Oxygen therapy for the premature infant Retinopathy of prematurity (ROP) Teaching Evidence-based Practise 15 th September 2015 Kenneth Tan Monash Newborn.

Slides:



Advertisements
Similar presentations
Retinopathy of Prematurity By Jennie & Vicki. Statistics Approximately 30% of all premature infants with a birth weight of under 1500 grams will develop.
Advertisements

Experience of inhaled nitric oxide in babies with pulmonary hypertension in a tertiary neonatal unit Supriya Bhoomaiah Vishna Rasiah Birmingham Womens.
 may be efective in preventing SGA birth in women at high risk of preeclampsia although the effect size is small. (c)
Bilateral Eviscerations-Retinopathy of Prematurity
Matthew Mouawad Medical Biophysics Presented April 3 rd, 2012 Western University QUANTITATIVE ANALYSIS OF WHITE MATTER INJURY AND REDUCTION OF DEEP GRAY.
Mechanical Ventilation in the Neonate RC 290 CPAP Indications: Refractory Hypoxemia –PaO2 –Many hospitals use 50% as the upper limit before changing.
Controversies & Oxygen DR Resuscitation Premature Infants.
The premature newborn infant
Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Surgery and Neurodevelopmental Outcome of VLBW Infants Morriss FH Jr, Saha S, Bell.
Team Members The Outstanding NICU Nursing Staff
UOG Journal Club: September 2012 Perinatal outcome in women treated with progesterone for the prevention of preterm birth: a meta-analysis Sotiriadis A,
Atrial Fibrillation in Patients with Cryptogenic Stroke Gladstone DJ et al. N Engl J Med 2014; 370: Presented by Kris Huston | July 21, 2014.
Oxygen therapy in the preterm: Too much of a good thing? Keith J Barrington CHU Ste Justine Université de Montréal.
Copyright restrictions may apply JAMA Pediatrics Journal Club Slides: Oxygen Saturation Target Range for Extremely Preterm Infants Manja V, Lakshminrusimha.
Premature Infant Outcomes Linda Wallen, MD. Prevalence of Cerebral Palsy VLBW Infants MortalityCerebral Palsy (% live births)(% survivors)
SEPSIS Early recognition and management. Aims of the talk Understand the definition of sepsis and severe sepsis Understand the clinical significance of.
Reference Cooper BA, and the IDEAL study group. A randomized controlled trial of early versus late initiation of dialysis. N Engl J Med [Accessed.
COMPLICATIONS OF PREMATURITY
How is place of death for cancer patients changing and what affects it? UKACR Conference September 28 th 2004 Elizabeth Davies Karen Linklater Ruth Jack.
THERAPEUTIC HYPOTHERMIA Heike Geduld August 2007.
2014 Summit Co-Convener:Founder: Patient Safety Science & Technology Summit 2014.
Cadenza Conference Hong Kong Chronic Disease Management and its relevance for older people Steve Iliffe Professor of Primary Care for Older People, University.
Pulse Oximetry screening for Cardiac malformations in the neonate Majd Abu-Harb September 2014.
Retinopathy of Prematurity Geoffrey T. Tufty, MD Sanford Clinic Ophthalmology.
An interdisciplinary approach to care of infants with bronchopulmonary dysplasia. Alfred L. Gest, MD.
The TRial Of Preventing HYpertension (TROPHY) TROPHY.
Relation of Vascular Endothelial Growth Factor and Insulin Like Growth factor-1 to the Development of Retinopathy in Premature Infants Prof. Dr: Enas Raafat.
Retinopathy of Prematurity: A Neglected Public Health Issue Krishnendu Sarkar Professor Regional Institute of Ophthalmology Kolkata.
Community Management of Retinopathy of Prematurity Alex R. Kemper, MD, MPH, MS Sheri Carroll, MD David K. Wallace, MD, MPH November 13, 2007 CM-ROP.
Retinopathy of Prematurity: An Overview Nakhleh E. Abu-Yaghi Retinopathy of Prematurity: An Overview Nakhleh E. Abu-Yaghi.
Retinopathy Of Prematurity Sigal Peter-Wohl MD Mark Kadrofske MD PhD.
RETINOPATHY OF PREMATURITY. What is Retinopathy of Prematurity (ROP)? b Disease of the retina in premature infants b Usually occurs in 1.5 kg or less.
Retinopathy of Prematurity screening and management
Seminar 2 We will get started right at 7:00.. Genetics, Prenatal Development, & Birth Genetic Screening – What is it? Systematic screening of one or both.
International Neonatal Immunotherapy Study. Co-ordinating Centre National Perinatal Epidemiology Unit Oxford
Oxygen Control and Measure System Development Divia Patel, Angie Powe, Stacey Scheib Advisors: Dr. John Penn Dr. Paul King.
Premature Babies Brooke Jensen. Introduction Preterm death is the leading cause of death among newborns. Prematurity is a growing, serious problem in.
Case Study 28 Julia Kofler, M.D.. The brain in this case is from a male infant who was delivered prematurely at 30.5 weeks gestation due to intrauterine.
Jason Sorell, DO Suzie Nemmers MD
An Evidence-Based Approach to Transfusion of the Preterm Infant
ROP. What is ROP  Retinopathy of prematurity (ROP) is a potentially blinding eye disorder that primarily affects premature infants weighing about 2¾.
Oxygen Control and Measure System Development Divia Patel, Angie Powe, Stacey Scheib Advisors: Dr. John Penn Dr. Paul King.
Risks of Standard of Care (Experimental Aspects of Study) Patrick Herbison Continuing Education for IRB Members.
Introducing a new practice on the NICU: Probiotics A James 1 H Tranter 2 A Davies 1 S Cherian 2 Royal Gwent Hospital 1 & University Hospital of Wales 2.
Causes of neonatal mortality Lawn JE, et al. Intl J Epidemiol (2006)
Weight Profile of Preterm Infants: A Longitudinal Study Sujoy Banerjee Hesham Naseef Anitha James Mallinath Chakraborty.
Middle cerebral artery peak systolic velocity: a new Doppler parameter in the assessment of growth-restricted fetus G.MARI, F HANIF, M KRUGER, et. al,.
Retinopathy of Prematurity: Oxygen Weaning in the NICU
Hypoxic-Ischaemic Encephalopathy (HIE) in Wales R Adappa.
Barbara Schmidt, Kristine Sandberg Knisely Chair in Neonatology
Therapeutic Hypothermia in Neonatal Hypoxic-Ischaemic Encephalopathy An audit of clinical management and follow up Malini Ketty, Nitin Goel, Sujoy Banerjee.
Retinopathy of Prematurity (ROP)
DEPARTMENT OF COUNSELLING
Retinopathy of Prematurity
James M. Roberts, M.D., Leslie Myatt, Ph.D.,et al.
Long –Term Developmental Outcomes in Preterm Neonates Exposed to Hyperglycemia Camila Goldner Pérez, Judy Saslow MD, Vilmaris Quiñones Cardona MD, Elizabeth.
HOPE: Heart Outcomes Prevention Evaluation study
Correlation of developmental outcome with severity of bronchopulmonary dysplasia in extremely low gestational age neonates Karen Belen, Chengqiu Lu, Narges.
Outcomes of Extremely Preterm Infants
Retinopathy of prematurity (ROP)
Does Hyponatremia in Asphyxiated Newborn infants correlate with incidence of death or disability? 1Mohamed S. Elboraee, 1,2Ernest Phillipos, 4Leonora Hendson,
Teaching Tool: Blood Pressure Classification
CIBIS II: Cardiac Insufficiency Bisoprolol Study II
MANAGEMENT OF PCP Dr. Akaninyene A. Otu, MBBCh, DTM&H, MPH, MRCP (UK), FWACP University of Calabar Teaching Hospital Calabar, Nigeria.
Dr Immaculate Kariuki Consultant Paediatrician Nairobi, Kenya
Retinopathy of Prematurity
Neonatal and Perinatal Trials: 30 years in 10 minutes
Kaplan–Meier plots of survival by gestational week for babies born at 23–26 weeks of gestation in level 3 and level 2 centres in England in Kaplan–Meier.
Presentation transcript:

Oxygen therapy for the premature infant Retinopathy of prematurity (ROP) Teaching Evidence-based Practise 15 th September 2015 Kenneth Tan Monash Newborn

Objectives Preterm infants definitions Complications of preterm birth, including ROP Early trials oxygen NeoPROM collaboration trials

Preterm infant

Med J Aust. 1951;2(2):48-50

Campbell 1951

I I IIIII Macula Optic disc Right eye Left eye Oraserrata ROP - Classification I IIIII

Classification of ROP Staging: 5 stages - describe abnormal vascular response. Most severe stage is used to determine the stage of the eye as whole. Stage 1: Demarcation line Stage 2: Ridge

Classification of ROP Stage 3: Extaretinal Fibrovascular Proliferation Stage 4: Partial Retinal Detachment 4a - Extrafoveal 4b – Foveal Stage 5: Total Retinal Detachment Major cause of childhood blindness in developed world

Retinopathy of Prematurity

Clinical trials in the 1950s confirmed that restricting oxygen reduced the risk of eye damage, then called Retrolental Fibroplasia (RLF), and blindness

History of oxygen use in preterm neonates

Children's Hospital, Buffalo, NY Accessed via

Side-effects of oxygen Therapy Preterm infants lack a fully functioning antioxidant defence system (Frosali 2004) Oxygen rich environment Antioxidant defences Glutathione peroxidase, superoxide dismutase Other diseases of the preterm neonate where oxidative stress plays a role: Lungs - BPD (Davis, 2002) Brain - PVL (Kakita et al, 2009)

Reduced oxygen Therapy Less inspired oxygen (to target SpO2 <90%) may increase patent ductus arteriosus pulmonary vascular resistance apnoea impair survival and neurodevelopment Newburger N Engl J Med 1984, 310: Skinner JR, Arch Dis Child Fetal Neonatal Ed 1999, 80: F81-F87. Subhedar Arch Dis Child Fetal Neonatal Ed 2000, 82:F243-F247.

Cost of preventing ROP For each case of RFLP by oxygen restriction prevented about 16 infants died or had cerebral palsy Competing goals of treatment Kenneth Cross Lancet 1973;2(7835):954–956

Monitoring of oxygenation Monitoring paO2 Levels of pO2 that is damaging to the retina 80 mmHg Flynn JT et al N Engl J Med 1992, 326: tcpO2 Arterialised capillary bed Disadvantage that it heats the skin up (40 C) SpO2 Introduced in 1980s

History of oxygen therapy in preterm infants After trials in 1950s, very little study on oxygen therapy (Silverman 1980) Northern Neonatal Network (North of England) Newcastle, Middlesbrough et al Centres with 4 different SpO2 targets policy Problem with this was a study Shows association cannot determine cause-effect relationship

Outcomes – Northern Neonatal Network Arch Dis Child Fetal Neonatal Ed Mar;84(2):F What type of study is this?

NeOProM

Aim To determine whether, in infants < 28 weeks gestation, targeting SpO2 85 – 89% versus 91 – 95% when in supplementary oxygen leads to a lower rate of death or disability at two years

Target 88 – 92% Alarm limits: upper - 94% lower – 86%

Primary Outcome Death or major disability at two years corrected for gestationon Bayley III scales Secondary outcomes: –Retinopathy, chronic lung disease, PDA, NEC, Sepsis, Growth

Actual target 85-89% Actual target 91-95% (3% below displayed value) (3% above displayed value) Study oximeter adjusted to display either 3% above or 3% below actual saturation for values between 85% - 95%. Outside that range the true values are displayed. Staff are asked to target display with masked study oximeter SpO % Lower groupHigher group Masking O 2 saturation in BOOST II

SUPPORT Trial SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research NetworkN Engl J Med 2010; 362:

What about the other RCTs? Continue or stop RCT Data and safety monitoring committee of BOOST- Aus ANZ

Stopping the RCT Stenson B et al. N Engl J Med 2011;364:

BOOST-II In December 2010, a joint safety analysis of survival at 36 weeks' postmenstrual age was undertaken –2315 infants in the U.K., Australian, and New Zealand trials with the 1316 infants in the SUPPORT trial Investigators be told the results if the difference in 36-week survival between groups for all infants, or for those recruited after introducing the new calibration algorithm, exceeded 3 SE (equivalent to 99.73% CI, with P=0.003) (UK BOOST protocol) Stenson et al N Engl J Med 2011; 364:

Implications for practise Main question: should we change current practise from 88-92% targetting to 91-95% Two NICUs (USA, UK) have already implementation this Most NICUs in Australia have changed practise to higher SpO2 target

Take home message Meta-analysis Odd ratios Cohort study Randomised control trial (double blind) Individual patient meta-analysis