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Published on: August 25, 2022
Neuroprotection Bundles and Intraventricular Hemorrhage Rates in Neonates <29 Weeks' Gestation
Poorva Deshpande1, Ipsita Goswami2, Khorshid Mohammad3
1Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
Insights
The intraventricular hemorrhage-neuroprotection bundle (IVH-NB) improved care practices in neonatal intensive care units. However, it did not significantly reduce rates of severe intraventricular hemorrhage (IVH) or death in preterm infants.
Area of Science:
- Neonatalogy
- Perinatal Medicine
- Clinical Quality Improvement
Background:
- Intraventricular hemorrhage (IVH) is a significant concern in preterm infants, associated with adverse neurological outcomes.
- Neuroprotection bundles aim to standardize care and reduce IVH incidence.
- The effectiveness of the intraventricular hemorrhage-neuroprotection bundle (IVH-NB) on IVH rates in extremely preterm infants requires evaluation.
Purpose of the Study:
- To assess the impact of implementing the intraventricular hemorrhage-neuroprotection bundle (IVH-NB) on intraventricular hemorrhage (IVH) rates.
- To determine if IVH-NB implementation influences severe IVH, post-hemorrhagic ventricular dilatation (PHVD), or severe neurological injury in neonates born at <29 weeks' gestation.
Main Methods:
- A multicenter, retrospective, pre- and post-implementation cohort study was conducted.
- Data from 17 Canadian neonatal intensive care units (NICUs) were analyzed for 6522 infants born at <29 weeks' gestation.
- Primary outcome was a composite of severe IVH (grade III/IV) or death within 7 days; secondary outcomes included severe IVH, PHVD, and severe neurological injury.
Main Results:
- Implementation of IVH-NB was associated with increased use of deferred cord clamping, prophylactic indomethacin, and normothermia, and decreased cardiopulmonary resuscitation and endotracheal intubation at birth.
- No significant changes were observed in the adjusted odds ratios for the composite outcome, severe IVH, or PHVD post-implementation.
- Early treatment of patent ductus arteriosus (PDA), adopted by two sites, was the only bundle component linked to improved outcomes (aOR 0.30).
Conclusions:
- The IVH-NB implementation led to positive changes in clinical practices within NICUs.
- Despite practice improvements, the IVH-NB did not demonstrate a significant reduction in severe IVH or associated adverse outcomes in this cohort.
- Further research may be needed to refine neuroprotection strategies for extremely preterm infants.
Objective:
To evaluate the association of intraventricular hemorrhage-neuroprotection bundle (IVH-NB) implementation on intraventricular hemorrhage (IVH) rates in infants born at <29 weeks' gestation.
Study Design:
This multicenter, retrospective, preimplantation and postimplementation cohort study included neonates of <29 weeks' gestation admitted to Canadian neonatal intensive care units (NICUs) participating in the Canadian Neonatal Network. Sites which implemented IVH-NB were identified via a survey. Data were collected for 36 months each for preimplantation and postimplementation periods per NICU, with 1-month washout. Infants with major anomalies or admitted >2 days after birth were excluded. Primary outcome was a composite of severe IVH (grade III/IV) or death ≤ first 7 days. Secondary outcomes included severe IVH, posthemorrhagic ventricular dilatation, and severe neurological injury (severe IVH or periventricular leukomalacia).
Results:
Seventeen NICUs that implemented IVH-NB were included, contributing a total of 6522 infants (3216 preimplementation and 3306 postimplementation). Postimplementation, deferred cord clamping (56% vs 62%, P < .0001), prophylactic indomethacin (15% vs 19%, P < .0001), and normothermia (50% vs 56%, P < .0001) increased, and cardiopulmonary resuscitation (29% vs 25%, P < .0001) and endotracheal intubation at birth decreased (46% vs 41%, P < .0001). After implementation, aOR for the composite outcome (aOR 1.07, 95% CI 0.84, 1.35), severe IVH (aOR 1.02, 95% CI 0.80, 1.31), and posthemorrhagic ventricular dilatation (aOR 1.18 95% CI 0.78, 1.79) were unchanged. The only bundle component associated with improved outcomes was early patent ductus arteriosus treatment adopted by 2 sites (aOR 0.30, 95% CI 0.17, 0.55). No temporal trend in outcomes was identified.
Conclusion:
In this large multicenter cohort, IVH-NB implementation was associated with improved practices but not with improved outcomes.
