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Excessive volume expansion and neonatal death in preterm infants born at 27-28 weeks gestation
Andrew K Ewer1, Wendy Tyler, Andre Francis
1West Midlands Perinatal Institute, and Birmingham Women's Hospital, Birmingham, UK. a.k.ewer@bham.ac.uk
Insights
Volume expansion in preterm infants is common but its optimal amount is unclear. This study found that administering 30 mL/kg or more of fluid in the first 48 hours was linked to higher mortality in very premature neonates.
Area of Science:
- Neonatal Medicine
- Pediatric Critical Care
- Perinatal Research
Background:
- Volume expansion is frequently used to manage presumed hypovolemia in preterm infants.
- The appropriate volume for fluid administration in this population remains uncertain.
- This study investigates the impact of volume expansion on mortality in extremely preterm neonates.
Purpose of the Study:
- To analyze the relationship between volume expansion and mortality in neonates born at 27-28 weeks' gestation.
- To determine if specific volume expansion thresholds are associated with increased risk.
- To provide evidence-based guidance on fluid administration in this vulnerable group.
Main Methods:
- A case-controlled study using anonymized data from Project 27/28.
- Analysis of clinical parameters, including volume expansion in the first 48 hours of life.
- Inclusion of all deaths within the first year and matched survivors from the West Midlands region.
Main Results:
- Neonates who died within 28 days received over twice the volume expansion (38.2 mL/kg) compared to controls (18.2 mL/kg).
- No significant differences in lowest blood pressure or base deficit were observed between groups.
- Receiving ≥30 mL/kg volume expansion was associated with a 4.5-fold increased odds of death (OR 4.5 [95% CI 1.2, 17.2]).
Conclusions:
- Administration of ≥30 mL/kg volume expansion in the first 48 hours is linked to increased mortality in neonates of 27-28 weeks' gestation.
- Clinicians should exercise caution with volume expansion unless clear evidence of hypovolemia exists.
- Further research is needed to establish optimal fluid management strategies for preterm infants.
Abstract:
Volume expansion is used commonly in preterm infants to treat presumed hypovolaemia. However, the amount that should be given is uncertain. We present data that were obtained from anonymised regional case notes of Project 27/28, a national case-controlled study run by the Confidential Enquiry into Stillbirths and Deaths in Infancy. Various clinical parameters were analysed, including the volume expansion administered during the first 48 h of life. All deaths in the first year of the study in the West Midlands (cases, n = 22) and matched regional controls (survivors, n = 29) were included. The primary outcome was death within 28 days. Sixteen of the 22 deaths were considered 'not inevitable' on the basis of the neonates' condition at birth. These newborns received on average more than twice the volume expansion compared with controls in the first 48 h of life (38.2 vs. 18.2 mL/kg, P = 0.007). There were no significant differences between the groups in lowest blood pressure or base deficit within the first 12 h of life. Newborns who received >or= 30 mL/kg volume expansion in the first 48 h of life were more likely to die than those who received < 30 mL/kg (OR 4.5 [95% CI 1.2, 17.2]). Our data suggest that administration of >or= 30 mL/kg volume expansion is associated with increased mortality in neonates of 27-28 weeks' gestation. Unless there is clear evidence of hypovolaemia, clinicians should exercise caution when prescribing volume expansion.