367 - Pulmonary Hemorrhage Management Practices in Extremely Preterm Infants: A Global Survey

Poster Number: 367
Publication Number: 367.440

Pratibha Thakkar, University of Kentucky College of Medicine, Lexington, KY, United States; Muppala Raju, Baylor Scott White McLane Children's Medical Center, Temple, TX, United States; Vinayak Govande, Baylor Scott and White, Temple, TX, United States; Kartikeya Makker, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Rani A. Bashir, Renai Medicity, Kochi, Kerala, India, Kochi, Kerala, India; Ranjit Torgalkar, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA, United States; Chintan K. Gandhi, Pennsylvania State University College of Medicine, Hershey, PA, United States; Naveed Hussain, Connecticut Children's, Farmington, CT, United States; Venkata Raju, Baylor Scott White McLane Children's Medical Center, Temple, TX, United States; Kaashif A. Ahmad, MEDNAX, Houston, TX, United States

Background: Pulmonary hemorrhage (PHEM) can be a life-threatening event in extremely premature infants, with only supportive treatment available. Little is known regarding specific management strategies for PHEM because of the rarity of its occurrence and significant associated mortality. Variation in management practices have not been well described.

Objective: Describe various interventions used in management of PHEM amongst neonatologists.  

Design/Methods: A working group was created with the common goal and interest of expanding knowledge about PHEM. We designed a 14-question survey around our experience and current controversies reported in the literature. The survey was circulated via various neonatal listservs (including MEDNAX neonatology forum, nicu99, Envision Physician Services and the AAP Training and Early Career neonatologists group) to capture management strategies of various neonatologists practicing under different settings and resources. The data was collected in REDCap software and statistical analysis conducted using SPSS version 27

Results: There were 291 responses. Table 1 and 2 show descriptive analysis of the responses. Very few (12.4%) reported access to unit based management guidelines which supports the variability seen in practice patterns. In decreasing order of severity, perceived risk factors for PHEM include, presence of hemodynamically significant patent ductus arteriosus (hsPDA), culture positive sepsis, following extubation in first week of life and after second dose of surfactant. Most neonatologists obtain echocardiograms (66%) and consider treatment for PDA (72.9%) after a pulmonary hemorrhage event. In this setting, acetaminophen (54%) was the drug of choice for PDA closure. Overall there was a consensus in using endotracheal epinephrine, packed red blood cells, fresh frozen plasma and high frequency oscillatory ventilation after acute PHEM. Other cited interventions include fluid restriction and head imaging following hemorrhage. Use of endotracheal cold saline, cocaine, hemocoagulase or surfactant replacement in acute management of hemorrhage was sparse. Use of systemic Factor VII was reported from a few centers. Figure 1 shows comparative analysis of practices in North America and other NICUs.Conclusion(s): Our study provides a global overview of experience and opinion-based practices used in management of PHEM. Treatment algorithms for stepwise management are lacking. Creating high quality evidence based guidelines are necessary to provide apposite care and to reduce heterogeneity in management of PHEM in preterm neonates.
Table 1: Demographics of survey participantsPHEM – pulmonary hemorrhage
Table 2: Management preferences of survey respondentsPHEM – pulmonary hemorrhage; PEEP – positive end expiratory pressure
PDA- patent ductus arteriosus; FFP- fresh frozen plasma