Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_37_библиотеки_им_акад_М_И_Перельмана
.pdf
CONTENTS
https://t.me/medicina_free
xix
UNIT FOUR
Infection and Hematologic Diseases
of the Neonate
20 Newborn Hematology, 623
Christopher Mckinney, Beth Boulden Warren, and Susan Harvey
21 Neonatal Hyperbilirubinemia, 662
Beena D. Kamath- Rayne, Patricia A. Froese, and Elizabeth H. Thilo
22 Infection in the Neonate, 692
Mohan Pammi, M. Colleen Brand, and Leonard E. Weisman
UNIT FIVE
Common Systemic Diseases of the
Neonate
23 Respiratory Diseases, 729
Sandra L. Gardner, Mary Enzman-Hines, and Michael Nyp
24 Cardiovascular Diseases and Surgical
Interventions, 836
Tara Swanson and Lori Erickson
25 Neonatal Nephrology, 886
Melissa A. Cadnapaphornchai, Danielle E. Soranno, Terri J. Bisio, Rosanne
Woloschuk, and Megan Kirkley
27 Genetic Disorders, Malformations, and
Inborn Errors of Metabolism, 969
Anne L. Matthews and Nathaniel H. Robin
28 Neonatal Surgery, 996
Margaret E. Gallagher, Annette S. Pacetti, Harold N. Lovvorn, III, and
Brian S. Carter
UNIT SIX
Psychosocial Aspects of Neonatal
Care
29 Families in Crisis: Theoretical and Practical
Considerations, 1039
Sandra L. Gardner and Kristin Voos
30 Grief and Perinatal Loss, 1096
Sandra L. Gardner and Brian S. Carter
31 Discharge Planning and Follow- Up of the
Neonatal Intensive Care Unit Infant, 1141
Angel Carter and Brian S. Carter
32 Ethics, Values, and Palliative Care in Neonatal
Intensive Care, 1167
Julie R. Swaney, Nancy K. English, and Brian S. Carter
26 Neurologic Disorders, 929
Ara S. Hall and Daphne A. Reavey
This page intentionally left blank
https://t.me/medicina_free
UNIT ONE EVIDENCE-BASED PRACTICE
https://t.me/medicina_free
EVIDENCE-BASED
1
CLINICAL PRACTICE
ALFONSO F. PANTOJA AND MARY ENZMAN-HINES
lobally, health care systems are experiencing
challenges when evaluating therapies, qual-
G
clinical practice. Over the past several decades, health
care disciplines have made major strides to ensure
that clinical decisions and actions are based on sound
scientific evidence. Expert practice decisions and
actions are embedded in a complex web that reflects
all forms of knowing and understanding. Each element of knowing has a similar but distinct foundation of reliability and validity. Health care scholars/
researchers who provide direct patient care, administrators, and educators have joined in the effort to
identify the most reliable and sound scientific evidence available to inform and guide practice.
use evidence. This failure is either from underuse,
overuse, or misuse of evidence-based therapies and/
or system failures.
(EBP) requires the integration of the best
research evidence with our clinical expertise
and each patient’s unique values and circumstances.
care could prevent therapeutic disasters resulting
from the informal “let’s-try-it-and-see” methods
of testing new therapies that are not recognized as
risky. The epidemic of retinopathy attributable to the
indiscriminate use of supplemental oxygen; gray baby
syndrome attributable to the administration of chloramphenicol; kernicterus attributable to the introduction of sulfonamides82; and death due to liver toxicity
of 40 premature newborns attributable to the administration of a parenteral form of vitamin E (E-Ferol)89
are examples of these therapeutic misadventures in
the field of neonatal care. Silverman described how
ity of care, and the risk of adverse events in
20
Often health care systems fail to optimally
92,93
Evidence-based practice
92,93
EBP approaches in all fields of health
painfully slow health care providers were to embrace
a culture of skepticism and emphasizes, “We must
insist on the highest standards of evidence in studies
involving the youngest human beings; and, since
there is no short route to this goal, we must prepare
to be patient.”82 The use of experimentation and the
scientific method has ultimately led to our present
views of how to ask and answer clinical questions.
Mistakes have also occurred at the other
extreme, resulting in a failure to adopt therapies
that are of proven benefit or an assumption that
the risks associated with changing practice justify complacency about current treatments. The
significant delay in the adoption of antenatal corticosteroids by the obstetric community to promote fetal
lung maturation
the available evidence. One of the most important
benefits of EBP is the constant questioning:
“Have our current clinical practices been studied in appropriately selected populations of
sufficient size to accurately predict their efficacy,
benefit, safety, side effects, and cost?”
EBP is a systematic way to integrate
the best patient-centered, clinically relevant
research with our clinical expertise and with
the unique preferences, concerns, and expectations that each patient brings to a clinical encounter.92 Furthermore, EBP presents an
opportunity to enhance patient health and illness
outcomes, increase staff satisfaction, and reduce
health care expenses. There is great interest in
identifying barriers and facilitators that could
help in closing the knowledge-to-practice gap
that is inherent to the acceptance and adoption of EBP by all providers.
23,86
is a good example of failure to use
96
71
BLUE type highlights content that is particularly applicable to clinical settings.
1
2
https://t.me/medicina_free
UNIT ONE Evidence-Based Practice
FINDING HIGH-QUALITY
EVIDENCE
As new therapies are integrated into neonatal care,
health care providers must continue to increase existing knowledge of the health and health problems of
newborns. Providers need to formulate well-de-
signed questions about the specific clinical
encounter and learn how to evaluate the quality of evidence regarding risks and benefits of
new practices. Most clinical questions arise through
daily practice and often involve knowledge gaps in
background (general knowledge) and foreground
(specific knowledge to inform clinical decisions or
actions). The knowledge needs will vary according to
the experience of the clinician.
It is not the purpose of this chapter to provide a
detailed review of the various research designs that
permit reliable scientific inference. Rather, our pur-
pose is to promote the propositions that (1)
challenge clinical observations and wisdom by
finding the current best evidence and (2) carefully assess and critique research that supports
or challenges the use of new and established
clinical practices.
Clinical observations, although valuable
in shaping research questions, are limited by
selective perception—a desire to see a strategy work or fail to work. At times, a single case
or case study may prompt us to question whether
we should consider changing current practice. In
some situations, much can be learned from carefully
maintained databases. Such knowledge is gained
only when we have formed databases with clear
intentions and have collected the necessary data.
Sinclair and Bracken85 described four levels of
clinical research used to evaluate safety and
efficacy of therapies, based on their ability to
provide an unbiased answer. In ascending order,
these are (1) single case or case series reports
without controls, (2) nonrandomized studies
with historical controls, (3) nonrandomized
studies with concurrent controls, and (4)
randomized controlled trials (RCTs). RCTs
test hypotheses by using randomly assigned
treatment and control groups of adequate
size to examine the efficacy and safety of a
new therapy. In theory, random assignment of the
treatment balances unknown or unmeasured factors
that might otherwise bias the outcome of the trial.
A meta-analysis is a systematic review of the
current literature that uses statistical methods
92
to combine the results of individual studies
and summarizes the results (http://neona-
tal.cochrane.org).22 Tyson97 has suggested criteria
for identifying proven therapies in current literature
(Box 1.1). Ideally, therapeutic recommenda-
tions are supported by evidence from systematic reviews of RCTs; however, such evidence
is not always available. It is then important to
have a system to grade the strength of the quality
of the evidence found. An international collabo-
ration developed GRADE (Grading of Recommendations Assessment, Development and
Evaluation) to provide an explicit strategy for
grading evidence and the strength of recommendations.44 GRADE classifies the evidence
into one of four levels: high, moderate, low,
and very low (Table 1.1). The strength of the
recommendation is graded as strong or weak. Factors
BOX
1.1
Reported to be beneficial in a well-performed meta-analysis of all trials
Beneficial in at least one multicenter trial or two single-center trials
Modified from Tyson JE. Use of unproven therapies in clinical practice and research: how
can we better serve our patients and their families? Semin Perinatol. 1995;19:98.
TABLE
1.1
LEVEL OF
EVIDENCE
1a Systematic reviews of RCTs
1b Individual RCT with narrow confidence interval
1c All or none
2a Systematic review of cohort studies
2b Individual cohort study (including low-quality RCT
3a Systematic review of case-control study
3b Individual case-control study
4 Case-control studies
5 Expert opinion without critical appraisal
RCT, Randomized controlled trial.
From Straus SE, Richardson WS, Haynes RB. Evidence-Based Medicine: How to Practice
and Teach It. 4th ed. London: Harcourt; 2011.
PROVEN THERAPIES
or
LEVELS OF EVIDENCE
THERAPY/PREVENTION/ETIOLOGY/HARM
[less than 80% follow-up])
TRIP database
searches these
n
https://t.me/medicina_free
simultaneously
Critically appraised individual
Quality of evidence
articles (article synopses)
Randomized controlled trials
CHAPTER 1 Evidence-Based Clinical Practice
Meta-
analysis
Systematic
reviews
Critically appraised
topics
(evidence syntheses)
3
Filtered
information
Cohort studies
Case-controlled studies
Case series/reports
Background information/expert opinion
FIGURE 1.1 Evidence appraisal. (Modified from DiCenso A, Bayley L, Haynes RB: Accessing pre-appraised evidence: fine-tuning the 5S
model into the 6S model. Evid Based Nurs. 2009;12(4):99.)
that influence the strength of the recommendation
include desirable or undesirable effects, values, preferences, and economic implications (Fig. 1.1).
Although conclusions drawn from quantitative
studies (RCTs, meta-analysis of RCTs) are regarded as the strongest level of evidence, evidence from
descriptive and qualitative studies should be factored
into clinical decisions. Qualitative research pro-
vides guidance in deciding whether the findings of quantitative studies could be replicated
in various patient populations. Qualitative
research can also facilitate an understanding of
the experience and values of patients, parents,
and health care providers. The validity, impor-
tance, and applicability of qualitative studies need to
be evaluated in a similar way as quantitative studies.
PRESSURES TO INTERVENE
RCTs of appropriate size are cited as providing the best evidence for guiding clinical
decisions; however, many take years to complete and publish. Providers find it difficult to
delay the introduction of promising therapies.
Bryce and Enkin15 discussed myths about RCTs
and rationales for not conducting them. One myth
Unfiltered
informatio
is that randomization is unethical. This might
be true in rare instances when an intervention
is dramatically effective and lifesaving. The more
common situation is one in which there is limited
evidence for a current or alternative strategy.
Pressure to intervene is, however, often overpowering. Believing that an infant is in trouble, interventions occur through a cascade of interventions, one
leading to the next and each carrying risk. One of
the most frequently cited examples is the epidemic
of blindness associated with the unrestricted use of
oxygen in newborns.
81,82
Oxygen, used since the
early 1900s for resuscitation and treatment of cyanotic episodes, was noted in the 1940s to “correct”
periodic breathing in premature infants. After World
War II and the introduction of new gas-tight incubators, an epidemic of blindness occurred, resulting
from retrolental fibroplasia (RLF). Silverman81 pointed out that although many causes were suspected, it
was not until 1954 that a multicenter, controlled trial
confirmed the association between high oxygen concentrations and RLF. Frequently forgotten, however,
is that in subsequent years, mortality was increased
in infants cared for with an equally experimental
regimen of strict restriction of oxygen administration,
and many survivors had spastic diplegia. In the 1960s,
the introduction of micro techniques for measuring
4
https://t.me/medicina_free
UNIT ONE Evidence-Based Practice
arterial oxygen tension permitted better monitoring
of oxygen therapy, with a reduction in mortality,
spastic diplegia, and RLF, now called retinopathy of
prematurity (ROP). Severe ROP is currently limited
to extremely-low-birth-weight (ELBW) infants.81
Research continues to explore causes, preventive
measures, and treatments (see Chapter 31).
Large multinational, pragmatic RCTs to
resolve the uncertainty surrounding the most
appropriate levels of oxygen saturation in
premature infants have been recently conducted and the results published.
78,94,95
The
publication of the results of the SUPPORT trial94
brought about a significant debate about the ethical
aspects of comparative effectiveness research and
parental informed consent when one of the elements of the composite outcome was death before
discharge.81 The practice of allowing very-lowbirth-weight (VLBW) infants to maintain lower
oxygen saturations during the first weeks of life had
been widely disseminated throughout the United
States and the world due to anecdotal reports of
a significant decrease in the severity of ROP and
blindness with this approach.21 A recent report of
five multicenter studies (NEOPROM) with similar allocations and outcome measures that were
prospectively organized with the aim to answer
whether extremely premature infants kept at a low
or a high oxygen saturation target had different
outcomes. These studies are the SUPPORT trial
(Surfactant, Positive Pressure and Pulse Oximetry
Randomized Trial), the three BOOST II trials
from the United Kingdom, Australia, and New
Zealand, and the Canadian Oxygen Trial (COT).
Low saturation targets (85% to 89%) until 36
weeks postmenstrual age (PMA) are associated with
more deaths and more necrotizing enterocolitis
(NEC). Higher saturation targets (91% to 95%)
are associated with more ROP.76 Results from
all five trials were systematically reviewed and a
final meta-analysis (the NeOProM) performed to
determine optimal oxygen saturation targets for
preterm infants (mean gestational age of 26 weeks;
mean birth weights of 820 to 850 g).7 At 18 to 24
months corrected age, no significant difference was
found between the lower and higher saturation
groups in mortality or major disability. 7 Secondary
analysis of the data found that the lower saturation
group had significantly higher death rates prior to
36 weeks PMA, before discharge from the neonatal
intensive care unit (NICU), and before reaching 18
to 24 months’ corrected age, a significantly higher
risk of severe NEC and a significantly higher risk of
PDA requiring ligation. Preterm infants randomized
to the higher saturation group had a significantly
higher risk of bronchopulmonary dysplasia (BPD)
and ROP requiring treatment but no increase in
blindness7 (see Chapter 23).
The desire to see an intervention “work” encourages practitioners and investigators to seek early
signs of benefit. Long-term effects are frequently
overlooked. One reason is that they may not be
foreseen. Consider the example of diethylstilbestrol
(DES). DES administration to pregnant women was
introduced in 1947 without clinical trials to prevent
miscarriage, fetal death, and preterm delivery.
15,37
It
was thought to be effective after uncontrolled studies
despite controlled trials summarized in an overview
(meta-analysis) by Goldstein et al.41 (Table 1.2) that
showed the opposite. Clearly, DES was not effective,
but it continued to be used until the 1970s, when
the Food and Drug Administration (FDA) finally
disapproved its use. The unforeseen result was that
female children born to mothers who were given
DES had structural abnormalities of the genital tract,
pregnancy complications, decreased fertility, and an
increased risk for vaginal adenocarcinoma in young
women. Male children had epididymal cysts. This is
not the only example of physicians continuing to
use therapies that have been shown in RCTs to be
of no benefit.
TABLE
1.2
Miscarriage 1.20 0.89–1.62
Stillbirth 0.95 0.50–1.83
Neonatal death 1.31 0.74–2.34
All three 1.38 0.99–-1.92
Prematurity 1.47 1.08–2.00
a
An odds ratio is an estimate of the likelihood (or odds) of being affected by an exposure
(e.g., a drug or treatment) compared with the odds of having that outcome without having
been exposed. Women receiving diethylstilbestrol did not have fewer stillbirths, premature
births, or miscarriages than women who were untreated.
Data from Goldstein PA, Sacks HS, Chalmers TC. Hormone administration for the maintenance of pregnancy. In Chalmers I, Enkin M, Keirse M, eds. Effective Care in Pregnancy
and Childbirth. New York, NY: Oxford University Press; 1989.
18
EFFECTS OF DIETHYLSTILBESTROL ON
PREGNANCY OUTCOMES
TYPICAL ODDS
A
RATIO
95% CONFIDENCE
LIMITS
CHAPTER 1 Evidence-Based Clinical Practice
https://t.me/medicina_free
5
The costs of long-term studies and follow-up
surveillance are numerous. However, when effects
are measured later in life (e.g., psychological problems, ability to function in school), the cost cannot
determine study design. Even when randomized
trials are conclusive, unanswered questions remain:
Will a technology or treatment have the same effect
in all settings? Has an “appropriate” target population been selected? Are there long-term unforeseeable consequences?
EVALUATION OF THERAPIES
The major cause of death in premature infants is
respiratory failure from respiratory distress syndrome (RDS) (see Chapter 23). Previously called
hyaline membrane disease, this syndrome of expiratory
grunting, nasal flaring, chest wall retractions, and
cyanosis unresponsive to high oxygen concentrations was a mystery until the 1950s.
82
The evaluation of various therapies for RDS
contrasts the value of controlled and uncontrolled
trials. Sinclair84 noted that uncontrolled studies were
more likely to show benefit than controlled trials.
In 19 uncontrolled studies, 17 popular therapies
showed “benefit.” In 18 controlled studies, only 9
demonstrated benefit. An untrained reviewer of the
research might base clinical practice on faulty conclusions of uncontrolled trials.
Surfactant Therapy
In contrast to many proposed treatments, surfactant therapy in premature infants has been
well studied in RCTs.
ed the use of surfactant in treatment of RDS, including the optimal source and composition of surfactant
and prophylactic versus rescue treatment. Morbidity
(including pneumothorax, periventricular or intraventricular hemorrhage, BPD, and patent ductus
arteriosus) and mortality rates in treatment and control groups have been compared. Systematic reviews
of surfactant therapy confirm the effect of surfactant
therapy in reducing the risk of morbidity and mortal-
85,90
ity.
Although RCTs involving thousands of
newborns have clearly demonstrated the benefits of surfactant therapy, unanswered questions
remain. One of these questions is if prophylactic
administration of surfactant to an infant judged to
be at risk of developing RDS was better than early
4,5,46,48
Studies have evaluat-
selective use of surfactant to infants with established
RDS. Early trials demonstrated a decreased risk of air
leak and mortality with the prophylactic approach.
However, recent RCTs that reflect current practice
(i.e., greater utilization of maternal steroids and routine postdelivery stabilization on continuous positive
airway pressure [CPAP]) do not support these differences and actually demonstrate less risk of chronic
lung disease (CLD) or death when using early stabilization on CPAP with selective surfactant administration to infants requiring intubation
75,94
(Fig. 1.2).
Corticosteroid Therapy
Misuse of corticosteroids in perinatal medicine illustrates the consequences of failure
to practice evidence-based care. Many practi-
tioners initially declined to use antenatal steroids to
promote maturation of the immature fetal lung and
to prevent RDS despite strong supportive evidence,
demonstrating a failure to use a proven therapy.
ANTENATAL CORTICOSTEROID
THERAPY: SINGLE COURSE
Antenatal administration of corticosteroids to preg-
nant women who threatened to deliver prematurely
was first shown in 1972 to decrease the neonatal
mortality rate and the incidence of RDS and
intraventricular hemorrhage (IVH) in premature
infants.57 In 1990, Crowley et al.25 used meta-analysis to evaluate 12 RCTs of maternal corticosteroid
administration involving more than 3000 women.
The data showed that maternal corticosteroid
treatment significantly reduced the risk for neonatal mortality, RDS, and IVH. Sinclair,86 using a
“cumulative meta-analysis” approach of randomized
trials, clearly demonstrated that the aggregate evidence that was sufficient to show that this treatment
reduces the incidence of RDS and neonatal death
was available for almost 20 years before the use of
antenatal corticosteroids was widely accepted by the
medical community.
This led to the National Institutes of Health
(NIH) consensus development conference statement
on “Effects of Corticosteroids for Fetal Maturation
on Perinatal Outcomes.”63 Antenatal corticosteroid
treatment of women at risk for preterm delivery
between 24 and 34 weeks of gestation has been
shown to be effective and safe in enhancing fetal
lung maturity and reducing neonatal mortality. Yet
adoption by caretakers was inexplicably slow.
53
6
Favors prophylactic Favors selective
https://t.me/medicina_free
UNIT ONE Evidence-Based Practice
Review: Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants
Comparison: 2 Prophylactic surfactant vs. treatment of established respiratory distress in preterm infants less than 30 weeks' gestation
Outcome: 1 Neonatal mortality
Study or subgroup
1 Studies without routine application of CPAP
Bevilacqua 1996
Bevilacqua 1997
Dunn 1991
Egberts 1993
Kendig 1991
Merritt 1991
Walti 1995
Subtotal (95% CI) 767 746 0.71 [ 0.58, 0.88 ]61.8%
Total events: 119 (Prophylactic), 161 (Selective)
Heterogeneity: Chi
Test for overall effect: Z 3.11 (P 0.0019)
2 Studies with routine application of CPAP
Dunn 2011
Support 2010
Subtotal (95% CI) 862 884 1.24 [ 0.97, 1.58 ]38.2%
Total events: 124 (Prophylactic), 102 (Selective)
Heterogeneity: Chi
Test for overall effect: Z 1.73 (P 0.083)
Total (95% CI) 1629 1630 0.91 [ 0.78, 1.07 ]100.0%
Total events: 243 (Prophylactic), 263 (Selective)
Heterogeneity: Chi
Test for overall effect: Z 1.11 (P 0.27)
Test for subgroup difference: Chi
Prophylactic
n/N
28/136
9/49
9/62
8/75
23/235
27/76
15/134
??
8.27, df 6 (P 0.22); I?? 27%
10/209
114/653
??
0.02, df 1 (P 0.88); I?? 0.0%
??
18.64, df 8 (P 0.02); I?? 57%
Selective
n/N
46/132
9/44
8/60
14/72
40/244
21/72
23/122
8/221
94/663
??
11.24, df 1 (P 0.00); I?? 91%
Risk Ratio
M-H, Fixed, 95% CI
Weight
17.6%
3.6%
3.1%
5.4%
14.8%
8.2%
9.1%
2.9%
35.3%
Risk Ratio
M-H, Fixed, 95% CI
0.59 [ 0.39, 0.89 ]
0.90 [ 0.39, 2.06 ]
1.09 [ 0.45, 2.63 ]
0.55 [ 0.24, 1.23 ]
0.60 [ 0.37, 0.97 ]
1.22 [ 0.76, 1.95 ]
0.59 [ 0.33, 1.08 ]
1.32 [ 0.53, 3.28 ]
1.23 [ 0.96, 1.58 ]
FIGURE 1.2 Table showing effect of prophylactic versus selective surfactant administration on morbidity and mortality rates in preterm
infants. (From Rojas-Reyes X, Morley C, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm
infants. Cochrane Database Syst Rev. 2012;3:CD000510.)
ANTENATAL CORTICOSTEROID
THERAPY: REPEATED COURSES
At the same time, other practitioners adminis-
tered repeated doses despite lack of evidence
of additional benefit and questions about
safety, representing unproven use of a proven
therapy. Repeated courses of antenatal cortico-
steroids have been shown in humans and animals
to improve lung function and the quantity of pulmonary surfactant.
26,43
effects on lung structure, fetal somatic growth, and
neonatal adrenocortical function, as well as poorly
understood effects on blood pressure, carbohydrate
homeostasis, and psychomotor development.
0.2
They may also have adverse
25,61
A
0.5 12 5
2000 NIH Consensus Development Conference
found limited high-quality studies on the use of
repeated courses of antenatal steroids.64 The con-
sensus statement discouraged routine use of
repeated courses of antenatal corticosteroids.
Published preliminary reports of infants exposed to
multiple doses of antenatal steroids reaching school
age are emerging.9 A recent meta-analysis of infants
who were exposed to more than one course of
antenatal corticosteroids concluded that “although
the short-term neonatal benefits of repeated courses of antenatal corticosteroids support their use,
long-term benefits have not been demonstrated,
and long-term adverse effects have not been ruled
CHAPTER 1 Evidence-Based Clinical Practice
https://t.me/medicina_free
7
out. The adverse effect of repeated doses of antenatal corticosteroids on birth weight and weight
at early childhood follow-up is a concern. Caution
should therefore be exercised to ensure that only
those women who are at particularly high risk of
very early preterm birth are offered treatment with
repeated courses of antenatal corticosteroids.”27
The American College of Obstetricians and
Gynecologists (ACOG) recommends a repeat
course of antenatal steroids if the fetus is less
than 34 weeks of gestation and the previous
course of antenatal steroids was administered
more than 14 days earlier.
POSTNATAL STEROID THERAPY
6
Postnatal glucocorticoids, administered to
the infant after birth, have been widely used
despite weak evidence of long-term benefit
and suggestions of possible harm, illustrating
use of an uncertain therapy.53 Despite early calls
for caution in the use of postnatal corticosteroids
to decrease the risk for CLD and limit ventilator
time, they were used liberally in the 1990s.
88,91
A number of years passed before RCTs
of postnatal corticosteroid administration
included long-term follow-up. Taken together,
these studies showed positive short-term effects
on the lungs. Studies also showed increased blood
pressure and blood glucose concentrations in the
short term; increased incidence of septicemia and
gastrointestinal perforation in the intermediate
term; and with dexamethasone administered soon
after birth, abnormal neurodevelopmental outcome,
including cerebral palsy, in the long term.
3,31,46,54,91
An increased risk for septicemia should have been
anticipated, because it was first identified in an
RCT by Reese et al.74 over 50 years earlier.
In 2002, the American Academy of Pediatrics
(Committee on Fetus and Newborn) and the
Canadian Paediatric Society (Fetus and Newborn
Committee) advised against the use of systemic
dexamethasone and suggested that “outside the
context of a RCT that include assessment of longterm development, the use of corticosteroids should
be limited to exceptional clinical circumstances
(e.g., an infant on maximal ventilator support and
oxygen requirement).”2 A 2005 reanalysis of many
of the same data by Doyle et al.31 suggests that relative risks and benefits of postnatal corticosteroids
vary with level of risk for BPD. When the risk for
BPD or death is high, the risk for developmental
impairment from postnatal corticosteroids might
be outweighed by benefit.
33, 36
Watterberg et al.
100
suggested that hydrocortisone might have the benefits of dexamethasone on the lungs without adverse
neurologic effects. Following these statements, the
exposure of at-risk premature infants decreased
dramatically.
99,100
After reviewing the short-term
and long-term effects of systemic and inhaled corticosteroid use for the prevention and treatment
of CLD/BPD in the VLBW infant, both the AAP
and the Canadian Pediatric Society issued and
reaffirmed position statements regarding the use of
postnatal steroids.
14,15,52
QUALITATIVE RESEARCH
EVALUATING EXPERIENCES IN
THE NEONATAL INTENSIVE
CARE UNIT
The contribution of qualitative research to
EBP is evident when “best evidence from
RCTs” may or may not work within the
context of specific NICU environments. The
context can be quite variable and influenced by
practitioners, staff, the unit leadership, and family
influence within the unit. The implementation
of family-centered care in the NICU has
shown promising outcomes, including minimizing parental stress related to the technology and complex care of a tiny, fragile preterm
infant.59 An environment of family-centered
care has also contributed in a positive way
to the success of the implementation of
clinical practice guidelines and evaluating
outcomes.32 An additional area garnering focus in
recent qualitative research is discharge planning for
VLBW infants and how teams have implemented
EBP projects to address the issues identified as key
to parental success once the infant is discharged
to home.
planning must include early integration of parents
into the care team, CPR readiness of parents, how
to deal with emergencies facing parents at home,
and supportive infant care of the fragile infant for
successful transition to home.
mation exists about a phenomenon or a deficiency
is evident in the quality, depth, or detail of research
in a specific area of clinical practice. Qualitative
research contributes to EBP in several
62,66,73,77
Findings suggest that discharge
Qualitative studies are useful when limited infor-
8
https://t.me/medicina_free
UNIT ONE Evidence-Based Practice
areas: (1) describing patient needs and experiences; (2) providing the groundwork for
instrument development and evaluation; and
(3) elaborating on concepts relative to theory
development.
60
Systematic reviews and meta-analyses are
emerging in qualitative literature researching
parental experiences in the NICU.
40,65
In neonatology, qualitative studies provide in-depth views
of parental and provider experiences within the
NICU setting to humanize the health care of fragile
infants. Parents of infants who require NICU
care begin an experience of parenthood in
an unfamiliar and intimidating environment
that results in delayed attachment
47,79,80
; high
levels of stress, including anxiety, depression,
trauma symptoms, and isolation (both physical and emotional) from their infant
16,38
; lack
of disclosure of their infant’s condition; and a
lack of control.19 Mothers often experience feel-
ings of ambivalence, shame, guilt, and failure because
the infant is in the NICU.79 Parents also experience
the tension between exclusion and participation
in their infant’s care.
101,102,103
In contrast, parents
describe factors that contribute to parental
satisfaction in the NICU, including assurance,
caring communication, provision of consistent information, education,24 environmental
follow-up care, appropriate pain management,38 parental participation in care, and
emotional, physical, and spiritual support.24
Conversely, health care professionals’ experiences of
parental presence and participation in the NICU
revealed similar findings to those described by parents: the need to develop a caring environment for
parents to be present and take care of their child
by guiding parents and giving parents permission
to care for their child and the need for personnel
training in the art of dealing with parents in crisis,
identifying a balance between closeness and distance, and dealing with parental worry.
102,103
Quality care is a major issue currently evaluating
the delivery of health care services, yet little research
has been conducted on what parents of premature
infants perceive as quality nursing care. Price72 used
a qualitative approach to reveal the meaning
of quality nursing care from parents’ perspectives and identified concepts inherent in the
process of receiving quality nursing care. Four
stages were identified: (1) maneuvering, (2) a
process of knowing, (3) building relationships,
and (4) quality care. For parents, nontechnical
aspects of care, such as comforting infants
after painful procedures, were as important
as the technical aspects of care. Another quali-
tative study revealed seven categories that influence
changes in practice: (1) staffing issues, (2) consistency
in practice, (3) the approval process for change, (4)
a multidisciplinary approach to care, (5) frequency
and consistency of communication, (6) rationale for
change, and (7) the feedback process. Three categories further delineate quality care: human resources,
organizational structure, and communications.
103
Conversely, nurse descriptions of quality care
included five core measure sets for evidence-based
developmental care: (1) protected sleep, (2) pain and
stress assessment and management, (3) developmental activities of daily living, (4) family-centered care,
and (5) providing a healing environment.28 Nurses
also revealed their experiences in developmental
care as “walking the line between the possible and
ideal” illuminated through the five aspects of care:
(1) being attentive to the infant-mother dyad, (2)
developing parent and provider relationships (the
body tells it all), (3) timing is everything, (4) working in the quiet and caring, crowded and distressing space, (5) teamwork—demanding, smooth and
helpful.45 Introducing developmental care in the
NICU requires an understanding of expectations,
timing, and relationships.
Another aspect currently investigated is the integration of parents as members of the care team in
the NICU (Family Integrated Care [FIC]). A recent
multicenter, multinational, cluster randomized controlled trial that included 26 tertiary NICUs from
Canada, Australia, and New Zealand demonstrated
that infants assigned to FIC had improved infant
weight gain, decreased parent stress and anxiety, and
increased high frequency of exclusive breastmilk
feeding at discharge66 (see Chapter 29).
SYSTEMATIC REVIEW IN
PERINATAL CARE AND
EVIDENCE-BASED PRACTICE
Evidence-based practice is the integration of the
best possible research evidence with clinical expertise and patient needs.
ature, such as those cited in the preceding sections,
illustrate how the application of the principles of
EBP offer a strong argument countering those who
71,92
Examples from the liter-
Соседние файлы в папке Библиотека им академика М.И. Перельмана