Presented at the Neonatal Society 2006 Spring Meeting.
Shetty N, Mullen N, Lal M
Neonatal unit, The James Cook University Hospital, Middlesbrough TS4 3BW, UK
Introduction: Evidence from a meta-analysis (1) suggests that using multiple doses of surfactant reduces mortality and the risk of pneumothorax. Manufacturers recommend two doses of surfactant 12 hours apart if the child is still ventilated and in oxygen. A recent cross sectional postal survey (2) done from our unit involving more than 100 neonatal centres across the UK showed that a large proportion used some form of selection criteria to limit the use of second dose of surfactant. However, the criteria used were variable and reflected the lack of consensus among clinicians. In our unit the decision to use second dose of surfactant is based on objective criteria of mean airway pressure (MAP) of 8 or more and FiO2 of 0.3 or more, 12 hours after the first dose.
Aim: To compare outcome in babies given a single dose (SD) of surfactant with those given 2 or more doses (MD).
Methods: A retrospective study was undertaken of all infants born between 26-32 weeks gestation who were ventilated and received at least one dose of surfactant over a 22 month period between January 2003 to October 2004 at The James Cook University Hospital. Babies with congenital malformations were excluded as were those who were ventilated in another unit for more than 24 hours before transfer. Apart from demographic details, antenatal risk factors and birth details, information was collected on outcomes such as duration of mechanical ventilation, total duration of respiratory support, duration on supplemental oxygen, length of hospital stay, time to establish full feeds, mortality and chronic lung disease (CLD).
Results: Of the 107 infants identified after exclusion 52 received one dose and 55 were given 2 or more doses. There was no significant difference between the two groups in terms of gestational age, birth weight and CRIB II scores. More of the SD group received antenatal steroids (39 vs 26, p < 0.025). Infants in the SD group were ventilated at lower MAP (7.32 vs 8.89, p < 0.0001) and more of them were extubated before 36 hours of age (20 vs 8, p < 0.01). Mean duration of mechanical ventilation, supplemental oxygen and time to full feeds in SD and MD groups were 4.4 vs 9.1 (p = 0.01), 17.5 vs 31.9 (p = 0.01) and 11.86 vs 12.08 (p = 0.89) respectively. Similarly, pneumothorax, CLD and mortality in the SD and MD groups were 1 vs 5 ( p < 0.02), 4 vs 13 (p < 0.0005) and 0 vs 3 (p = 0.2) respectively.
Conclusions: Our results show that objective criteria based approach can successfully identify a group of preterm infants who could be given a single dose of surfactant without adversely affecting their outcome.
References
1. Soll RF. Multiple versus single dose natural surfactant extract for severe neonatal respiratory distress syndrome. The Cochrane Database of Systematic Reviews 2006 Issue 1
2. Elizabeth Alsop, Prof S Sinha. Personal communication.