Dr. Pradeep Suryawanshi Professor & Head, Department of - - PowerPoint PPT Presentation

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Dr. Pradeep Suryawanshi Professor & Head, Department of - - PowerPoint PPT Presentation

Jan 20, 2023 120 likes •532 views

PDA: whom, when and how to treat Dr. Pradeep Suryawanshi Professor & Head, Department of Neonatalogy, BVU Medical college, Pune Senior Consultant Neonatologist, Sahyadri Hospital, Pune Chief Patron & Consultant Neonatologist, Noble

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PDA: whom, when and how to treat

10/3/2016 1

  • Dr. Pradeep Suryawanshi

Professor & Head, Department of Neonatalogy, BVU Medical college, Pune Senior Consultant Neonatologist, Sahyadri Hospital, Pune Chief Patron & Consultant Neonatologist, Noble Hospital, Pune Mentor, Department of Pediatrics, BLDE University, Bijapur

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Learning Objectives

  • Why

– Why treat a PDA?

  • What

– Can we identify a PDA that should be treated?

  • When

– Can we identify the best time to treat?

  • With what

– Do we have a treatment that has an acceptable risk/benefit ratio?

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Effects of PDA

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PDA Morbidity

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PDA Management Potential benefits of treatment

  • Avoid hypotesio
  • ‘edued severe IVH Prophylati
  • ‘edued puloary haeorrhage
  • ‘edued gut opliatios
  • ‘edued surgial ligatio
  • Possily redued CLD if losed earlier

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  • In first 72 hrs PDA can ONLY be diagnosed

with echocardiography as typical signs & symptoms of PDA shunting are absent

  • Haemodynamic significance precedes

development of clinical signs by an average

  • f 2 days (range 1–4 days)

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PDA Evaluation

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ECHO: What is a “significant” PDA?

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A three - legged stool appearae - Right pulmonary artery (RPA) and left pulmonary artery (LPA) forming the right and middle legs, and the duct forming the third leg

Is the ductus patent ? Imaging the duct – 2 D

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Colour Doppler ultrasound

  • Bright flare of colour
  • Detection of a patent

duct easy

Is the ductus patent ? Imaging the duct – Colour

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Small duct Big duct Color Doppler duct diameter

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Message 4-

Duct Diameter < 1.5 mm – Usually insignificant Duct Diameter 1.5 – 2 mm – Significant variable / Use with DA flow Duct Diameter > 2.0 mm – Usually Significant

Size of Duct

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Good early constriction Tend to close Poor early constriction Tend to stay patent

Range of ductal constriction at 5 hours < 30 weeks, N= 124

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Direction and Pattern of ductal shunt

Analysis of the direction

  • f ductal shunting

requires PD/CW Sampling gate placed at pulmonary end of duct

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Pure Left to Right shunt

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Bidirectional shunt Pulmonary pressures are still below systemic pressures There is a period in early systole when pulmonary pressures > systemic pressures, there is an early period of a R to L shunt, followed by L to R shunt

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Evaluation of chamber dilatation : LA: AO

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Ao LA Ao LA

LA: AO - > 1.4

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LVEDD/Ao >2.1

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PDA: (“Ductal steal”)

  • Diastolic aortic pressure is low with a large left to right

ductal shunt - ductal steal

  • Steal - Blood passing down the descending aorta

during systole goes backwards up the arterial duct and into the pulmonary arteries during diastole

  • Relative under perfusion of ALL systemic arteries
  • Cooly iterrogated arteries:
  • Descending aorta/Mesenteric/Renal/Anterior Cerebral

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Descending aorta flow

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Descending aorta flow

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Abnormal flow pattern – Absent ACA

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Abnormal flow pattern – REDF SMA

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Abnormal flow pattern – REDF Renal Artery

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Sehgal & McNamara Eur J Pediatrics. 2009

Take Home message

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Shahab Noori 2014

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Argument to treat early

  • Effects of shunt

– Short term – Hypotension, PH, IVH, Ductal steal – Medium term – CLD, PVL

  • Effects of treatment

– Acute – no increase shown in prophylaxis trials (NEC, SIP) – Long term – no difference in ND outcome (TIPP trial)

  • Benefits to earlier treatment

– Better timing – More efficacious – In right time frame for other benefits – reduced IVH, PH, hypotension

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Sellmer et al. ADC F&N 2013

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With what ? Treatment of PDA

  • Conservative

– positive pressure – fluid restritio/heial adig↑pCO2, ↓pO2 – Diuretics – increase hematocrit

  • Medical

– Indomethacin – Ibuprofen – Intravenous/Oral – Paracetamol

  • Surgical ligation

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Ibuprofen is as effective as indomethacin in closing a PDA and currently appears to be the drug of choice. Ibuprofen reduces the risk of NEC and transient renal insufficiency. Oro-gastric administration of ibuprofen appears as effective as iv administration.

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Key Messages

  • PDA is not benign and increases risk of death and

complications of prematurity

  • Clinical and echocardiography criteria differ for early

targeted and late symptomatic treatment

  • Late treatment of a symptomatic PDA does not

improve clinical & long term outcomes

  • If PDA unlikely to close spontaneously then

treatment before it becomes symptomatic may be beneficial – trials are needed to assess this approach