3) in
infants of 500 to 1500 g birth weight before and after the implementation
of a new clinical practice of O2 management in a large
level 3 neonatal intensive care unit (NICU). NeoNotes Journal Club
Andrew B. Kairalla MD, Editor
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Objective. A wide variability in the incidence of severe
retinopathy of prematurity (ROP) is reported by different centers.
The altered regulation of vascular endothelial growth factor from
repeated episodes of hyperoxia and hypoxia is 1 important factor in
the pathogenesis of ROP. Strict management of O2 delivery
and monitoring to minimize these episodes may be associated with
decreased rates of ROP. The objective of this study was to compare
the incidence of and need for surgery for severe ROP (stages
3) in
infants of 500 to 1500 g birth weight before and after the implementation
of a new clinical practice of O2 management in a large
level 3 neonatal intensive care unit (NICU).
Methods. An oxygen management policy that included strict
guidelines in the practices of increasing and weaning of fraction of
inspired oxygen (FIO2) and the monitoring of O2
saturation parameters in the delivery room, during in-house transport
of infants to the NICU, and throughout hospitalization was
implemented in April 1998. The main objectives were to monitor
oxygenation levels more precisely and to avoid hyperoxia and repeated
episodes of hypoxia-hyperoxia in very low birth weight infants.
Included in the policy were equipment for monitoring, initiation of
monitoring at birth, avoidance of repeated increases and decreases of
the FIO2, minimization of "titration" of FIO2,
modification of previously used alarm limits, and others. After an
educational process, each staff member signed an agreement stating
understanding of and future compliance with the guidelines.
Examinations were performed by experienced ophthalmologists following
international classification and
Results. The incidence of ROP 3 to 4 at this center decreased
consistently in a 5-year period from 12.5% in 1997 to 2.5% in 2001.
The need for ROP laser treatment decreased from 4.5% in 1997 to 0% in
the last 3 years.
Conclusion. We observed a significant decrease in the rate of
severe ROP in very low birth weight infants in association with an
educational program provided to all NICU staff and the implementation and
enforcement of clinical practices of O2 management and monitoring.
Although several confounders cannot be excluded, it is likely that
differences in these clinical practices may be, at least in part,
responsible for the documented intercenter variability in rates of
ROP.
Comment.
This report describes a
performance improvement effort, not a true clinical trial.
The patients were not randomized, and the controls were historical.
That said, I was still impressed that they were able to decrease their
incidence of severe ROP by 80% using strict guidelines for FIO2 adjustment
that avoided wide swings in oxygen saturation. I would be interested to know
if this also had an effect on reducing their incidence of chronic lung disease
in this population. ABK
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