Post on 27-Sep-2020
transcript
The next big thing… for little things
Susan Niermeyer, MD, MPH, FAAP University of Colorado Children’s Hospital Colorado Aurora, CO USA
Womb with a view
Partridge EA et al. Nature Communications 2017; 8:15112
The next big thing?
The next big thing….for little things
Bundles of interventions around birth to reduce mortality and morbidity • Significance of supporting physiological transition • Evidence for widespread effectiveness and impact of
bundles of care • Framework of community and family
Origins of neonatal care technology and intervention
Dr. Martin Couney’s incubators – 1901
Supporting physiologic transition T + A B C
Temperature
Airway
Breathing
Circulation
Temperature
• Temperature < 36⁰C at birth is an independent risk factor for death in premature infants
• Evidence from 36 observational studies • Low quality evidence upgraded to moderate due to effect
size, dose-effect relationship, single direction of evidence
• Hypothermia is associated with morbidities • Respiratory distress • Metabolic derangements - hypoglycemia • Intraventricular hemorrhage • Late-onset sepsis
hypothermia increases risk of death and morbidity in premature infants
Mullany LC et al. Arch Pediatr Adolesc Med 2010;164:650 Laptook AR et al Pediatrics 2007119:e643
Bundles of interventions to support physiologic transition
• Maintain normal temperature Plastic wrap, hat, thermal mattress, skin-to-skin contact
• Establish an airway as non-invasively as possible
• No routine suction • No routine intubation for
meconium • CPAP instead of routine
intubation and surfactant • Support breathing with low
supplemental oxygen (21-30%) • Facilitate circulation with
delayed umbilical cord clamping
Improving delivery room care for very preterm infants in a single hospital
Axillary temperature at admission to NICU
Endotracheal intubation without trial of CPAP (%infants)
Supplemental oxygen percent at 5 minutes after birth
DeMauro SB et al. Pediatrics 2013
Prevent heat loss
Reduce supplemental oxygen exposure
Increase non-invasive respiratory support
Improving delivery room care for very preterm infants
Outcome Epoch 1 Epoch 2 P-value
Duration of invasive ventilation (days)
5 (1, 31) 1 (0, 3) 0.008
Duration of non-invasive ventilation (days)
26 (8, 39) 18 (3, 30) 0.04
Supplemental oxygen at 36 wks
16 (24%) 15 (22%) 0.76
Postnatal steroid treatment of lung disease
12 (17%) 2 (3%) 0.004
Length of hospitalization (days)
80 (59, 100) 60 (50, 80) 0.02
DeMauro SB et al. Pediatrics 2013
Data shown as n (%) or median (interquartile range)
Improving delivery room care for preterm infants in a quality collaborative
• 3 groups of hospitals in California Perinatal Quality Care Collaborative: face-to-face collaboration (20), individual QI (31), non-participating (44)
• Improvement activities focusing on reducing hypothermia and invasive ventilatory support
____ collaboration - - - - individual QI ……. non-participating
Lee HC et al. Pediatrics 2014
Evidence-based practice to improve survival without severe morbidity EPICE population-based cohort of very preterm
infants
Effective Perinatal Intensive Care in Europe • 19 regions from 11
European countries • 850,000 annual births • 7336 infants born
between 24 and 31+6 weeks gestation in 2011/12
Zeitlin J et al. BMJ 2016; 354:i2976
Evidence-based practice to improve survival without severe morbidity EPICE population-based cohort of very preterm
infants
Zeitlin J et al. BMJ 2016; 354:i2976
Evidence-based practice to improve survival without severe morbidity EPICE population-based cohort of very preterm
infants • Only 58.3% (n=4275) of infants received all
evidence-based practices for which they were eligible
• Evidence-based care associated with o Lower in-hospital mortality
(risk ratio 0.72, 95% CI 0.60 - 0.87) o Lower in-hospital mortality or severe morbidity or both
(risk ratio 0.82, 95% CI 0.73 – 0.92) • Estimated 18% decrease in all deaths without
severe morbidity if evidence-based care provided to all infants
Zeitlin J et al. BMJ 2016; 354:i2976
Wrapping bundles of care in family and community
social determinants of health
Lorch SA. JAMA Pediatrics 2017
Neighborhood Built environment
Health and Health care
Economic stability
Education Social and
community context
Delivering bundles of care in a broader systems context
Temperature Airway Breathing Circulation
Planning, collaboration, education, access
Family - integrated care
The next big thing…for little things