2. Patent Ductus Arteriosus
دکتر علیرضا جشنی مطلق
فوق تخصص نوزادان
مدیر گروه کودکان-عضو هیئت علمی
دانشگاه علوم پزشکی البرز

3. 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

5. 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

7. 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)
Widened pulse pressure that is greater than 25 mmHg or if the difference between the systolic and diastolic blood pressure (BP) exceeds half of the value of the systolic BP
Respiratory Sx: Tachypnea, Apnea, CO2, increased vent settings

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

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

10. Echocardiogram
Gold standard for diagnosing PDA
Taken from Neo Reviews

11. 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

12. What are complications of having hemodynamically significant PDA?
Pulmonary Edema
Pulmonary Hemorrhage
BPD
Heart Failure
Pulmonary haemorrhage
CLD

13. What are complications of having hemodynamically significant PDA?
IVH
NEC
Prolonged ventilator/O2 support
Longer Duration of hospitalization.
IVH
NEC

14. 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. Pedea:

17. 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)

18. Management of PDA: Ibuprofen or Indometacin
Surgery (if DA fails to close after two course of medical management or reopen )
Cardiac catheterization

19. ibuprofen IS THE GOLDEN STANDARD TO ESCAPE FROM:

22. 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

23. 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 5 5 10 5 10 5

24. Drug usage advisement
Intravenous infusion with an infusion pump without dilution during 15 minutes

25. 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

26. Complications

27. Clinical study

38. 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 but sever acute renal failure (Erdeve 2008)
Oral trials are underpowered to detect complications (Jobe 2011)
Higher dose needed to close PDA with enteral ibu than IV (Sharma 2003)
EMA/FDA approved not oral = off label
Higher reopening rates with Oral and safety underpowered (Erdeve et al 2011)

39. 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