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Session 8B BAPM/NNS: Resuscitation, Early Care and Prematurity

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8.5 EPICURE 2: INTERVENTIONS TO STABILISE EXTREMELY PRETERM BABIES AT BIRTH

K. Costeloe1, E. S. Draper2, J. Myles1, E. M. Hennesy1. 1Barts and the London School of Medicine and Dentistry, London, UK, 2University of Leicester, Leicester, UK

Background: Survival of liveborn babies at 23 weeks’ gestation in England is low at approximately 13% (EPICure2, unpublished data); this may reflect reluctance to stabilise and provide intensive care for these babies.

Objective: To record interventions at birth and to study differences between management at different gestations.

Methods: Details of signs of life and interventions at birth were recorded for all births 23 + 0 to 26 + 6 weeks in English hospitals in 2006.

Results: 1762 livebirths were recorded; 318 (18%) at 23 weeks. Although statistically fewer than at other gestations, nonetheless 83% of 23-week gestation infants were offered active support. Of these, similar proportions across gestations were intubated by 5 minutes and more extremely immature babies were given cardiopulmonary resuscitation and/or adrenaline. Good response, assessed by heart rate at 5 minutes was associated with increasing gestational age; there was an inverse relationship between gestational age and the proportion of deaths (see table).

Conclusions: These data refute the suggestion of systematic reluctance actively to resuscitate babies at 23 weeks’ gestation.

8.6 SEX-SPECIFIC DIFFERENCES IN CIRCULATING CARBON MONOXIDE AND THE INCREASED INCIDENCE OF HYPOTENSION IN MALE PRETERM INFANTS

M. J. Stark, V. L. Clifton, I. M. R. Wright. Mother and Babies Research Centre, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia

Aim: Carbon monoxide (CO)-mediated cGMP release may result in abnormal vascular resistance and hypotension. With male sex a strong predictor of cardiovascular instability we hypothesised sex-specific differences in circulating CO contribute to the increased incidence of hypotension in preterm boys.

Methods: Infants 24–28 (n  =  44) and 29–34 (n  =  43) weeks’ gestation were studied. Haemoglobin-bound CO (% COHb) was measured by spectrophotometry in umbilical arterial blood and at 24, 72, and 120 h postnatally. Blood pressure was measured invasively and microvascular blood flow determined by laser Doppler flowmetry.

Results: Umbilical COHb was higher in the most preterm infants (p = 0.043) and in boys (p = 0.049). Similar gestational (p = 0.011) and sex effects (p = 0.025) were observed over the first 5 days of life. COHb fell over time (p<0.001). A negative correlation was observed between COHb and mean arterial pressure at 24 (r  =  −0.393, p<0.001), 72 (r  =  −0.436, p<0.001) and 120 h of age (r  =  −0.314, p = 0.009). A positive correlation was observed with microvascular blood flow at 24 (r  =  0.495, p<0.001) and 120 h of age (r  =  0.548, p<0.001). Controlling for gestation and sex, COHb was greater in infants who died in the first week of life at 72 h (p = 0.035).

Conclusions: The relationship between CO, blood pressure and microvascular blood flow are novel findings, not confined solely to sick preterm infants. CO was greatest immediately after birth. Both inducible heme-oxygenase and non-heme oxygenase-dependent pathways related to oxidative stress may initially play a more central role in carbon monoxide production, with boys more susceptible to oxidative injury and its sequelae.

8.7 PREDICTING NEONATAL MORTALITY: A COMPARISON OF THE CRIB-II SCORE WITH AND WITHOUT TEMPERATURE AT ADMISSION

B. N. Manktelow, E. S. Draper, D. J. Field. University of Leicester, Leicester, UK

Introduction: In 2003 the Clinical Risk Index for Babies was updated as CRIB-II. However, CRIB-II includes admission temperature, which complicates the use of this score as it can be influenced by early neonatal care. This work investigates the ability of CRIB-II with and without admission temperature (CRIB-II(−T)) to predict in-hospital mortality among very preterm infants.

Methods: All infants born ⩽32 weeks’ gestation and admitted for neonatal care were identified from the Neonatal Survey 2005–2006. Infants with lethal congenital malformations were excluded. Predictive probabilities for mortality were calculated for each infant using the published algorithm for CRIB-II and then recalibrated for CRIB-II and CRIB-II(−T) using the study data. The predictive abilities of the scores, investigated overall and by groups defined by gestational age and admission temperature, were summarised by c-statistics, Cox’s regression and Brier scores.

Results: 3268 infants were included: 317 (9.7%) died before discharge. Using the published algorithm both versions of the score showed excellent discrimination (c  =  0.92) but underpredicted the total number of deaths (CRIB-II, 255.2: CRIB-II(−T), 216.6). After recalibration CRIB-II and CRIB-II(−T) displayed excellent predictive characteristics both overall and for the groups defined by gestation. Whereas CRIB-II(−T) also displayed excellent predictive characteristics for the groups defined by temperature, CRIB-II showed a statistically significant lack of calibration (Cox’s regression 36.1°C to 37.5°C, p = 0.021; ⩾36.0°C or >37.5°C, p = 0.011).

Conclusions: After recalibration CRIB-II without temperature showed excellent predictive qualities and should be used when benchmarking neonatal care to avoid the risk of results being influenced by early neonatal care.

8.8 THE BLISS CLUSTER RANDOMISED CONTROLLED TRIAL OF THE EFFECT OF “ACTIVE DISSEMINATION OF INFORMATION” ON STANDARDS OF CARE FOR PREMATURE BABIES IN ENGLAND (BEADI)

D. Acolet, E. Allen1, R. Houston2, D. Elbourne1. 1Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, UK, 2Confidential Enquiry into Maternal and Child Health (CEMACH) Central Office, London, UK

Background: Traditional dissemination of information has limited impact on change in practice. Clarification of which dissemination strategies work best in neonatal units is needed. The trial aim was to assess the effectiveness of an innovative active strategy for dissemination of neonatal recommendations.

Methods: Cluster randomised controlled trial, all English neonatal units, randomised by hospital (n  =  182), stratified by networks and unit level of care. Multifaceted intervention: audit/feedback, interactive educational meetings, organisational changes. Outcomes: hospital policies (hypothermia prevention, resuscitation team at birth) and practices in preterm babies (resuscitation team and surfactant in labour ward, admission temperature). Data: EPICure2 study (baseline), CEMACH survey (post-intervention). Statistical analysis (intention to treat): post-intervention differences between active and control group accounting for clustering effect (practice outcomes).

Results: There were no differences between active/control units in level of care, number of admissions or babies <1.5 kg per year and between preterm babies in active/control groups in relevant baseline demographics characteristics. There were no significant post-intervention differences between active/control units in hospital policies. There were post-intervention differences in practice for preterm babies: eg, mean admission temperature higher in the active group, mean difference 0.29°C (95% CI 0.22 to 0.55), more use of polyethylene occlusive wrapping 79% versus 62% (p = 0.05), more surfactant given in labour ward 78% versus 60% (p = 0.04) and a trend to more ideal birth resuscitation teams composition 68% versus 57% (p = 0.09).

Conclusions: An innovative “active” strategy for dissemination of neonatal recommendations is more likely to lead to practice changes in preterm babies than current knowledge transfer mechanisms in England.

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