Delivery Room Management of the Apparently Vigorous Meconium-Stained Neonate: Results of the Multicenter, International Collaborative Trial

Wiswell, Thomas E.; Gannon, Catherine M.; Jacob, Jack; Goldsmith, Leonard S.; Szyld, Edgardo; Weiss, Kerry; Schutzman, David L.; Cleary, Gerard M.; Filipov, Panayot; Kurlat, Isabel; Caballero, Carlos L.; Abassi, Soraya; Sprague, Daniel; Oltorf, Charles; Padula, Michael A.

doi:10.1097/00006254-200007000-00009

Cited by 58 publications

(95 citation statements)

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“…The inclusionary and exclusionary criteria included in the guideline may be so narrow as to have little practical value in improving clinical care, and the application of a guideline may lead to unintended effects. As recently documented by Wiswell (1998), when the neonatal resuscitation guideline used in delivery room management of apparently vigorous meconium-stained infants was put to a formal test of guideline-dictated management of intubation and airway suctioning, vs. expectant (non-intubation) management in 2094 infants, both treatment groups experienced a 7% incidence of respiratory distress, and there were no differences in meconium aspiration syndrome. In this instance, the clinical trial was performed years after the guideline was implemented.…”

Section: Analysis Of the Literaturementioning

confidence: 92%

A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

Merritt

Gold

Holland

1999

Evaluation Clinical Practice

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Clinical practice guidelines and care pathways have become a focus of quality improvement efforts in Neonatology. Health care administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice guidelines and surveys of consumer satisfaction have grown in use partly because third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care have championed their development, implementation, and monitoring. Overall there is minimal evidence-based medicine to support that neonatal outcomes have benefitted from their implementation, although some studies show affirmative effects in limited populations or in a limited number of centres. For highly autonomous physicians and nurses this standardization of medical decision making may represent a difficult transition into efforts to improve quality, based on evidence-based care, and in some instances into corporate medicine. By realigning the traditional values of patient relationships, including parent involvement, the implementation of guidelines has been fast-tracked in some institutions, without appropriate audit to determine their effectiveness in achieving their goals. However, because guidelines and clinical pathways are here to stay, neonatologists need to think critically about how their content and method of implementation, monitoring and modification may influence medical and nursing teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores their impact on the quality of medical care and thereby restricts needed care, then neonatologists must be quick to challenge the potentially damaging and inappropriate use of guidelines and care pathways. Several international efforts are underway to study both the impact of evidence-based guidelines and to determine if they can be imported from one care system into another. Furthermore, there are many medico-legal implications of guideline and clinical pathway implementation that may not favour physicians and other neonatal care practitioners, and leave to hospitals, insurers, and ultimately the courts, decisions regarding evidence-based care. Neonatologists and other practitioners in neonatal care centres should critically analyse the goals of guideline development, implementation and monitoring and should restrict themselves to guideline directed care only at those practices for which there is evidence supporting their implementation and continuous monitoring.

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Section: Analysis Of the Literaturementioning

confidence: 92%

A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

Merritt

Gold

Holland

1999

Evaluation Clinical Practice

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“…7 Large randomised trials, however, showed no benefit of routine 'intrapartum' suctioning of the pharynx 20 and no benefit from intubating and suctioning the trachea of vigorous infants born through meconium-stained liquor. 21 Neither procedure is now recommended by ILCOR. 10 It found that the benefits and risks of tracheal suctioning of nonvigorous infants born through meconium were unclear and made no recommendation.…”

Section: Suctioning the Airway For Meconiummentioning

confidence: 99%

“…Innovative approaches such as a waiver of informed consent -where eligible subjects are enrolled and consent is subsequently sought from the individual, their guardian or next of kin for their continued participation in the study -have been used in trials of emergency interventions in many age groups, including newborns. 21,35 These studies have yielded important information that has changed clinical practice. It has been thought difficult if not impossible to study interventions in the DR, a fraught environment where uncertainty is unwelcome.…”

Section: Circulatory Supportmentioning

confidence: 99%

Turn and face the strange – ch..ch..ch..changes to neonatal resuscitation guidelines in the past decade

O'Donnell

2012

J Paediatrics Child Health

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Resuscitation of newborns has been described since ancient times and is among the most commonly performed emergency medical interventions. The International Liaison Committee on Resuscitation first made recommendations on resuscitation in newborns in 1999. Over the last decade, new research and careful review of the available evidence have resulted in substantial changes to these recommendations - in particular, regarding the assessment of colour, giving supplemental oxygen, suctioning infants born through meconium-stained liquor, confirming endotracheal tube position, the use of pulse oximetry, giving CPAP to premature infants, keeping preterm infants warm using polyethylene wrapping and cooling term infants with encephalopathy. This process has also highlighted the paucity of evidence to support much of the care given to infants in the delivery room and the need for research to refine our techniques.

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“…Routine endotracheal suctioning of babies who have meconium stained liquor, and who are vigorous (breathing or crying, good muscle tone), is discouraged because it does not alter their outcome and may cause harm [Class A, LOE II 5,6 ] Observational studies suggest that depressed infants born with meconium stained amniotic fluid are at increased risk to develop MAS [LOE IV 7,8 ]. However, for non-vigorous infants, available evidence does not support or refute the value of routine endotracheal suctioning in preventing MAS.…”

Section: Endotracheal Suctionmentioning

confidence: 99%

Airway Management and Mask Ventilation of the Newborn Infant. ARC and NZRC Guideline 2010

2011

Emerg Medicine Australasia

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Delivery Room Management of the Apparently Vigorous Meconium-Stained Neonate: Results of the Multicenter, International Collaborative Trial

Cited by 58 publications

References 0 publications

A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

A critical evaluation of clinical practice guidelines in neonatal medicine: does their use improve quality and lower costs?

Turn and face the strange – ch..ch..ch..changes to neonatal resuscitation guidelines in the past decade

Airway Management and Mask Ventilation of the Newborn Infant. ARC and NZRC Guideline 2010

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