Enhanced intensive care for the neonatal ductus arteriosus

Abstract

Failure of ductal closure is common in extremely low birth weight infants with significant postnatal morbidities from both pulmonary overcirculation (i.e. chronic lung disease) and/or systemic hypoperfusion (i.e. necrotizing enterocolitis). Early clinical signs of a hemodymanically significant ductus may be non‐specific (i.e. hypotension, increasing ventilator requirements, metabolic acidosis) necessitating early screening by echocardiography. Cyclooxygenase inhibitors remain the first‐line treatment option. Indomethacin remains the most commonly used agent, despite comparable efficacy and reduced risk of adverse events with ibuprofen. Surgical intervention is recommended after failure of medical therapy, contraindications to medical treatment or fulminating duct‐related cardiorespiratory deterioration. Wherever possible, surgical intervention in ELBW infants should be avoided in the first week of life due to the potential risks of ischemia‐reperfusion cerebral hemorrhage. The postoperative course is often complicated by left ventricular failure, pulmonary edema, and/or hemodynamic instability requiring close monitoring and physiologically relevant therapeutic interventions.

Patent ductus arteriosus ligation and post-operative hemodynamic instability: Case report and framework for enhanced neonatal care

“…1 Surgical ligation is indicated when medical therapy is unsuccessful or is contraindicated. As the postoperative period is often complicated by a postligation cardiac syndrome (PLCS), which is characterized by haemodynamic instability and respiratory failure, 2 a standardized approach to cardiac intensive care is required.…”

Patent Arterial Duct

“…Although the duct, the preterm newborn continues to respond to PGE2 after birth, it becomes less dependent on prostaglandins and more dependent on other vasodilators during the weeks following delivery. This could explain why the effectiveness of prostaglandin inhibitors, as a pharmacologic treatment to promote ductal closure, wanes with increasing postnatal age [23].…”

“…Whether to treat or not, as well as when to treat a PAD, has been a controversial topic for the past decade [21,24,25]. It has become apparent from systematic review of the literature that there is no clear evidence of effect on long-term outcomes of treating PAD, which some authors consider a physiologic phenomenon in sick preterm infants [23,24]. Non-steroidal anti-inflammatory drugs have been traditionally used to close PADs to prevent associated complications [21,24].…”

Indomethacin vs ibuprofen: comparison of efficacy in the setting of conservative therapeutic approach

“…A higher incidence is seen in extremely low-birth-weight infants and those ≤29 weeks of gestational age [1]. A haemodynamically significant PDA has been associated with common neonatal morbidities such as bronchopulmonary dysplasia (BPD), intra-cranial haemorrhage (ICH), necrotising enterocolitis (NEC) and renal failure [3,31]. Persistent patency has also been associated with increased mortality [20].…”