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

Abstract

Objective. Using an evidence-based approach, a Vermont Oxford Network focus group whose goal was to reduce brain injury developed and implemented a number of potentially better practices. Each center approached implementation of the practices differently. Reducing the incidence of intraventricular hemorrhage and periventricular leukomalacia are important for improving long-term outcomes for low birth weight infants. Methods. Implementation approaches for some but not all of the practices at the various centers are discussed. The practices reviewed include optimal peripartum management, such as resuscitation, avoidance of hypothermia, optimal surfactant delivery, early neonatal management by the most experienced providers, and measures to minimize pain and stress. Additional practices include maintenance of neutral head positioning, fluid volume therapy for hypotension, indomethacin prophylaxis, ventilator management, avoidance of routine suctioning, and limiting the use of sodium bicarbonate and postnatal dexamethasone. Results. Approaches to implementation were center specific, and results vary. Although some practices were easier to implement than others, communication, education, and leadership were critical to the process. Conclusions. The quality improvement multidisciplinary approach is a useful tool for finding ways to reduce the incidence of intraventricular hemorrhage and periventricular leukomalacia.

Neurodevelopmental and Behavioral Outcomes in Extremely Premature Neonates With Ventriculomegaly in the Absence of Periventricular-Intraventricular Hemorrhage

“…Despite an association in magnetic resonant imaging studies with poor neurodevelopmental outcomes data on nonhemorrhagic ventriculomegaly remain sparse, to our knowledge . Although identification is potentially easy, these findings are not routinely collected by clinicians and researchers in many quality-improvement collaboratives focused on very low-birth-weight infants .…”

Care Bundle Application Decreases The Frequency and Severity of Intraventricular Hemorrhage in Preterm Neonates: Single Center Study

“…Pain and stress may impede venous return, increasing cerebral blood volume (CBV); thus swaddling, boundaries, preemie hugs, minimal stimulation, quiet and dark environment are recommended (39). Midline head positioning has been included in recent germinal matrix-IVH prevention bundles at many institution (7) as an increase in intracranial pressure and CBV after head rotation, caused by obstruction of the homolateral jugular veins, has been reported to predispose to IVH (40)(41)(42).…”

“…The evidence-based quality improvement approach suggests that some potentially better practices can be developed and implemented to decrease brain injury. The practices include antenatal measures such as giving antenatal corticosteroids to mothers for neuroprotection; perinatal measures such as delayed cord clamping and prevention of hypothermia in the delivery room, as well as minimal handling and stimulation; and postnatal measures such as early resuscitation, maintaining the body's temperature at ≥36°C, minimizing pain and stress via developmental care, and maintenance of neutral head position (7,8). Our study aimed to assess the effect of implementation of similar perinatal measures in an effort to decrease incidence and severity of IVH in our unit at Kasr Al Ainy University Hospital NICU, Cairo University.…”

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

“…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. While difficulties in adhering to these suggested practices have been reported, 22 their impact on the incidence of PIVH has not yet been elucidated.…”