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Patent Ductus Ateriosus

Patent Ductus Ateriosus. Neonatal Intensive Care Nursery Night Curriculum Series. Fetal Circulation. During Fetal Life: What is the resistance in the Pulmonary Vasculature? What is the systemic vascular resistance? Which direction does blood shunt through the Ductus Arteriosus ?.

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Patent Ductus Ateriosus

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  1. Patent DuctusAteriosus Neonatal Intensive Care Nursery Night Curriculum Series

  2. FetalCirculation • During Fetal Life: • What is the resistance in the Pulmonary Vasculature? • What is the systemic vascular resistance? • Which direction does blood shunt through the DuctusArteriosus? PDA: RL Shunting Pulmonary Vascular Resistance: HIGH Systemic Vascular Resistance: LOW

  3. What Major Changes in Infant Circulation occur following birth? • Lungs: • Lungs expand • PaO2↑’s Pulmonary vasodilatation • Drop in pulmonary vascular resistance. • Systemic Circulation: • Resistance ↑’s with placental removal • PDA: • flow reverses to L R shunting • Begins to functionally close due to ↑ PaO2, and decreased PGE2 levels

  4. Case • Called to the bedside of a 5 day old 25 week infant with worsening respiratory distress. He is requiring higher O2 settings and continues to have multiple desaturations despite increased ventilator settings

  5. What is in your initial differential for this infant’s respiratory distress? Respiratory: Respiratory Distress Syndrome (RDS) Pneumothorax Pulmonary Hemorrhage Cardiac Persistent DuctusArteriosus (PDA) Ductal Dependent Heart Lesion ID Sepsis Pneumonia GI NEC Neuro: IVH Seizures

  6. Physical Exam • Vitals: 160, RR 68, BP 45/20, SaO2 85% • Weight: 980 grams (up 80 grams from 1 day prior) • HEENT: unremarkable • Pulm: tachypneic, decreased lung sounds at bases, crackles heard bilaterally posterior lung fields • CV: 3/6 systolic murmur loudest at LUSB, bounding palmar pulses, active precordium, 2+femoral pulses, CR <2 seconds • Abdomen: soft, active bowel sounds • Skin: warm, dry

  7. What is the likely cause of this infants respiratory distress? • Respiratory Distress Syndrome • PDA • Sepsis • NEC

  8. What is the likely cause of this infants respiratory distress? • Respiratory Distress Syndrome • PDA • Sepsis • NEC

  9. What Physical Exam findings are consistent with PDA? Cardiac: Active Precordium, Widened Pulse Pressure, Bounding Pulses Murmur: systolic at LUSB/Left Infraclavicular, may progress to continuous (machinery) Respiratory Sx: Tachypnea, Apnea, CO2, increased vent settings

  10. What further diagnostic studies could be done to confirm this? • CXR • Echocardiogram

  11. What findings on this CXR are suggestive of a PDA? Increased Pulmonary vascular makings Cardiomegaly Uptodate.com

  12. Echocardiogram • Gold standard for diagnosing PDA Taken from Neo Reviews

  13. Which Infants are at greatest risk? • The Youngest: risk increases with decreasing gestational age • The Smallest: 80% of ELBW infants (BW <1000g) with a murmur progress to large persistent PDAs

  14. What are complications of having hemodynamically significant PDA? • Pulmonary Edema • Pulmonary Hemorrhage • BPD • NEC • Heart Failure • IVH • Prolonged ventilator/O2 support • Longer Duration of hospitalization.

  15. What makes a PDA Hemodynamically Significant? Pulmonary Overcirculation (↑ Qp) Systemic Hypoperfusion (↓ Qs) Oxygenation failure Increased Vent Requirements Pulmonary Edema Cardiomegaly Systemic Hypotension End-Organ Hypoperfusion Renal Insufficiency NEC IVH Acidosis (metabolic, lactic)

  16. What are three main options for treatment? • Conservative/Supportive Management • Pharmacotherapy • Surgery

  17. What Supportive Measures can you take in an infant with a symptomatic PDA? • Ventilator Strategies: • Adequate Oxygenation • Permissive Hypercapnea • Use of PEEP • Mild Fluid restriction: 110-130 ml/kg/day • Heme: Maintenance of HCT 35-40%

  18. Pharmacotherapy • What 2 agents are typically used? • Indomethacin • Ibuprofen

  19. Your Patient is on indocin • The team decides to treat your patient with indomethacin... • How does indomethacin help close a PDA?

  20. Indomethacin • MOA: • Cyclooxygenase inhibitor • COX enzyme necessary for generating PGE2 (potent vasodilator) • Adverse-Effects: • reduces cerebral, gastrointestinal, and renal blood flow • Decreased urine output • Platelet dysfunction • Would you continue/start feeds on this infant? • given concern for increased risk of NEC many neonatologists hold feeds during indomethacin therapy

  21. What are some contraindications to indomethacin? • Proven/ suspected infection • Active bleeding • e.g. IVH, NEC • Thrombocytopenia and/or coagulation defects • Necrotizing enterocolitis • Severe Renal Impairment • Congenital heart disease with ductal dependent lesion

  22. Complications to watch for… • What are you going to instruct the RN to notify you about in this patient? • Decreased Urine Output • Indocin should be held if UOP < 1 ml/kg/h • Abdominal Changes • Signs/Sx of bleeding • Are there any labs you would like to check before/after starting indomethacin? • CBC: to check platelets • BMP: to check BUN and Creatinine

  23. After two trials of indocin your patient still has a symptomatic PDA what next steps might you take? • Continue supportive therapy through ventilator and fluid management • If infant continues to require high ventilator support and echo demonstrates a large PDA consider surgical ligation

  24. Surgical Ligation • Indications? • Persistent Symptomatic PDA after 1-2 trials of Indomethacin or Motrin • Contraindication to Indomethacin or Motrin • Complications? • recurrent laryngeal nerve paralysis • blood pressure fluctuations • respiratory compromise • infection • intraventricular hemorrhage • chylothorax • BPD • death

  25. Surgical Ligation • Long Term Outcomes • Current studies do not demonstrate that ligation decreases incidence of BPD • Some data to suggest infants that have surgical ligation are at greater risk for neurocognitive delays • Surgery should only be used for infants that have failed medical management and are symptomatic

  26. Objectives • Clinical Findings and Symptoms Consistent with PDA • Diagnosis of PDA • Complications of PDA • Indications for treatment • Treatment Options • Complications of Treatment

  27. References: • Chorne N, Leonard C, Piecuch R, Clyman RI. Patent ductusarteriosus and its treatment as risk factors for neonatal and neurodevelopmental morbidity. Pediatrics. 2007;119(6):1165. • Gien, J. Controversied in the Management of Patent DuctusArteriosus. Neoreviews 2008: 9, 477-482 • Masalli, R. Optimal Fluid Management in Premature Infants with PDA. Neoreviews2010; 11: 495-502 • Philips , Joseph B. Management of patent ductusarteriosus in premature infants. UptoDate (www.uptodate.com) • Phillips, J. Pathophysiology, clinical manifestations, and diagnosis of patent ductusarteriosus in premature infants. UptoDate (www.uptodate.com) • Nelson Text Book of Pediatrics

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