Evaluation and Development of Potentially Better Practices for the Prevention of Brain Hemorrhage and Ischemic Brain Injury in Very Low Birth Weight Infants

Abstract

Objective. Neonatal care providers from 5 institutions formed a multidisciplinary focus group with the purpose of identifying potentially better practices, the implementation of which would lead to a reduction in the incidence of intracranial hemorrhage and periventricular leukomalacia in very low birth weight infants. Methods. Practices were analyzed, 4 benchmark neonatal intensive vare units were identified and evaluated, and the literature was assessed using an evidence-based approach. The work was also reviewed by a nationally respected expert. Results. Ten potentially better clinical practices were identified. In addition, variability in cranial ultrasound practice, related to both procedural process and interpretation, was identified as a confounding problem in evaluating quality. Using the same process, potentially better cranial ultrasound practices were also identified. Conclusions. Implementation of these practices will improve clinical outcomes as well as the reliability of sonogram interpretation, the basis for evaluating the quality of the team’s work.

Uso antenatal do corticosteroide e hemorragia peri-intraventricular

“…A hipotensão deverá ser tratada somente quando evidente. Na assistência respiratória, deve-se evitar a hipercapnia, a hipoxemia, a fisioterapia respiratória e as aspirações traqueais nas primeiras 72 horas de vida (9) .…”

Impact of bundle implementation on the incidence of peri/intraventricular hemorrhage among preterm infants: a pre-post interventional study

“…The results from the present study corroborate data in the literature indicating that a set of simultaneous measures aimed at improving the quality of neonatal care might have a significant impact with regard to PIVH prevention. In 2003, Carteaux et al 14 implemented a set of practices at five institutions to reduce the incidence of intracranial hemorrhage and periventricular leukomalacia in very low birth weight infants. These practices included antenatal betamethasone administration; optimization of peripartum management; optimization of direct clinical management by neonatologists and trained nurses; implementation of measures to minimize pain and stress responses; maintaining neutral head position in the first days of life; judicious treatment of hypotension by means of fluid volume therapy followed by use of inotropic agents as needed; judicious use of indomethacin to help close cases of PDA; optimization of respiratory management; limited use of sodium bicarbonate; and judicious postnatal use of dexamethasone.…”

“…The bundle implemented within the first 72 hours of life among all the eligible infants consisted of the following procedures: 1) maintaining the infant in dorsal decubitus and neutral elevated head position; 14 , 15 , 17 2) avoidance of physical therapy maneuvers and aspiration of the tracheal cannula; 18 , 19 3) postponing cerebrospinal fluid (CSF) collection for sepsis work-up until after 72 hours of life; 14 , 20 5) assessment of daily weight only after the first 72 hours of life; and 6) reinforcement of minimal handling and environmental policies. 14 , 15 …”

“… 12 , 13 However, few studies have addressed the use of bundles for prevention of PIVH. 8 , 14 , 15 Carteaux et al 14 implemented a set of practices to reduce the incidence of intracranial hemorrhage and periventricular leukomalacia among very low birth weight infants, although the impact of those measures was not reported. Schmid et al 8 implemented a bundle of measures targeting delivery care and the initial care of neonates in the delivery room and neonatal intensive care unit (NICU) that emphasized minimal handling, and they reported that these measures reduced the incidence of PIVH by 50% among preterm infants with birth weight under 1,500 g. A nursing intervention bundle applied in two Dutch centers reduced the risk of severe PIVH, and it was also associated with a lower risk of any degree of IVH, cystic periventricular leukomalacia and/or mortality.…”

Tendência temporal e desenvolvimento de escore de risco para hemorragia peri-intraventricular em recém-nascidos pré-termo de muito baixo peso

“…A reanimação ao nascimento deve seguir as normas já estabelecidas do Programa de Reanimação Neonatal da Sociedade Brasileira de Pediatria. A adesão a essas diretrizes ajuda a melhorar as condições de atendimento ao recém-nascido imaturo, uma vez que tanto a asfixia como um processo de reanimação inadequado podem levar a flutuações do FSC (27,28) (74). Incluem ainda, manter a cabeça em posição neutra no intuito de evitar a estase e a congestão venosa encefálica ( 75), e medidas para minimizar a dor e o estresse (76).…”