Targeted Management of PDA in Preterm...
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Targeted Management of PDA in Preterm Infants Dr. Abdulla Al Tuhami Consultant Pediatrics & Neonatology
Transcript of Targeted Management of PDA in Preterm...
Targeted Management of PDA in Preterm Infants
Dr. Abdulla Al TuhamiConsultant Pediatrics & Neonatology
• Still controversy • Pathological or non pathological• Causality or co occurrence
PDA with high volume shunt
Chronic lung changes NEC
First 72 hours Evidence
First 5 days
After 5 days
Long term
Evidence
Less Evidence
No Evidence
Pulmonary Hemorrhage
Neurodevelopmental
IVH
Therapeutic strategies for a PDA in extremely preterm infants
Prophylactic treatment
Symptomatic treatment
Early targeted
treatment
Following MENT Trial
1994
Increase of use indo
Following TIPP Trial
2001
Decline of use of indo
Prophylactic treatment approach
Within 24 hr of age in ELBW
May reduce the rates of PDA, PDA ligation, severe IVH, and pulmonary hemorrhage (multicenter controlled trial-Ment-trial)*
May reduce BPD and BPD or death **
*Pediatrics , 1994;93:543e50**J Pediatr 2017;187:119e26
Prophylactic treatment approach
Unnecessary treatment
No evidence of benefits on long-term neurodevelopmental outcome (TIPP trial )
*Schemedit B et al : N Engl J Med 2001;344
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Prophylactic treatment approach
Prophylactic treatment approach
The available evidence does not support a routine universal prophylactic approach
A reasonable choice for ELBW in NICUs where IVH and PDA are frequent problems
J.pedneo.2019.10.002
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Symptomatic treatment approach
Select populations vulnerable to hsPDA
Serial echo daily Echocardiographic
parameters of hsPDA
Treatment
Early targeted treatment approach
BiomarkersNIRS
A)POPULATIONS VULNERABLE TO hsPDA
• Clinical factors• Risk Category based on –GA • Risk of organ injury –based on
chronologic age
Early targeted treatment approach
A ) Vulnerable population
Early targeted treatment approach
J Perinat Med 2005;33:161-164
Arch Dis Child Fetal Neonatal Ed 1997;77:F36e40
precede clinical signs by ~1.8 days
NO standard definition of
hsPDA
Low sensitivity /high specificity
• False negative results
Echocardiography has become essential in the evaluation ofclinically significant ductal shunting
B) Echocardiographic parameters of hsPDA
APDA DIAMETER
BPulmonary over-circulation
CSystemic hypo-perfusion
Moderate PDA
1.5-3.0 mmor PDA:LPA= 0.5-1
Vmax <2 m/s
At least 2 of the following:
-LA: Ao 1.5-2.0- IVRT 45-55 ms- E:A 1.0- LVO 300-400 mL/kg/min
Absent diastolic flow in at least 2 of the following:
- Abdominal aorta- Celiac trunk- Middle cerebral artery
large PDA
>3.0 mm
or PDA: LPA >1
Vmax <2 m/s
At least 2 of the following:-LPA EDV more than 0.2 m/sec - LA: Ao >2.0- IVRT <45 ms- E:A >1.0- LVO >400 mL/kg/min
Reversed diastolic flow in at least 2 of the following:
- Abdominal aorta- Celiac trunk- Middle cerebral artery
B) Echocardiographic parameters of hsPDA
LA/Ao ratioLA/Ao ratio >1.5 beyond DOL 1
Correlates significantly with increased PDA flow
Sensitivity Specificity
79% D188% after D1
95%
ArchDisChild1994;70:F112-F117
LA/Ao ratio use in 1st day is not recommended
Ductal diameter >2.0 mm
Ductal flow
pattern (growing, pulsatile )
Simultaneously Using a ductal diameter >2.0 mm and the ductal flow pattern (growing, pulsatile ) may further enhance the clinical predictive capacity of ECHO
• The best markers of hemodynamic significance :
• color Doppler diameter ≥2mm
• absent or retrograde diastolic flow in the post-ductal aorta
Evans NJ, Iyer P. Journal of Pediatrics 1994;125:778-785.
Therapeutic modalities for PDA in extremely preterm infants
Conservative management
Pharmacological treatment
Surgical ligationCatheterization
closure
How to treat ?
Conservative managementShunt modulating strategy
Fluid restriction ?? Evidence
Optimal saturation
Maintain adequate PEEP
Maintain the hemoglobin above 110 g/L
Indomethacin
used for prophylactic or symptomatic treatment
Prophylactic indomethacin for IVH beginning within 24 h of birth may reduce IVH, early severe pulmonary hemorrhage and PDA ligation
Indomethacin
Adverse effects include hyponatremia, oliguria, active bleeding, and transient impaired renal function
Simultaneous administration of indomethacin and steroids has been shown to increase the incidence of gastrointestinal perforations/NEC
Ibuprofen
Intravenous ibuprofen is as effective as indomethacin in closing PDA
may reduce the risk of NEC and transient renal insufficiency
Oral ibuprofen as effective as intravenous ibuprofen
Paracetamol
Paracetamol appears to be an alternative to indomethacin and ibuprofen
possibly fewer adverse effects
Transient increase in liver enzymes
Association with Autism ???
There is insufficient evidence to recommend paracetamol as standard treatment
Echocardiography guided approach has the potential to reduce the number of drug doses*
Follow up NPE after treatment (PA branch stenosis /CoA )**
A second course If there are no contraindications or side effects from a first course
*Carmo K , Evans .N , J Pediatrics 2009**Bravo et al , J Matern. Fetal Neonatal Med , 2014David Van et al , Pediatric Research 2018
