71 Trends, Practice Patterns, and Opportunities for Improvement in Postnatal Steroids Use for Bronchopulmonary Dysplasia – Eleven Years Observational Study

Abstract

Abstract Background Postnatal steroids (PNS) use in preterm infants improves pulmonary function in a select subset of patients but can potentially increase the risk of spontaneous intestinal perforation and cerebral palsy. Despite national guidelines, reducing intra-centre variation and demonstrating responsible stewardship in PNS use have been challenging. Objectives To describe (i) PNS type, regimen, time of initiation, use over time, and identify opportunities for improving practices in the use of PNS for bronchopulmonary dysplasia (BPD); (ii) outcome at discharge for infants who received PNS. Design/Methods We conducted a retrospective observational study in a quaternary NICU that included infants born at <33 weeks gestational age who received PNS to prevent or treat BPD between 2011 and 2021. We initially identified all infants who received PNS from the pharmacy registry, followed by demographic, PNS use details, and outcome data collection from the Canadian Neonatal Network (CNN) database, discharge summaries and, occasionally, by reviewing individual charts. Results The mean (SD) gestational age and birth weight of 184 eligible infants were 25(24-26) weeks and 720(625-841) grams respectively. Based on timing of first course of PNS, 2(1.1%), 93(50.5%), 85(46.2%), and 4(2.2%) infants received PNS in early (E) (< 7 days), early evolving (EE) (7-28 days), late evolving (LE) (29 days – 36 + 6 weeks PMA), and established (Es) (≥ 37 weeks) phases, respectively. 157 (85.3%) infants received dexamethasone and 22 (12%) received hydrocortisone as the first PNS course. Infants in the EE group, when compared with the LE group, received more days and higher cumulative dose of PNS 13(10-28) vs. 10(10-16) p= 0.04, and 24(24-60) vs. 24(24-25) hydrocortisone equivalents in milligrams/kilograms, p=0.01, respectively. Two common regimens used at our centre were 10-day Dexamethasone: A Randomized Trial (DART) and 22-day tapering doses of hydrocortisone (STOP-BPD). Deviation from published protocols based on duration (±20%), dose (±10%) or timing was 66.7% and 33.3% with hydrocortisone and dexamethasone use. Dexamethasone usage remained stable, but a small increase in hydrocortisone use and the cumulative PNS dose received occurred over time. Survival, survival without major morbidity, moderate to severe BPD, and technology dependence at discharge were 87%, 1.6%, 90.8% and 66.9%, respectively. Identified opportunities for improvement were: adapting national guidelines to local context, creating order sets to reduce deviations, and using this study’s outcomes during PNS decision-making conversations with family. Conclusion Variation in the use of hydrocortisone was higher than for dexamethasone, and cumulative dose received per infant increased over time. Potential interventions to reduce variation in PNS use and optimize decision- making were identified.