Effect of implementing a clinical practice guideline for prophylactic indomethacin on reduction of severe IVH in extremely preterm infants.

Abstract

BackgroundProphylactic indomethacin in preterm infants has been associated with reduction of severe intraventricular hemorrhage (SIVH) but no improvement in neurodevelopmental outcome. Since January 2016, Brigham and Women's Hospital has implemented a clinical practice guideline (CPG) for prophylactic indomethacin to prevent SIVH. Our aim was to compare the predicted and observed rate of SIVH before and after CPG implementation. Second, to evaluate the association between indomethacin and development of SIVH.MethodsThis retrospective cohort study included infants born between 23 and 28 weeks of gestation. Variables were compared between before (pre-group) and after the CPG implementation (post-group). Risk categories for SIVH were defined as the following based on a validated model: low <15%, moderate ≥15% to <25%, and high risk ≥25%. Multivariate logistic regression model was applied to evaluate the association between SIVH and the administration of indomethacin.ResultsInfants in the post-group (n = 325) presented with lower Apgar scores, higher rate of necrotizing enterocolitis, abdominal surgery, and mortality comparing to pre-group (n = 424). The use of indomethacin for any reason was 44% in pre-group and 62% in post-group (p < 0.001). There was no significant difference in the predicted and observed rate of SIVH between the 2 groups in any risk categories. There was no association between the use of indomethacin and development of SIVH in multivariate regression models.ConclusionThe implementation of CPG for prophylactic indomethacin was not associated with reduction in the incidence of SIVH and no association was found between the use of indomethacin and development of SIVH.