Download Pedea

‫دکتر علیرضا جشنی مطلق‬
‫فوق تخصص نوزادان‬
‫مدیر گروه کودکان‪-‬عضو هیئت علمی‬
‫دانشگاه علوم پزشکی البرز‬
DUCTUS ARTERIOSUS(DA)
The ductus arteriosus is a
vascular connection found directly
between the pulmonary artery and
the aorta. Blood is shunted from the
pulmonary artery directly into the
aorta and again away from the fetal
lungs
 Is patent in all newborns till 72 h of
birth

DA is held open
by Increased PGI2 & PGE2
Decreased PO2


Incidence: 57/100,000
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

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
WHAT FURTHER DIAGNOSTIC
STUDIES COULD BE DONE TO
CONFIRM THIS?
CXR
Echocardiogram
WHAT FINDINGS ON THIS CXR ARE
SUGGESTIVE OF A PDA?
Increased
Pulmonary
vascular
makings
Uptodate.com
Cardiomegaly
ECHOCARDIOGRAM

Gold standard for diagnosing PDA
Taken from Neo Reviews
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
WHAT ARE COMPLICATIONS OF
HAVING HEMODYNAMICALLY
SIGNIFICANT
PDA?
Pulmonary Edema
 Pulmonary Hemorrhage
 BPD
 Heart Failure

Pulmonary haemorrhage
CLD
WHAT ARE COMPLICATIONS
OF HAVING
HEMODYNAMICALLY SIGNIFICANT
PDA?
IVH
 NEC
 Prolonged ventilator/O2 support
 Longer Duration of hospitalization.

IVH
NEC
WHAT MAKES A PDA
HEMODYNAMICALLY SIGNIFICANT?
Pulmonary Overcirculation (↑ Qp)
Oxygenation failure
Increased Vent
Requirements
Pulmonary Edema
Cardiomegaly
Systemic Hypoperfusion (↓ Qs)
Systemic Hypotension
End-Organ
Hypoperfusion
Renal Insufficiency
NEC
IVH
Acidosis (metabolic,
lactic)
PEDEA:
TREATING?
Lower
death, need for rescue treatment and
patient drop-out (Aranda 2009)
Lower
mortality rate after PDA closure (Noori
2009)
Lower
incidence of NEC (Cassady 1989)
Failure
to close PDA is a risk factor for CLD
(Adrouche-Amrani 2012)
MANAGEMENT OF PDA:
Ibuprofen
or Indometacin
Surgery
(if DA fails to close after
two course of medical
management or reopen )
Cardiac
catheterization
IBUPROFEN IS THE GOLDEN STANDARD TO
ESCAPE FROM:
IBUPROFEN:
Indication:
 treatment of significant patent ductus arterious
in preterm newborn infants less than 34 weeks
GA but is less efficient in preterms
less than 27 weeks
Dosage form:
 5mg/ml ibuprofen IV solution ,
2 ml amp
TREATMENT REGIMEN
The dose is adjusted to the body weight as follows:
1st injection:10mg/kg
 2nd injection :5 mg/kg
 3rd injection: 5 mg/kg

Second course :
48 hours after the
last injection
10
10
5
5
5
5
DRUG USAGE ADVISEMENT
Intravenous
infusion with an
infusion pump
without dilution
during 15
minutes
CONTRAINDICATION
Life
threatening infection
Thrombocytopenia or
Coagulation defect
Hepatic or Renal disorders
Cyanotic Heart Disease that is
duct dependent(PA,TOF,…)
Suspect or Definite NEC
Hypersensitivity to iboprufen
COMPLICATIONS
Clinical study
WHY ORAL IS NOT A GOOD OPTION
2x
More NEC with enteral Ibu (Gouyon 2010)
Additionnal
risk due to hyperosmolarity in enteral
formulations (Perera-da-Silva 2008)
Transient
Oral
2011)
but sever acute renal failure (Erdeve 2008)
trials are underpowered to detect complications (Jobe
Higher
dose needed to close PDA with enteral ibu than IV
(Sharma 2003)
EMA/FDA
Higher
approved not oral = off label
reopening rates with Oral and safety underpowered
(Erdeve et al 2011)
SUMMARY

Ready to use formula intravenous ibuprofen

EMEA approved

Good safety profile vs Surgery


Preferred drug in many reviews(cochrane golden
standard)
High dose vs Standard dose