2009; 28:211-9; quiz 255-8. [PMID: 19592362 DOI: 10.1891/0730-0832.28.4.211] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Care practices during the first hour of life, the Golden Hour, can have a significant impact on outcomes of low birth weight infants. Although the latest edition of the Neonatal Resuscitation Program added guidelines for preterm infants, additional care is often indicated. Complications that could potentially be impacted by care in the first hour of life include thermoregulation, intraventricular hemorrhage, chronic lung disease, and retinopathy of prematurity. Our unit has implemented and revised a Golden Hour evidence-based care process that includes the use of realistic videotaped simulations, followed by team debriefing sessions. Early results of the revised process show reductions in the targeted complications.
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Affiliation(s)
- Regina D Reynolds
- Baylor University Medical Center , 3500 gaston Avenue, Dallas, TX 75246, USA.
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Moeschler JB, Amato RS, Brewster T, Burke L, Dinulos MB, Smith R, Smith W, Miller P. Improving genetic health care: A Northern New England pilot project addressing the genetic evaluation of the child with developmental delays or intellectual disability. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2009; 151C:241-54. [DOI: 10.1002/ajmg.c.30221] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Affiliation(s)
- William McGuire
- Centre for Reviews and Dissemination, Hull York Medical School, University of York, YO10 5DD, UK.
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Elective high-frequency oscillatory ventilation in preterm infants with respiratory distress syndrome: an individual patient data meta-analysis. BMC Pediatr 2009; 9:33. [PMID: 19445701 PMCID: PMC2698824 DOI: 10.1186/1471-2431-9-33] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 05/16/2009] [Indexed: 11/22/2022] Open
Abstract
Background Despite the considerable amount of evidence from randomized controlled trials and meta-analyses, uncertainty remains regarding the efficacy and safety of high-frequency oscillatory ventilation as compared to conventional ventilation in the early treatment of respiratory distress syndrome in preterm infants. This results in a wide variation in the clinical use of high-frequency oscillatory ventilation for this indication throughout the world. The reasons are an unexplained heterogeneity between trial results and a number of unanswered, clinically important questions. Do infants with different risk profiles respond differently to high-frequency oscillatory ventilation? How does the ventilation strategy affect outcomes? Does the delay – either from birth or from the moment of intubation – to the start of high-frequency oscillation modify the effect of the intervention? Instead of doing new trials, those questions can be addressed by re-analyzing the individual patient data from the existing randomized controlled trials. Methods/Design A systematic review with meta-analysis based on individual patient data. This involves the central collection, validation and re-analysis of the original individual data from each infant included in each randomized controlled trial addressing this question. The study objective is to estimate the effect of high-frequency oscillatory ventilation on the risk for the combined outcome of death or bronchopulmonary dysplasia or a severe adverse neurological event. In addition, it will explore whether the effect of high-frequency oscillatory ventilation differs by the infant's risk profile, defined by gestational age, intrauterine growth restriction, severity of lung disease at birth and whether or not corticosteroids were given to the mother prior to delivery. Finally, it will explore the importance of effect modifying factors such as the ventilator device, ventilation strategy and the delay to the start of high-frequency ventilation. Discussion An international collaborative group, the PreVILIG Collaboration (Prevention of Ventilator Induced Lung Injury Group), has been formed with the investigators of the original randomized trials to conduct this systematic review. In the field of neonatology, individual patient data meta-analysis has not been used previously. Final results are expected to be available by the end of 2009.
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28
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Park JJ, Lee PS, Lee SG. The effects of early surfactant treatment and minimal ventilation on prevention of bronchopulmonary dysplasia in respiratory distress syndrome. KOREAN JOURNAL OF PEDIATRICS 2009. [DOI: 10.3345/kjp.2009.52.1.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jong Jin Park
- Department of Pediatrics, Fatima Hospital, Daegu, Korea
| | - Pil Sang Lee
- Department of Pediatrics, Fatima Hospital, Daegu, Korea
| | - Sang Geel Lee
- Department of Pediatrics, Fatima Hospital, Daegu, Korea
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29
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Abstract
Respiratory failure secondary to surfactant deficiency is a major cause of morbidity and mortality in preterm infants. Surfactant therapy substantially reduces mortality and respiratory morbidity for this population. Secondary surfactant deficiency also contributes to acute respiratory morbidity in late-preterm and term neonates with meconium aspiration syndrome, pneumonia/sepsis, and perhaps pulmonary hemorrhage; surfactant replacement may be beneficial for these infants. This statement summarizes indications, administration, formulations, and outcomes for surfactant-replacement therapy. The impact of antenatal steroids and continuous positive airway pressure on outcomes and surfactant use in preterm infants is reviewed. Because respiratory insufficiency may be a component of multiorgan dysfunction, preterm and term infants receiving surfactant-replacement therapy should be managed in facilities with technical and clinical expertise to administer surfactant and provide multisystem support.
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Abstract
High quality of care in neonatology implies providing an appropriate level of care to well newborn babies as well as more specialised care for the few babies who need it. Audit, surveillance and outcome studies may not always capture the complexity of quality of care and its contribution to outcome, and a more focused approach to standards of care evaluation may be required. Future progress in this field in the UK would benefit from a more coordinated approach from different organisations to bring together expertise in large database, management and analysis, audit and a national profile for feedback, evidence-based guidelines and guidelines development skills, expertise in the practice of changes together with the promotion by credible perinatal authorities of clinical practice.
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Affiliation(s)
- D Acolet
- Confidential Enquiry into Maternal and Child Health (CEMACH) Central Office, 188 Baker Street, London NW1 5SD, UK.
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31
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Shinwell ES, Blickstein I. The risks for very low birth weight infants from multiple pregnancies. Clin Perinatol 2007; 34:587-97, vi-vii. [PMID: 18063107 DOI: 10.1016/j.clp.2007.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Advances in perinatal and neonatal care in recent years have resulted in dramatic improvements in the rate of intact survival of preterm infants. As a result, neonatologists have focused on the new challenge of bringing about similar advances for the tiniest infants who are born at or near the current limits of viability. Although these tiny infants comprise only a small proportion of all births, the ravages of prematurity make them by far the most challenging group of infants who require our attention in the neonatal intensive care unit.
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Affiliation(s)
- Eric S Shinwell
- Department of Neonatology, Kaplan Medical Center, Rehovot, Hebrew University, Jerusalem, Israel.
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32
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Been JV, Zimmermann LJI. What's new in surfactant? A clinical view on recent developments in neonatology and paediatrics. Eur J Pediatr 2007; 166:889-99. [PMID: 17516084 PMCID: PMC7102086 DOI: 10.1007/s00431-007-0501-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 04/18/2007] [Indexed: 11/29/2022]
Abstract
UNLABELLED Surfactant therapy has significantly changed clinical practice in neonatology over the last 25 years. Recent trials in infants with respiratory distress syndrome (RDS) have not shown superiority of any natural surfactant over another. Advancements in the development of synthetic surfactants are promising, yet to date none has been shown to be superior to natural preparations. Ideally, surfactant would be administered without requiring mechanical ventilation. An increasing number of studies investigate the roles of alternative modes of administration and the use of nasal continuous positive airway pressure to minimise the need for mechanical ventilation. Whether children with other lung diseases benefit from surfactant therapy is less clear. Evidence suggests that infants with meconium aspiration syndrome and children with acute lung injury/acute respiratory distress syndrome may benefit, while no positive effect of surfactant is seen in infants with congenital diaphragmatic hernia. However, more research is needed to establish potential beneficial effects of surfactant administration in children with lung diseases other than RDS. Furthermore, genetic disorders of surfactant metabolism have recently been linked to respiratory diseases of formerly unknown origin. It is important to consider these disorders in the differential diagnosis of unexplained respiratory distress although no established treatment is yet available besides lung transplantation for the most severe cases. CONCLUSION Research around surfactant is evolving and recent developments include further evolution of synthetic surfactants, evaluation of surfactant as a therapeutic option in lung diseases other than RDS and the discovery of genetic disorders of surfactant metabolism. Ongoing research is essential to continue to improve therapeutic prospects for children with serious respiratory disease involving disturbances in surfactant.
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Affiliation(s)
- Jasper V Been
- Department of Paediatrics, Research Institute Growth and Development, Maastricht University Hospital, Maastricht, The Netherlands.
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Jenkins J, Alderdice F, McCall E. Improvement in neonatal intensive care in Northern Ireland through sharing of audit data. Qual Saf Health Care 2007; 14:202-6. [PMID: 15933318 PMCID: PMC1744012 DOI: 10.1136/qshc.2004.010371] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PROBLEM Ten percent of infants born will require admission to a neonatal facility. Coordinated activity to monitor and improve the quality of care for this high risk, high cost group of infants is considered a high priority. At the time of initiation of this project no system for collection and analysis of neonatal data existed in Northern Ireland. DESIGN In 1994 an ongoing prospective centralised data collection system was implemented to facilitate quality improvement and research in neonatal care. We aim to ascertain if there has been a demonstrable improvement in the quality of care provided since the initiation of this system. SETTING All nine Northern Ireland neonatal intensive care units returned prospectively collected socioeconomic, obstetric and neonatal episode data. KEY MEASURES FOR IMPROVEMENT Achievement of the agreed quality indicators relating to transfer patterns, thermoregulation, antenatal steroid administration, and timing of administration of surfactant during the period 1 April 1999 to 31 March 2000 were compared with data for the period 1 April 1994 to 31 March 1996. STRATEGIES FOR CHANGE Monitoring included audit and annual feedback of timely clear and relevant data where results were provided confidentially as standardised reports, together with anonymised comparisons with other similar sized units. Draft recommendations were made at regional level and units were asked to adopt finalized consensus guidelines at the local level and to implement changes to clinical practice. EFFECTS OF CHANGE The proportion of transfers taking place in utero increased from 26% to 42% and antenatal steroid administration from 68% to 82%. Normothermia on first admission improved from 66% to 71% for inborn infants. The proportion of infants receiving surfactant where the first dose was given within an hour of birth increased from 13% to 66%. LESSONS LEARNT A multi-professional regional care network can facilitate the development of agreed standards and a culture of regular evaluation leading to quality improvement.
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Affiliation(s)
- J Jenkins
- Department of Child Health, Queen's University Belfast, Institute of Clinical Science, Belfast, UK.
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Abstract
PURPOSE OF REVIEW To present existing data on the potential use of aerosolized surfactants for treatment of neonatal respiratory distress syndrome in the era of noninvasive ventilatory support. RECENT FINDINGS Current surfactant therapy requires endotracheal intubation and application of positive pressure ventilation. Instillation of the drug itself can be complicated by 'peridosing adverse events' including, but not limited to, desaturations, bradycardias, changes in blood pressure, drug reflux and even the need for reintubations. Increasing use of noninvasive ventilatory support for neonatal respiratory distress syndrome has motivated clinicians and researchers to look for alternate ways of introducing surfactants to patients. Aerosolized surfactants have been tested in animal models of respiratory distress syndrome. In addition, four small clinical studies have been performed to date. The effectiveness of this form of treatment requires further study, however, which will need to include optimizing the dose of aerosolized surfactant, choosing particle size, developing the best delivery system, and using a surfactant formulation that maintains its activity once aerosolized. SUMMARY Aerosolized surfactants for neonatal respiratory distress syndrome may prevent the need for endotracheal intubation. Appropriately designed randomized controlled studies are required to determine if this form of surfactant administration is as effective and safe as tracheal instillation.
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Affiliation(s)
- Jan Mazela
- Poznan University of Medical Sciences, Poland.
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Abstract
The neonatal intervention trials of the 1980s and early 1990s focused primarily on short-term outcomes. Contemporary clinical trials have recognized the importance of longer-term outcomes but have rarely been powered to achieve that aim. This review discusses important and clinically relevant outcomes that future trials should be powered to address and identifies the challenges facing the neonatal clinical trials community. These challenges include consensus definitions of relevant outcomes that are objective and validated, variability among centers in populations and practices, and the need for predictive surrogate markers of long-term outcomes. Future trials must be designed and powered to address the potential for harm as well as the prospect of benefit.
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Affiliation(s)
- Judy L Aschner
- Department of Pediatrics and The Vanderbilt Kennedy Center, Vanderbilt University Medical Center, Nashville, TN 37232-9544, USA.
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Fiori HH, Fritscher CC, Fiori RM. Selective surfactant prophylaxis in preterm infants born at < or =31 weeks' gestation using the stable microbubble test in gastric aspirates. J Perinat Med 2007; 34:66-70. [PMID: 16489887 DOI: 10.1515/jpm.2006.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate the stable microbubble test (SMT) ability to select candidates for surfactant prophylaxis for respiratory distress syndrome (RDS). STUDY DESIGN We followed patients treated according to a new routine for surfactant prophylaxis based on the SMT to determine timing of the initial dose of surfactant, proportion of infants using surfactant, and the predictive value of the SMT. Gastric secretions were collected after birth. Newborns with < 25 microbubbles (MB)/mm(2) received prophylactic surfactant. Surfactant was given only after confirmation of RDS (rescue therapy) to newborns with > or =25 MB/mm(2). RESULTS Fifty-four (55%) had a low MB count and received prophylactic surfactant. Three out of 44 infants with a high MB count required rescue therapy (negative predictive value 93%; CI:81.3-98.6%). The median interval and interquartile range between surfactant administration and birth in the prophylaxis group was 20 (17-27) minutes. Surfactant was used in 23 of 28 (82%) infants born at < 28 weeks of gestation and in 34 of 70 (49%) infants between 28 and 31 weeks. CONCLUSIONS The SMT may be useful to determine surfactant prophylaxis (< 30 min after birth). This approach may reduce costs and the number of unnecessary interventions.
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Affiliation(s)
- Humberto H Fiori
- Department of Pediatrics, Hospiral São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Av. Ipiranga 6690-5o andar, CEP 90670-020, Porto Alegre, RS, Brazil
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van Veenendaal MB, van Kaam AH, Haitsma JJ, Lutter R, Lachmann B. Open lung ventilation preserves the response to delayed surfactant treatment in surfactant-deficient newborn piglets. Crit Care Med 2006; 34:2827-34. [PMID: 17006360 DOI: 10.1097/01.ccm.0000243794.09377.96] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Delayed surfactant treatment (>2 hrs after birth) is less effective than early treatment in conventionally ventilated preterm infants with respiratory distress syndrome. The objective of this study was to evaluate if this time-dependent efficacy of surfactant treatment is also present during open lung ventilation. DESIGN Prospective, randomized controlled animal study. SETTING University-affiliated research laboratory. SUBJECTS Thirty-eight newborn piglets. INTERVENTIONS Following repeated whole-lung lavage, animals were randomly allocated to conventional positive pressure ventilation (PPVCON) using a positive end-expiratory pressure (PEEP) of 5 cm H2O and a tidal volume of 7 mL/kg or open lung positive pressure ventilation (PPVOLV). During PPVOLV, collapsed alveoli were actively recruited and thereafter stabilized with sufficient PEEP. Within each ventilation group, animals received surfactant (25 mg/kg) either after 2 hrs (PPVCON-2 and PPVOLV-2) or after 4 hrs (PPVCON-4 and PPVOLV-4) of ventilation. A control group received surfactant immediately after lung lavage. Following surfactant administration, all animals were conventionally ventilated for an additional 2 hrs. MEASUREMENTS AND MAIN RESULTS Two hours after surfactant treatment, both oxygenation and lung mechanics showed a clear deterioration in the PPVCON-4 group compared with PPVCON-2 and the control group. However, this deterioration of the surfactant response over time was not observed during PPVOLV. Analysis of the bronchoalveolar lavage fluid obtained at the end of the experiment showed that the protein concentration and the conversion of large to small aggregate surfactant was significantly higher in the PPVCON-4 group compared with the PPVCON-2 group while comparable in both PPVOLV groups. In addition, interleukin-8 and myeloperoxidase levels tended to be higher in the PPVCON-4 group compared with the PPVOLV-4 group. CONCLUSIONS In contrast to conventional ventilation, open lung ventilation preserves the response to delayed surfactant treatment in surfactant-deficient newborn piglets. This sustained response is accompanied by an attenuation of secondary lung injury.
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Affiliation(s)
- Mariëtte B van Veenendaal
- Department of Neonatology, Emma Children's Hospital AMC, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
OBJECTIVE To search for recent clinical trials of neonatal surfactant treatment and report their findings. METHODS Recent was defined as published between 2000 and 2005. An online search on PubMed was made on 30th December 2005 using the following terms: surfactant treatment, clinical trials and neonate, with limits of years 2000 to 2005 and age - newborn from birth to 1 month. Randomised clinical trials (RCTs) and systematic reviews of RCTs were prioritised and studies in children and animals were excluded from further analysis. RESULTS 175 papers were found in this search. Only about half of these papers were directly related to some aspect of surfactant treatment and of these just over one-half were either RCTs or systematic reviews of RCTs. Of the 34 RCTs of surfactant treatment, 3 were excluded as they involved children or animals rather than neonates. Twenty-nine trials studied preterm babies with respiratory distress syndrome (RDS) and 2 were for meconium aspiration syndrome (MAS) in term infants. The median sample sizes of these studies were RDS (92, range 19-1,361) and MAS (42, range 22-61). Eighteen of the RDS trials compared two or more surfactant preparations, the most frequently studied being Curosurf and Survanta but altogether 11 different surfactants were compared. These new RCTs need to be analysed by meta-analyses in systematic reviews. Twelve systematic reviews were found and these demonstrated the superiority of prophylactic over selective use of surfactant in babies <30 weeks, natural over synthetic surfactant and the absence of an increase in long-term developmental sequelae. Surfactant for MAS may reduce the severity of respiratory illness and the need for extracorporeal membrane oxygenation. Of the non-randomised trials' novel delivery methods, failure to use evidence-based guidelines and the benefit of surfactant for babies <25 weeks were the most interesting. CONCLUSIONS Surfactant remains one of the most effective and safest interventions in neonatology. Prophylactic natural surfactant seems to be the most evidence-based treatment for babies <30 weeks. Of the newer synthetic surfactants, only Surfaxin has been compared with currently used surfactants and systematic reviews are needed to establish if it has a role in treatment of RDS. The improvement in outcome for babies <25 weeks has been due to a number of interventions: prenatal steroids, prenatal antibiotics and postnatal surfactant. Clinical trials of surfactant replacement in the neonate continue to be published with remarkable frequency.
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Affiliation(s)
- Henry L Halliday
- Regional Neonatal Unit, Royal-Jubilee Maternity Service, Royal Maternity Hospital and Department of Child Health, Queen's University Belfast, Northern Ireland, UK.
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Hughes JL, McCall E, Alderdice F, Jenkins J. More and earlier surfactant for preterm infants. Arch Dis Child Fetal Neonatal Ed 2006; 91:F125-6. [PMID: 16492949 PMCID: PMC2672669 DOI: 10.1136/adc.2005.073148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2005] [Indexed: 11/04/2022]
Abstract
Surfactant administration to infants born at less than 32 weeks gestation was compared between two time periods (1 April 1994 to 31 March 1996 and 1 April 1999 to 31 March 2001). Overall administration increased significantly from 41% to 54%, and within one hour of birth from 13% to 60%. Regional data collection and feedback helps promote quality improvement and implementation of published evidence and guidelines.
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Affiliation(s)
- J L Hughes
- Department of Child Health, Queen's University Belfast, Institute of Clinical Science, North Ireland, UK
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Gray PH, Trotter JA, Langbridge P, Doherty CV. Pain relief for neonates in Australian hospitals: a need to improve evidence-based practice. J Paediatr Child Health 2006; 42:10-3. [PMID: 16487382 DOI: 10.1111/j.1440-1754.2006.00782.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To ascertain the extent to which neonatal analgesia was used in Australia for minor invasive procedures as an indicator of evidence-based practice in neonatology. METHODS A cross-sectional telephone survey of hospitals in all Australian states and territories with more than 200 deliveries per year was carried out. Questions were asked regarding awareness of the benefits and the use of analgesia for minor invasive procedures in term and near term neonates. Analysis was undertaken according to state and territory, annual birth numbers and the level of neonatal nursery care available. RESULTS Data were available from 212 of 214 eligible hospitals. Of the total respondents, 51% and 70% respectively were aware of the benefits of sucrose and breast-feeding for neonatal analgesia. Eleven per cent of units administered sucrose before venepuncture and 25% of units used breast-feeding. Ten per cent of units used sucrose before heel prick with 49% utilizing breast-feeding. Expressed breast milk was used in 10% of units. Analgesia was given less frequently before intravenous cannulation compared to venepuncture and heel prick. Awareness and implementation of neonatal analgesia varied widely in the states and territories. There was a trend for hospitals providing a higher level of neonatal care to have a greater awareness of sucrose as an analgesic (P < 0.0001) and the use of sucrose for venepuncture (P = 0.029), heel prick (P = 0.025) and intravenous catheter insertion (P = 0.013). Similar trends were found on analysis according to birth number of the maternity units. Smaller units had a greater usage of breast-feeding as an analgesic for heel prick (P = 0.017). CONCLUSION Despite good evidence for the administration of sucrose and breast milk in providing effective analgesia for newborn infants, it is not widely used in Australia. It is imperative that the gap between research findings and clinical practice with regard to neonatal analgesia be addressed.
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Affiliation(s)
- Peter H Gray
- Department of Neonatology, Mater Mothers' Hospital, University of Queensland, Brisbane, Queensland, Australia.
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Acolet D, Elbourne D, McIntosh N, Weindling M, Korkodilos M, Haviland J, Modder J, Macintosh M. Project 27/28: inquiry into quality of neonatal care and its effect on the survival of infants who were born at 27 and 28 weeks in England, Wales, and Northern Ireland. Pediatrics 2005; 116:1457-65. [PMID: 16322171 DOI: 10.1542/peds.2004-2691] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To identify variations in standards of neonatal care in the first week of life that might have contributed to deaths in infants who were born at 27 and 28 weeks' gestation. METHODS A case-control study was conducted of infants who were born at 27 and 28 weeks' gestation in England, Wales, and Northern Ireland during a 2-year period. Cases were neonatal deaths; control subjects were randomly selected survivors at day 28. Main outcome measures were failures of prespecified standards of care or deficiencies in care reported by regional panels assessing anonymized medical records. RESULTS Failures of standards of care relating to ventilatory support (adjusted odds ratio [OR]: 3.29; 95% confidence interval [CI]: 1.97-5.49), cardiovascular support (OR: 2.37; 95% CI :1.36-4.13), and thermal care (OR: 1.71; 95% CI: 1.21-2.43) were associated with neonatal death. Frequencies of unmet resuscitation standards (range: 3%-46%) and of delays in surfactant administration (range: 38%-40%) were similar in cases and control subjects. Panels identified significantly more deficiencies in all aspects of neonatal care in cases with the exception of the management of infection. Stratification by clinical condition of infants at birth showed a stronger association between overall standard of care and death when infants were in a good condition at birth. CONCLUSIONS Our findings suggest an association between quality of neonatal care and neonatal deaths, most marked for early thermal care and ventilatory and cardiovascular support. Poor overall quality of care was more strongly associated with deaths when the infant was in a good condition at birth.
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Affiliation(s)
- Dominique Acolet
- Confidential Enquiry into Maternal and Child Health (CEMACH) Central Office, London NW1 5SD, United Kingdom.
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Jobe AH. Transition/adaptation in the delivery room and less RDS: "Don't just do something, stand there!". J Pediatr 2005; 147:284-6. [PMID: 16182661 DOI: 10.1016/j.jpeds.2005.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Accepted: 05/02/2005] [Indexed: 11/19/2022]
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Schechter MS, Margolis P. Improving subspecialty healthcare: lessons from cystic fibrosis. J Pediatr 2005; 147:295-301. [PMID: 16182664 DOI: 10.1016/j.jpeds.2005.03.044] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2004] [Revised: 01/25/2005] [Accepted: 03/16/2005] [Indexed: 11/19/2022]
Affiliation(s)
- Michael S Schechter
- Department of Pediatrics, Brown Medical School, Rhode Island Hospital/Hasbro Children's Hospital, Providence, Rhode Island 02903, USA
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Clark RH. Interneonatal intensive care unit variation in growth rates and feeding practices in healthy moderately premature infants. J Perinatol 2005; 25:437-9. [PMID: 15983620 DOI: 10.1038/sj.jp.7211288] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fernandes CJ, Horst DA, O'Donovan DJ. Nasopharyngeal surfactant administration to prevent neonatal respiratory distress syndrome. J Perinatol 2005; 25:361-2; author reply 363. [PMID: 15861205 DOI: 10.1038/sj.jp.7211264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Shinwell ES. Neonatal morbidity of very low birth weight infants from multiple pregnancies. Obstet Gynecol Clin North Am 2005; 32:29-38, viii. [PMID: 15644287 DOI: 10.1016/j.ogc.2004.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The epidemic of multiple births has translated into a marked rise in very low birth weight infants, who are at risk for major neonatal morbidity and mortality. Gestational age-adjusted comparisons of outcome between singletons and multiples have shown conflicting results. Comparisons that corrected for relevant confounding variables show that twins and singletons have similar risks for early morbidity and mortality. Very low birth weight triplets may have increased risk for neonatal mortality, however. Second-born very low birth weight twins seem to be at risk for increased respiratory morbidity, even in the era of routine antenatal corticosteroids and postnatal surfactant therapy.
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Affiliation(s)
- Eric S Shinwell
- Department of Neonatology, Kaplan Medical Center, PO Box 1, Rehovot 76100, Jerusalem, Israel.
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Horbar JD, Carpenter JH, Buzas J, Soll RF, Suresh G, Bracken MB, Leviton LC, Plsek PE, Sinclair JC. Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial. BMJ 2004; 329:1004. [PMID: 15514344 PMCID: PMC524548 DOI: 10.1136/bmj.329.7473.1004] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2004] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation. DESIGN Cluster randomised controlled trial. SETTING AND PARTICIPANTS 114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001). MAIN OUTCOME MEASURES Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax. INTERVENTION Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email. RESULTS Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax. CONCLUSION A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.
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Affiliation(s)
- Jeffrey D Horbar
- Vermont Oxford Network, 33 Kilburn Street, Burlington, VT 05401, USA.
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