NeoNotes
Journal Club
Mark Hydak MD, Guest Editor
5-020 | Additional Comments | Previous Article | Next Article | Search | List of Articles | Submit Comments | Index | FSN Home Page
Surfactant in the Delivery Room
Timing of Initial Surfactant Treatment for Infants 23 to 29 Weeks’ Gestation: Is Routine Practice Evidence Based? PEDIATRICS Vol. 113 No. 6 June 2004, pp. 1593-1602. Horbar JD, Carpenter JH, Buzas J, et al.
Objective. To describe the timing of initial surfactant treatment for high-risk preterm infants in routine practice and compare these findings with evidence from randomized trials and published guidelines.
Methods. Data from the Vermont Oxford Network Database for infants who were born from 1998 to 2000 and had birth weights 401 to 1500 g and gestational ages of 23 to 29 weeks were analyzed to determine the time after birth at which the initial dose of surfactant was administered. Multivariate models adjusting for clustering of cases within hospitals identified factors associated with surfactant administration and its timing. Evidence on surfactant timing from systematic reviews of randomized trials and from published guidelines was reviewed.
Results. A total of 47,608 eligible infants were cared for at 341 hospitals in North America that participated in the Vermont Oxford Network Database from 1998 to 2000. Seventy-nine percent of infants received surfactant treatment (77.6% in 1998, 79.4% in 1999, and 79.6% in 2000). Factors that increased the likelihood of surfactant treatment were outborn birth, lower gestational age, lower 1-minute Apgar score, male gender, white race, cesarean delivery, multiple birth, or birth later in the study period. The first dose of surfactant was administered at a median time after birth of 50 minutes (60 minutes in 1998, 51 minutes in 1999, and 42 minutes in 2000). Over the 3-year study period, inborn infants received their initial dose of surfactant earlier than outborn infants (median time: 43 minutes vs 79 minutes). Other factors associated with earlier administration of the initial surfactant dose were gestational age, lower 1-minute Apgar score, cesarean delivery, antenatal steroid treatment, multiple birth, and small size for gestational age. In 2000, 27% of infants received surfactant in the delivery room. There was wide variation among hospitals in the proportion of infants who received surfactant treatment in the delivery room (interquartile range: 0%–75%), in the median time of the initial surfactant dose (interquartile range: 20-90 minutes), and in the proportion of infants who received the first dose >2 hours after birth (interquartile range: 7%–34%). Six systematic reviews of randomized trials of surfactant timing were identified. No national guidelines addressing the timing of surfactant therapy were found.
Conclusion. Although the time after birth at which the first dose of surfactant is administered to infants 23 to 29 weeks’ gestation decreased from 1998 to 2000, in 2000 many infants still received delayed treatment, and delivery room surfactant administration was not routinely practiced at most units. We conclude that there is a gap between evidence from randomized controlled trials that supports prophylactic or early surfactant administration and what is actually done in routine practice at many units.
Comment:
As a commentator, I will go out on a limb and state upfront
that my reading of the literature on this issue is that viable infants born at
less than 30 weeks gestation should be intubated, stabilized, and treated with
surfactant (unless testing of amniotic fluid suggests fetal lung maturity).
By what time should this be done? There is some room for wiggle here, but the
goal should be by 10-15 minutes of age. What are the benefits? A greater
rate of survival and a reduced incidence of pulmonary air leaks are
indisputable. This survey documents that clinical practice in the VO network
(at least through 2000) was not consistent with this approach. Why?
Doubtless many neonatologists do not accept Dr. Horbar’s and my reading of the
evidence. It is also possible that some have not carefully reviewed the
literature or have not been able to overcome operational obstacles that delay
surfactant treatment. Some neonatologists argue (without data) that higher
rates of antenatal steroid therapy render early surfactant treatment
unnecessary. However, available animal and limited clinical data show that
combined antenatal steroid/early postnatal surfactant treatment is superior to
either strategy alone. It is also interesting that VO network infants whose
mothers received antenatal steroids were treated with surfactant earlier than
infants without this prenatal benefit. I wish that the authors had surveyed
each network center on the rationale for its practice. I was also a bit
disappointed that the authors did not attempt to explore the relationship
between treatment and outcome (although there are many limitations to post hoc
analysis of an uncontrolled experience) – perhaps this is a forthcoming
paper. MH
Date: 21 Jul 2004
Time: 17:56:49
It should be noted that early administration of surfactant is not recommended in
the resucitation of a depressed newborn, premature or term. I have noted many
neonatologists taking the approach of administering surfactant during the
resuscitation of a depressed new born whose HR is below 100. This is dangerous
and does not follow any NRP guideline. Early surfactant administration should
be reserved for those infants who are not in need of chest compressions or
epinephrine or other resuscitation and whose HR is greater than 100 bpm.
UserName: Alexander B. Kenton
Institution: Pediatrix
telephone: 8324532943
email: AKENTON@satx.rr.com
You may add your own comments to the discussion of this topic by selecting : Submit Comments.