RESUMO
OBJECTIVE: To assess decisional conflict and knowledge about prematurity among mothers facing extreme premature delivery when the counseling clinicians were randomized to counsel using a validated decision aid compared with usual counseling. STUDY DESIGN: In this randomized trial, clinicians at 5 level III neonatal intensive care units in the US were randomized to supplement counseling using the decision aid or to counsel mothers in their usual manner. We enrolled mothers with threatened premature delivery at 220/7 to 256/7 weeks of gestation within 7 days of their counseling. The primary outcome was the Decisional Conflict Scale (DCS) score. One hundred mothers per group were enrolled to detect a clinically relevant effect size of 0.4 in the Decisional Conflict Scale. Secondary outcomes included knowledge about prematurity; scores on the Preparedness for Decision Making scale; and acceptability. RESULTS: Ninety-two clinicians were randomized and 316 mothers were counseled. Of these, 201 (64%) mothers were enrolled. The median gestational age was 24.1 weeks (IQR 23.7-24.9). In both groups, DCS scores were low (16.3 ± 18.2 vs 16.8 ± 17, P = .97) and Preparedness for Decision Making scores were high (73.4 ± 28.3 vs 70.5 ± 31.1, P = .33). There was a significantly greater knowledge score in the decision aid group (66.2 ± 18.5 vs 57.2 ± 18.8, P = .005). Most clinicians and parents found the decision aid useful. CONCLUSIONS: For parents facing extremely premature delivery, use of a decision aid did not impact maternal decisional conflict, but it significantly improved knowledge of complex information. A structured decision aid may improve comprehension of complex information. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01713894.
Assuntos
Cuidadores/psicologia , Aconselhamento/métodos , Técnicas de Apoio para a Decisão , Lactente Extremamente Prematuro , Pais/psicologia , Adulto , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Doenças do Prematuro/diagnóstico , Doenças do Prematuro/enfermagem , Terapia Intensiva Neonatal , Masculino , Gravidez , Taxa de Sobrevida , Resultado do Tratamento , Estados UnidosRESUMO
Our objective was to survey neonatologists regarding international practice of red cell transfusion thresholds for premature infants with <1000-g birth weight and/or <28-week gestation. An invitation to fill out an 11-question web-based survey was distributed to neonatologists through their professional societies in 22 countries. Physicians were asked about which specific factors, in addition to hemoglobin levels, influenced their decisions about transfusing premature infants. These factors included gestational age, postnatal age, oxygen need, respiratory support, reticulocyte count, and inotropic support. Physicians were presented with 5 scenarios and asked to identify hemoglobin cutoff values for transfusing infants with <1000-g birth weight and/or <28-week gestation. One thousand eighteen neonatologists responded: the majority were from the United States (67.5%), followed by Germany (10.7%), Japan (8.0%), the United Kingdom (4.9%), Spain (3.9%), Italy (2.6%), Colombia (0.6%), Argentina (0.4%), Canada (0.4%), Belgium (0.1%), and the Netherlands (0.1%). Half of the respondents (51.1%) reported having a written policy with specific red cell transfusion guidelines in their unit. Factors considered "very important" regarding the need to administer blood transfusions included degree of oxygen requirement (44.7%) and need for respiratory support (44.1%). Erythropoietin was routinely used to treat anemia by 26.0% of respondents. Delayed cord clamping or cord milking was practiced by 29.1% of respondents. The main finding was of a wide variation in the hemoglobin values used to transfuse infants, regardless of postnatal age. Step-wise increments in the median hemoglobin cutoffs directly paralleled an increase in the need for levels of respiratory support. In the first week of life, there was a wider range in the distribution of hemoglobin transfusion thresholds for infants requiring no respiratory support and full mechanical ventilation compared with the thresholds used in the second, third, and fourth weeks of life. An international survey using hypothetical scenarios shows that red blood cell transfusion practices vary widely among practicing neonatologists in participating countries.
Assuntos
Transfusão de Eritrócitos/estatística & dados numéricos , Neonatologia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Anemia Neonatal/terapia , Argentina , Bélgica , Canadá , Colômbia , Índices de Eritrócitos , Eritropoetina/uso terapêutico , Alemanha , Idade Gestacional , Hematínicos/uso terapêutico , Hemoglobinas , Humanos , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Lactente Extremamente Prematuro , Recém-Nascido , Itália , Japão , Países Baixos , Espanha , Inquéritos e Questionários , Reino Unido , Estados UnidosRESUMO
OBJECTIVE: To develop and pretest a decision-aid to help parents facing extreme premature delivery during antenatal counseling regarding delivery room resuscitation. STUDY DESIGN: Semistructured interviews with 31 clinicians and with 30 parents of children born <26 weeks' gestation were conducted following standard methods of qualitative research. These characterized perceptions of prenatal counseling to identify information that parents value when making decisions regarding delivery room resuscitation. These parental needs were formatted into a decision-aid. We assessed the primary outcome of how effectively the decision-aid improved knowledge during a simulated counseling session. Two groups of women were studied: parents with a history of prematurity ("experienced") and healthy women without prior knowledge of prematurity ("naïve"). RESULTS: Interviewees thought that visual formats to present survival and short- and long-term outcome information facilitated their own preparation, recall, and understanding. Accordingly, we designed a decision-aid as a set of cards with pictures and pictographs to show survival rates and complications. There was significant improvement in knowledge in 13 "experienced" parents (P = .04) and 11 "naïve" women (P < .0001). Participants found the cards useful and easy to understand. CONCLUSIONS: A decision-aid for parents facing extreme premature delivery may improve their understanding of complicated information during antenatal counseling.