Deferred1电缆夹紧(DCC)挽救生命,那么为什么它没有更常规地实施?尽管新生儿有好处,DCC未得到充分利用,特别是在早产中。脐带挤奶(UCM)还可以改善早产儿的某些结局,例如减少输血的需要。在学期,DCC和UCM改善血液学指标。
本章的目的是检查早产和足月DCC(和UCM)的证据质量,临床实践指南和实施问题。
关键证据,主要来自网络荟萃分析,来自随机临床试验的早产和足月DCC(和UCM)的荟萃分析和系统评价,临床实践指南和实施研究,通过证据的确定性和质量来总结。关于证据的确定性,对于网络荟萃分析,使用网络荟萃分析工具中的置信度,对于荟萃分析,Cochrane偏差风险工具和建议评估分级,使用开发和评价(GRADE)。使用两种工具对指南质量进行了评估:评估和评估指南II(AGREEII)和同意建议证明(AGREE-REX)。实施研究质量使用混合方法评估工具进行评估。
在对56个脐带管理策略RCT的网络荟萃分析中,与立即夹钳(ICC)相比,DCC将早产儿的死亡率降低了30%,包括33周前出生的婴儿亚组,两者都使用网络信心荟萃分析工具进行了适度的信心评估。DCC将脑室内出血(IVH)的几率降低了30%,输血的几率超过50%,两者对网络荟萃分析的信心都有很高的评价。与ICC相比,脐带挤奶(UCM)并未降低死亡率。与DCC在早产中显示的益处相反,系统的审查表明,在任期内,除血液学指标改善外,无死亡率获益,也几乎没有获益.对临床实践指南的系统回顾表明,所有这些指南都认可DCC用于未受损的早产儿,11更谨慎地指出,当DCC不可行时,可能会考虑挤奶。然而,根据AGREE-II和AGREE-REX,只有一半(49%)的DCC最佳持续时间指南建议得到高质量证据支持.不到十分之一的陈述(8%)引用了DCC对早产儿的死亡率益处。关于DCC的吸收,对18项关于促进者和实施障碍的研究进行了系统审查,发现几乎所有研究(14项研究中有12项)都侧重于协议等战略,政策,或工具包;此外,14项研究中有8项使用了教学教学课程。18项研究中只有8项在混合方法评估工具的所有四个领域得分高。
与ICC相比,早产儿的DCC对死亡率有显著的益处,IVH和红细胞输血,信心评级为中等(死亡率)或高。尽管全球指南鼓励早产(和术语)DCC,临床实践指南的质量仍有改进的空间;只有一半关于早产DCC最佳持续时间的建议得到高质量证据的支持.大多数指南没有提到早产DCC的死亡率获益,也缺乏实施的实际方面的细节。在实施研究中,主要集中在协议上,政策,工具包或教学教学,质量也显示出改进的机会。
Deferred1 cord clamping (DCC) saves lives, so why is it not implemented more routinely? Despite neonatal benefits, DCC is under-utilized, particularly in preterm births. Umbilical cord milking (UCM) also improves some outcomes for preterm infants such as decreasing the need for transfusions. At term, DCC and UCM improve hematological indices.
The objective of this chapter is to examine the quality of evidence for both preterm and term DCC (and UCM), clinical practice guidelines and implementation issues.
Key evidence, primarily from network meta-analyses, meta-analyses and systematic reviews on both preterm and term DCC (and UCM) from randomized clinical trials, clinical practice guidelines and implementation studies, are summarized through a lens of the certainty and quality of the evidence. Regarding the certainty of evidence, for network meta-analysis the Confidence in Network Meta-analysis tool was used, and for meta-analyses the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used.
Guideline quality was appraised with two tools: Appraisal of
Guidelines for REsearch & Evaluation II (AGREE II) and AGREE-Recommendation EXcellence (AGREE-REX). Implementation study quality was evaluated using The Mixed Method Appraisal tool.
In a network meta-analysis of 56 RCTs of cord management strategies, DCC reduced the odds of mortality in preterm infants by 30% compared to immediate cord clamping (ICC), including in the subgroup of infants born before 33 weeks\', both with a moderate confidence assessment using the Confidence in Network Meta-analysis tool. DCC reduced the odds of any intraventricular hemorrhage (IVH) by 30%, and the odds of red blood cell transfusion by more than 50%, both with high ratings on the Confidence in Network Meta-analysis. Umbilical Cord Milking (UCM) did not reduce mortality compared to ICC. In contrast to the benefits shown in preterm birth with DCC, a systematic review showed that at term, there were no mortality benefits and few benefits at all except for improved hematological indices. A systematic review of clinical practice guidelines demonstrated that all of them endorsed DCC for uncompromised preterm infants, and 11 more cautiously noted that cord milking might be considered when DCC was not feasible. However, only half (49%) of the recommendations in the
guidelines on the optimal duration of DCC were supported by high-quality evidence per AGREE-II and AGREE-REX. Fewer than one in 10 statements (8%) cited a mortality benefit with DCC for preterm infants. Regarding the uptake of DCC, a systematic review of 18 studies on facilitators and barriers to implementation found that almost all (12 of the 14 studies) focused on strategies such as protocols, policy, or toolkits; additionally, 8 of 14 studies used didactic teaching sessions. Only 8 of 18 studies scored high on all four domains of the Mixed Method Appraisal tool.
Compared to ICC, DCC in preterm infants conferred significant benefits for mortality, IVH and red blood cell transfusion, with confidence ratings of moderate (mortality) or high. Although
guidelines worldwide encouraged preterm (and term) DCC, the quality of the clinical practice
guidelines had room for improvement; only half of the recommendations on the optimal duration of preterm DCC were supported by high-quality evidence. Most
guidelines did not mention a mortality benefit with preterm DCC and lacked details on practical aspects of implementation. Among implementation studies, which have focused mainly on protocols, policies, toolkits or didactic teaching, quality also demonstrated an opportunity for improvement.