Marked variation in delivery room management in very preterm infants

Abstract

BackgroundThe International Liaison Committee on Resuscitation (ILCOR) and UK Resuscitation Council (UKRC) updated guidance on newborn resuscitation in late 2010.ObjectivesTo describe delivery room (DR) practice in stabilisation following very preterm birth (<32 weeks gestation) in the UK.MethodsWe emailed a national survey of current DR stabilisation practice of very preterm infants to all UK delivery units and conducted telephone follow-up calls.ResultsWe obtained 197 responses from 199 units (99%) and complete data from 186 units. Tertiary units administered surfactant in the DR (93% vs. 78%, P = 0.01), instituted DR CPAP (77% vs. 50%, P = 0.0007), provided PEEP in the delivery room (91% vs. 69%, P = 0.0008), and started resuscitation in air or blended oxygen (91% vs. 78%, P = 0.04) more often than non-tertiary units. Routine out of hours consultant attendance at very preterm birth was more common in tertiary units (82% vs. 55%, P = 0.0005).ConclusionsMarked variation in DR stabilisation practice of very preterm infants persisted one year after the publication of revised UKRC guidance. Delivery room care provided in non-tertiary units was less consistent with current international guidance.

Percentiles of Oxygen Saturations (SpO2) and Heart Rates (HR) in Premature Infants in the Delivery Room

“…At present, pulse oximetry is used routinely to monitor HR or titrate oxygen delivery in only 30% of United Kingdom delivery units (20). However, van Vonderen JJ et al stated that ECG is the faster way to acquire HR after birth but ECG has disadvantages in premature babies like the risk of pulseless electrical activity being misinterpreted, difficulty ensuring its adhesion to the skin [blood, mucus, vernix, amniotic fluid], possible skin damage, insufficient space in premature babies, and delayed resuscitation (21)(22)(23).…”

Respiratory Care Protocols in Neonatal Intensive Care

“…Units provide positive pressure ventilation using various methods, including the flow-inflating bag (2-63%), self-inflating bag (6-96%), T-piece/Neopuff (1-79%) and ventilator (16-49%) [2][3][4][5][6][7][8][9]. These can be delivered via face mask, binasal prongs, single nasal prong or a nasopharyngeal tube.…”

“…Continuous positive airway pressure (CPAP) in the delivery room has gained popularity over the past years, particularly for the preterm population. But its use varies between 50 and 85% across countries, with units setting different gestational age thresholds (anywhere from 24-32 weeks) above which they would attempt CPAP [2,3,5,9]. For those infants who get intubated, 3-45% of units have reported using CO 2 detectors [4,[6][7][8][9].…”

“…Despite evidence-based recommendations on the use of pulse oximetry (PO), oxygen blenders and resuscitation of term infants with room air [1], some units have not yet adopted these practices. Routine use of PO and O 2 blenders ranges from 30 to 100% and 36 to 100% across units, respectively [2,[5][6][7][8][9][10]. Although guidelines recommend preductal saturation measurements, one survey showed that only 37% of units placed their saturation probes correctly [3].…”

“…One way to decrease unnecessary variations in practice is through the use of clinical protocols. The objective of this chapter is to (1) describe the variability of respiratory care practices in neonatology; (2) evaluate the impact of practice variability on patient and health care outcomes; (3) review the evidence for using respiratory care protocols in neonates; and (4) provide an overview on how to develop and implement these protocols in the NICU.…”