Initiation of resuscitation in the delivery room for extremely preterm infants: a profile of neonatal resuscitation instructors

OBJECTIVE: The goal of the present study was to examine the decisions of pediatricians who teach neonatal resuscitation in Brazil, particularly those who start resuscitation in the delivery room for newborns born at 23-26 gestational weeks. METHODS: The present study was a cross-sectional study that used electronic questionnaires (Dec/11-Sep/13) sent to instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics. The primary outcome was the gestational age at which the respondent said that he/she would initiate positive pressure ventilation in the delivery room. Latent class analysis was used to identify the major profiles of these instructors, and logistic regression was used to identify variables associated with belonging to one of the derived classes. RESULTS: Of 685 instructors, 82% agreed to participate. Two latent classes were identified: ‘pro-resuscitation’ (instructors with a high probability of performing ventilation on infants born at 23-26 weeks) and ‘pro-limitation’ (instructors with a high probability of starting ventilation only for infants born at 25-26 weeks). In the multivariate model, compared with the ‘pro-limitation’ class, ‘pro-resuscitation’ pediatricians were more likely to be board-certified neonatologists and less likely to base their decision on the probability of the infant’s death or on moral/religious considerations. CONCLUSION: The pediatricians in the most aggressive group were more likely to be specialists in neonatology and to use less subjective criteria to make delivery room decisions

Suggestion of recommendations for initiation or not of intensive care in prematures born at the threshold of viability in Brazil

Despite recent advances in neonatal intensive care, prematures born at less than 25 weeks gestation have high rates of morbidity and mortality. Parents and doctors face difficult decisions concerning instituting and/or continuing resuscitation and intensive care of these babies. This is, therefore, a complex ethical/moral problem with a strong impact on the lives of the surviving prematures and their families, as well as for the heath care system and society. There is increasing interest in regulating and standardizing the care of very premature babies. However, there are significant differences between the protocols used in different countries concerning the decision to resuscitate premature babies that are at the threshold of viability. In Brazil, there is no protocol on this matter. The purpose of this study is to describe the biological, bioethical, economic and legal aspects present in the decisions of resuscitation or not at the threshold of viability and to propose recommendations appropriate to Brazilian conditions. The authors suggest that comfort care measures should be offered to babies of less than 25 weeks and intensive care to those beyond this gestational age. If parents, after detailed discussions and clear information about the medical recommendation for comfort care measures to those between 23 and 25 weeks decide in favor of intensive care measures, it should be provided and rediscussed continually.Mestre em Ciências da SaúdeApesar dos grandes avanços ocorridos, nos últimos anos, no cuidado intensivo neonatal, recém-nascidos pretermo com idade gestacional abaixo de 25 semanas ainda apresentam altos índices de mortalidade e morbidade, de tal forma que familiares e médicos enfrentam dificuldades para decidir a respeito da instituição e/ou continuação da reanimação desses bebês. Trata-se, portanto, de um problema ético/moral complexo com profundo impacto na vida dos recém-nascidos pretermo sobreviventes e dos seus familiares, além das implicações para o sistema de saúde e a sociedade. Há um crescente interesse na normatização e na padronização do atendimento ao prematuro extremo. Verificam-se, no entanto, diferenças significativas entre os protocolos publicados por sociedades científicas de vários países acerca da decisão reanimar ou não recém-nascidos pretermo no limite de viabilidade. O Brasil ainda não conta com um protocolo de conduta a respeito dessa decisão. O presente estudo tem como objetivo não só descrever os aspectos biológicos, bioéticos, econômicos e legais presentes na decisão de reanimar ou não recém-nascidos pretermo no limite de viabilidade, como também propor uma recomendação de conduta adequada à realidade brasileira. Os autores sugerem que devem ser oferecidas medidas de conforto aos bebês menores de 25 semanas e cuidados intensivos neonatais aos maiores dessa idade. Caso os pais, após o diálogo exaustivo e informação esclarecida a respeito dos fundamentos da recomendação médica de apenas oferecer medidas de conforto aos bebês entre 23 e 25 semanas, ainda assim optarem pelo tratamento intensivo, este deverá ser fornecido e rediscutido continuamente

Opinions of Brazilian resuscitation instructors regarding resuscitation in the delivery room of extremely preterm newborns,

Abstract Objective: To describe the opinions of pediatricians who teach resuscitation in Brazil on initiating and limiting the delivery room resuscitation of extremely preterm infants. Method: Cross-sectional study with electronic questionnaire (Dec/2011-Sep/2013) sent to pediatricians who are instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, containing three hypothetical clinical cases: (1) decision to start the delivery room resuscitation; (2) limitation of neonatal intensive care after delivery room resuscitation; (3) limitation of advanced resuscitation in the delivery room. For each case, it was requested that the instructor indicate the best management for each gestational age between 23 and 26 weeks. A descriptive analysis was performed. Results: 560 (82%) instructors agreed to participate. Only 9% of the instructors reported the existence of written guidelines at their hospital regarding limitations of delivery room resuscitation. At 23 weeks, 50% of the instructors would initiate delivery room resuscitation procedures. At 26 weeks, 2% would decide based on birth weight and/or presence of fused eyelids. Among the participants, 38% would re-evaluate their delivery room decision and limit the care for 23-week neonates in the neonatal intensive care unit. As for advanced resuscitation, 45% and 4% of the respondents, at 23 and 26 weeks, respectively, would not apply chest compressions and/or medications. Conclusion: Difficulty can be observed regarding the decision to not resuscitate a preterm infant with 23 weeks of gestational age. At the same time, a small percentage of pediatricians would not resuscitate neonates of unquestionable viability at 26 weeks of gestational age in the delivery room

Opinions of Brazilian resuscitation instructors regarding resuscitation in the delivery room of extremely preterm newborns,

Abstract Objective: To describe the opinions of pediatricians who teach resuscitation in Brazil on initiating and limiting the delivery room resuscitation of extremely preterm infants. Method: Cross-sectional study with electronic questionnaire (Dec/2011-Sep/2013) sent to pediatricians who are instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, containing three hypothetical clinical cases: (1) decision to start the delivery room resuscitation; (2) limitation of neonatal intensive care after delivery room resuscitation; (3) limitation of advanced resuscitation in the delivery room. For each case, it was requested that the instructor indicate the best management for each gestational age between 23 and 26 weeks. A descriptive analysis was performed. Results: 560 (82%) instructors agreed to participate. Only 9% of the instructors reported the existence of written guidelines at their hospital regarding limitations of delivery room resuscitation. At 23 weeks, 50% of the instructors would initiate delivery room resuscitation procedures. At 26 weeks, 2% would decide based on birth weight and/or presence of fused eyelids. Among the participants, 38% would re-evaluate their delivery room decision and limit the care for 23-week neonates in the neonatal intensive care unit. As for advanced resuscitation, 45% and 4% of the respondents, at 23 and 26 weeks, respectively, would not apply chest compressions and/or medications. Conclusion: Difficulty can be observed regarding the decision to not resuscitate a preterm infant with 23 weeks of gestational age. At the same time, a small percentage of pediatricians would not resuscitate neonates of unquestionable viability at 26 weeks of gestational age in the delivery room

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status