patent ductus ateriosus n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Patent Ductus Ateriosus PowerPoint Presentation
Download Presentation
Patent Ductus Ateriosus

Loading in 2 Seconds...

play fullscreen
1 / 27

Patent Ductus Ateriosus - PowerPoint PPT Presentation


  • 380 Views
  • Uploaded on

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 ?.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Patent Ductus Ateriosus' - manon


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
patent ductus ateriosus

Patent DuctusAteriosus

Neonatal Intensive Care Nursery

Night Curriculum Series

slide2

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

what major changes in infant circulation occur following birth
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
slide4
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
what is in your initial differential for this infant s respiratory distress
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

physical exam
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
what is the likely cause of this infants respiratory distress
What is the likely cause of this infants respiratory distress?
  • Respiratory Distress Syndrome
  • PDA
  • Sepsis
  • NEC
what is the likely cause of this infants respiratory distress1
What is the likely cause of this infants respiratory distress?
  • Respiratory Distress Syndrome
  • PDA
  • Sepsis
  • NEC
what physical exam findings are consistent with pda
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

what findings on this cxr are suggestive of a pda
What findings on this CXR are suggestive of a PDA?

Increased Pulmonary vascular makings

Cardiomegaly

Uptodate.com

echocardiogram
Echocardiogram
  • Gold standard for diagnosing PDA

Taken from Neo Reviews

which infants are at greatest risk
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
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.
what makes a pda hemodynamically significant
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)

what are three main options for treatment
What are three main options for treatment?
  • Conservative/Supportive Management
  • Pharmacotherapy
  • Surgery
what supportive measures can you take in an infant with a symptomatic pda
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%
pharmacotherapy
Pharmacotherapy
  • What 2 agents are typically used?
    • Indomethacin
    • Ibuprofen
your patient is on indocin
Your Patient is on indocin
  • The team decides to treat your patient with indomethacin...
  • How does indomethacin help close a PDA?
indomethacin
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
what are some contraindications to indomethacin
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
complications to watch for
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
after two trials of indocin your patient still has a symptomatic pda what next steps might you take
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
surgical ligation
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
surgical ligation1
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
objectives
Objectives
  • Clinical Findings and Symptoms Consistent with PDA
  • Diagnosis of PDA
  • Complications of PDA
  • Indications for treatment
  • Treatment Options
  • Complications of Treatment
references
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