IVH-Prävention bei ELBW-Frühgeborenen in zwei Perinatalzentren

Zusammenfassung

Hintergrund Im Rahmen eines Projekts zur konsequenten Vermeidung zahlreicher bekannter Risikoindikatoren sank die Inzidenz von intraventrikulären Hämorrhagien (IVH) am Ulmer Perinatalzentrum. Ein Vergleich mit dem Leipziger Zentrum sollte Hinweise liefern, an welchen Stellen es an beiden Zentren noch Verbesserungsmöglichkeiten gibt.

Methoden Eine retrospektive Datenerhebung wurde für 189 Leipziger und 89 Ulmer Frühgeborene mit einem Geburtsgewicht von unter 1000 g durchgeführt. Für diese Daten wurde ein Vergleich zwischen den beiden Zentren durchgeführt.

Ergebnisse Eine IVH aller Schweregrade wurde in Leipzig (56/197, 28,4%) häufiger (p=0,01) als in Ulm (13/89, 14,6%) gefunden. Der Unterschied betraf nur die leichten IVH Grade 1–2; die Inzidenz der schweren IVH (Grad 3–4) unterschied sich nicht zwischen den beiden Zentren (p=0,59, Leipzig 12/197, 6,1%; Ulm 4/89, 4,5%). Weiterhin zeigte sich bei einzelnen IVH-Risikoindikatoren eine unterschiedliche Verteilung zwischen den beiden Zentren. So trat eine postnatale Hypokapnie in Leipzig (42/197, 21,3%) häufiger auf (p<0,01) als in Ulm (3/86, 3,5%). Auch eine postnatale Hypothermie ereignete sich häufiger (p<0,01) in Leipzig (53/197, 26,9%) als in Ulm (10/89, 11,2%). In Ulm wurde hingegen eine rasche postnatale Surfactantapplikation seltener (p<0,01) durchgeführt (32/60, 53,3%) als in Leipzig (136/158, 86,1%) und Bikarbonat wurde in Ulm häufiger gegeben (48/89, 46,1% gegenüber 183/197, 7,1%, p<0,01).

Schlussfolgerung Potenziell vermeidbare Risikofaktoren traten in beiden Zentren in unterschiedlicher Häufigkeit auf. Diese Ergebnisse ermöglichen es beiden Zentren, die jeweils mit erhöhte Häufigkeit aufgetretenen Risikofaktoren gezielt zu vermeiden und so die IVH-Rate weiter abzusenken.

Abstract

Background In a project to carefully observe and minimize risk factors of intraventricular hemorrhages (IVH) in preterm infants, the incidence decreased markedly at the perinatal Center in Ulm, Germany. By comparing its data with the perinatal center in Leipzig, Germany, we sought to identify what improvements could still be made.

Methods A retrospective survey was performed, including 189 infants from Leipzig and 89 from Ulm, all of whom weighed less than 1000 grams. A comparison between both perinatal centers was made.

Results IVH was more frequently detected in Leipzig (28.4%) than in Ulm (14.6%, p=0.011), yet only the incidence of mild IVH (grade 1–2) was affected since the incidence of severe IVH did not differ between the 2 centers (p=0.59, Leipzig 6.1%, Ulm 4.5%). Furthermore, several potentially avoidable risk factors of IVH were differentially distributed between the 2 centers. For example, postnatal hypocapnia and postnatal hypothermia occurred with higher frequency in Leipzig than in Ulm. Conversely, rapid postnatal application of surfactant was the rule in Leipzig but not in Ulm. Furthermore, sodium bicarbonate application occurred more frequently in Ulm.

Conclusion Both centers avoided certain risk factors for IVH with varying success. These results allow both centers to specifically target the risk factors that occurred with greater frequency to further reduce the incidence of IVH.

Schlüsselwörter

Frühgeborene - intrakranielle Blutung - Neonatalperiode - Perinatal Zentren - Prävention - Risikofaktoren

Key words

preterm infants - intracranial haemorrhage - perinatal centre - prevention - risk factors - neonates

• Literatur

• 1 Allen MC, Cristofalo EA, Kim C. et al. Outcomes of preterm infants: morbidity replaces mortality. Clinics in perinatology 2011; 38: 441-454
• 2 Vogtmann E-G et al. Festschrift zum 15 jährigen Jubiläum der Perinatal- und Neonatalerhebung in Sachsen 2006; 10
• 3 McCrea HJ, Ment LR. et al. The diagnosis, management, and postnatal prevention of intraventricular hemorrhage in the preterm neonate. Clinics in perinatology 2008; 35: 777
• 4 Bassan H, Feldman HA, Limperopoulos C. et al. Periventricular hemorrhagic infarction: risk factors and neonatal outcome. Pediatric neurology 2006; 35: 85-92
• 5 Vogtmann C, Koch R, Gmyrek D. et al. Risk-adjusted intraventricular hemorrhage rates in very premature infants: towards quality assurance between neonatal units. Deutsches Arzteblatt international 2012; 109: 527-533
• 6 Schmid MB, Reister F, Mayer B. et al. Prospektive Überwachung von Risikofaktoren reduziert Hirnblutungsrate bei Frühgeborenen. Deutsches Arzteblatt international 2013; 110: 489-496
• 7 Ballabh P. et al. Pathogenesis and prevention of intraventricular hemorrhage. Clinics in perinatology 2014; 41: 47-67
• 8 Obladen M, Metze B, Henrich W. et al. Interdisciplinary surveillance of intraventricular haemorrhage associated conditions in infants<1000 g. Acta paediatrica 2008; 97: 731-737
• 9 Fanaroff AA, Fanaroff JM. et al. Short- and long-term consequences of hypotension in ELBW infants. Seminars in perinatology 2006; 30: 151-155
• 10 Erickson SJ, Grauaug A, Gurrin L. et al. Hypocarbia in the ventilated preterm infant and its effect on intraventricular haemorrhage and bronchopulmonary dysplasia. Journal of paediatrics and child health 2002; 38: 560-562
• 11 Cools F, Offringa M, Askie LM. et al. Elective high-frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database of Systematic Review 2015; 3: 7-9
• 12 Papile LA, Burstein J, Burstein R. et al. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. The Journal of pediatrics 1978; 92: 529-534
• 13 Sweet D, Bevilacqua G, Carnielli V. et al. European consensus guidelines on the management of neonatal respiratory distress syndrome. Zhonghua er ke za zhi=Chinese journal of pediatrics 2008; 46: 30-34
• 14 Kribs A, Vierzig A, Hunseler C. et al. Early surfactant in spontaneously breathing with nCPAP in ELBW infants – a single centre four year experience. Acta paediatrica 2008; 97: 293-298
• 15 Soll R, Ozek E. Prophylactic protein free synthetic surfactant for preventing morbidity and mortality in preterm infants. The Cochrane database of systematic reviews 2010; 1
• 16 Ambalavanan N, Carlo WA, Wrage LA. et al. PaCO2 in surfactant, positive pressure, and oxygenation randomised trial (SUPPORT). Archives of disease in childhood. Fetal and neonatal edition 2015; 100: 9
• 17 Bennet L, Davidson JO, Koome M. et al. Glucocorticoids and preterm hypoxic-ischemic brain injury: the good and the bad. Journal of pregnancy 2012; 8
• 18 Blickstein I, Reichman B, Lusky A. et al. Plurality-dependent risk of severe intraventricular hemorrhage among very low birth weight infants and antepartum corticosteroid treatment. American journal of obstetrics and gynecology 2006; 194: 1329-1333
• 19 Chawla S, Bapat R, Pappas A. et al. Neurodevelopmental outcome of extremely premature infants exposed to incomplete, no or complete antenatal steroids. The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 2013; 26: 1542-1547
• 20 Wong D, Abdel-Latif M, Kent A. et al. Antenatal steroid exposure and outcomes of very premature infants: a regional cohort study. Archives of disease in childhood. Fetal and neonatal edition 2014; 99: 20
• 21 Lightburn MH, Gauss CH, Williams DK. et al. Observational study of cerebral hemodynamics during dopamine treatment in hypotensive ELBW infants on the first day of life. Journal of perinatology: official journal of the California Perinatal Association 2013; 33: 698-702
• 22 Dempsey EM, Barrington KJ.. Treating hypotension in the preterm infant: when and with what: a critical and systematic review. Journal of perinatology : official journal of the California Perinatal Association 2007; 27: 469-478
• 23 Brouwer A, Groenendaal F, van Haastert I-L. et al. Neurodevelopmental outcome of preterm infants with severe intraventricular hemorrhage and therapy for post-hemorrhagic ventricular dilatation. The Journal of pediatrics 2008; 152: 648-654
• 24 Bolisetty S, Dhawan A, Abdel-Latif M. et al. Intraventricular hemorrhage and neurodevelopmental outcomes in extreme preterm infants. Pediatrics 2014; 133: 55-62
• 25 Reubsaet P, Brouwer AJ, van Haastert IC. et al. The Impact of Low-Grade Germinal Matrix-Intraventricular Hemorrhage on Neurodevelopmental Outcome of Very Preterm Infants. Neonatology 2017; 112: 203-210
• 26 Sherlock RL, Anderson PJ, Doyle LW. et al. Neurodevelopmental sequelae of intraventricular haemorrhage at 8 years of age in a regional cohort of ELBW/very preterm infants. Early human development 2005; 81: 909-916
• 27 Fanaroff AA, Stoll BJ, Wright LL. et al. Trends in neonatal morbidity and mortality for very low birthweight infants. American journal of obstetrics and gynecology 2007; 196: 147.e1-8
• 28 Adams-Chapman I, Hansen NI, Stoll BJ. et al. Neurodevelopmental outcome of extremely low birth weight infants with posthemorrhagic hydrocephalus requiring shunt insertion. Pediatrics 2008; 121: 77
• 29 Dani C, Poggi C, Ceciarini F. et al. Coagulopathy screening and early plasma treatment for the prevention of intraventricular hemorrhage in preterm infants. Transfusion 2009; 49: 2637-2644
• 30 Knüpfer M, Ritter J, Pulzer F. et al. IVH in VLBW preterm babies – therapy with recombinant activated F VII?. Klin Padiatr. 2017; 229: 335-341
• 31 Thome UH, Genzel-Boroviczeny O, Bohnhorst B. et al. Permissive hypercapnia in extremely low birthweight infants (PHELBI): a randomised controlledmulticentre trial. Lancet Respir Med 2015; 3: 534-543