This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Kaempf, J. W. Articles by McDonald, J. V. Search for Related Content PubMed PubMed Citation Articles by Kaempf, J. W. Articles by McDonald, J. V. Related Collections Premature & Newborn Related AAP Red Book topics: Yersinia enterocolitica and... Social Bookmarking                         What's this?

PEDIATRICS Vol. 111 No. 4 April 2003, pp. e534-e541

ELECTRONIC ARTICLE

Implementing Potentially Better Practices to Improve Neonatal Outcomes After Reducing Postnatal Dexamethasone Use in Infants Born Between 501 and 1250 Grams

Joseph W. Kaempf, MD, Betty Campbell, RNC, Ronald S. Sklar, MD, Cindy Arduza, NNP, Robert Gallegos, RRT, Mara Zabari, RN, Allen Brown, BA, BS and John V. McDonald, MD

From the Providence St Vincent Medical Center, Portland, Oregon

--> Objective. The purpose of this article is to describe how a neonatal intensive care unit (NICU) was able to reduce substantially the use of postnatal dexamethasone in infants born between 501 and 1250 g while at the same time implementing a group of potentially petter practices (PBPs) in an attempt to decrease the incidence and severity of chronic lung disease (CLD).

Methods. This study was both a retrospective chart review and an ongoing multicenter evidence-based investigation associated with the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2000). The NICU specifically made the reduction of CLD and dexamethasone use a priority and thus formulated a list of PBPs that could improve clinical outcomes across 3 time periods: era 1, standard NICU care that antedated the quality improvement project; era 2, gradual implementation of the PBPs; and era 3, full implementation of the PBPs. All infants who had a birth weight between 501 and 1250 g and were admitted to the NICU during the 3 study eras were included (era 1, n = 134; era 2, n = 73; era 3, n = 83). As part of the NIC/Q 2000 process, the NICU implemented 3 primary PBPs to improve clinical outcomes related to pulmonary disease: 1) gentle, low tidal volume resuscitation and ventilation, permissive hypercarbia, increased use of nasal continuous positive airway pressure; 2) decreased use of postnatal dexamethasone; and 3) vitamin A administration. The total dexamethasone use, the incidence of CLD, and the mortality rate were the primary outcomes of interest. Secondary outcomes included the severity of CLD, total ventilator and nasal continuous positive airway pressure days, grades 3 and 4 intracranial hemorrhage, periventricular leukomalacia, stages 3 and 4 retinopathy of prematurity, necrotizing enterocolitis, pneumothorax, length of stay, late-onset sepsis, and pneumonia.

Results. The percentage of infants who received dexamethasone during their NICU admission decreased from 49% in era 1 to 22% in era 3. Of those who received dexamethasone, the median number of days of exposure dropped from 23.0 in era 1 to 6.5 in era 3. The median total NICU exposure to dexamethasone in infants who received at least 1 dose declined from 3.5 mg/kg in era 1 to 0.9 mg/kg in era 3. The overall amount of dexamethasone administered per total patient population decreased 85% from era 1 to era 3. CLD was seen in 22% of infants in era 1 and 28% in era 3, a nonsignificant increase. The severity of CLD did not significantly change across the 3 eras, neither did the mortality rate. We observed a significant reduction in the use of mechanical ventilation as well as a decline in the incidence of late-onset sepsis and pneumonia, with no other significant change in morbidities or length of stay.

Conclusions. Postnatal dexamethasone use in premature infants born between 501 and 1250 g can be sharply curtailed without a significant worsening in a broad range of clinical outcomes. Although a modest, nonsignificant trend was observed toward a greater number of infants needing supplemental oxygen at 36 weeks’ postmenstrual age, the severity of CLD did not increase, the mortality rate did not rise, length of stay did not increase, and other benefits such as decreased use of mechanical ventilation and fewer episodes of nosocomial infection were documented.

Key Words: chronic lung disease • dexamethasone • extremely low birth weight infants • nasal continuous positive airway pressure • permissive hypercarbia • Vermont Oxford Network • collaborative quality improvement • NIC/Q 2000

Abbreviations: NICU, neonatal intensive care unit • PBPs, potentially better practices • NCPAP, nasal continuous positive airway pressure • CLD, chronic lung disease • NIC/Q 2000, Neonatal Intensive Care Quality Improvement Collaborative • ReLi, reduce lung injury • PCO₂, partial pressure of carbon dioxide

---

Received for publication Aug 13, 2002; Accepted Oct 24, 2002.

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				E S Shinwell, L Lerner-Geva, A Lusky, B Reichman, and in collaboration with the Israel Neonatal Network Less postnatal steroids, more bronchopulmonary dysplasia: a population-based study in very low birthweight infants Arch. Dis. Child. Fetal Neonatal Ed., January 1, 2007; 92(1): F30 - F33. [Abstract] [Full Text] [PDF]

				C. R. Neal Jr., G. Weidemann, M. Kabbaj, and D. M. Vazquez Effect of neonatal dexamethasone exposure on growth and neurological development in the adult rat Am J Physiol Regulatory Integrative Comp Physiol, August 1, 2004; 287(2): R375 - R385. [Abstract] [Full Text] [PDF]