PATENT DUCTUS ARTERIOSUS
Saturday, August 16, 2008
Essentials of Diagnosis & Typical Features
Clinically significant patent ductus arteriosus usually presents on days 3–7 as the respiratory distress from hyaline membrane disease is improving. Presentation can be on days 1 or 2, especially in infants born at less than 28 weeks’ gestation and in those who have received surfactant replacement therapy. The signs include a hyperdynamic precordium, increased peripheral pulses, and a widened pulse pressure with or without a systolic heart murmur. Early presentations are sometimes manifested by systemic hypotension without a murmur or hyperdynamic circulation. These signs are often accompanied by an increase in respiratory support. The presence of significant patent ductus arteriosus can be confirmed by echocardiography. Before undertaking medical or surgical ligation, other structural heart disease must be ruled out.
Treatment
The ductus arteriosus is managed by medical or surgical ligation. A clinically significant ductus causing compromise in the infant can be closed (in about two thirds of cases) with indomethacin, 0.1–0.2 mg/kg intravenously every 12–24 hours for three doses. If the ductus reopens, a second course of drug may be utilized. If indomethacin fails to close the ductus or if a ductus reopens a second time, surgical ligation is called for. In some cases, a more prolonged course of indomethacin is being used to prevent recurrences. In addition, in the extremely low-birth-weight infant (< 1000 g) who is at very high risk of developing a symptomatic ductus, a prophylactic strategy starting indomethacin on the first day of life can be used. The major side effect of indomethacin is transient oliguria, which can be managed by fluid restriction until urine output improves. Transient decreases in intestinal and cerebral blood flow caused by indomethacin can be ameliorated by giving the drug as a slow infusion over 1–2 hours. The drug should not be used if the infant is hyperkalemic, if the creatinine is greater than 2 mg/dL, or if the platelet count is less than 50,000/µL.
- Hyperdynamic precordium.
- Widened pulse pressure.
- Hypotension.
- Presence of a systolic heart murmur in many cases.
Clinically significant patent ductus arteriosus usually presents on days 3–7 as the respiratory distress from hyaline membrane disease is improving. Presentation can be on days 1 or 2, especially in infants born at less than 28 weeks’ gestation and in those who have received surfactant replacement therapy. The signs include a hyperdynamic precordium, increased peripheral pulses, and a widened pulse pressure with or without a systolic heart murmur. Early presentations are sometimes manifested by systemic hypotension without a murmur or hyperdynamic circulation. These signs are often accompanied by an increase in respiratory support. The presence of significant patent ductus arteriosus can be confirmed by echocardiography. Before undertaking medical or surgical ligation, other structural heart disease must be ruled out.
Treatment
The ductus arteriosus is managed by medical or surgical ligation. A clinically significant ductus causing compromise in the infant can be closed (in about two thirds of cases) with indomethacin, 0.1–0.2 mg/kg intravenously every 12–24 hours for three doses. If the ductus reopens, a second course of drug may be utilized. If indomethacin fails to close the ductus or if a ductus reopens a second time, surgical ligation is called for. In some cases, a more prolonged course of indomethacin is being used to prevent recurrences. In addition, in the extremely low-birth-weight infant (< 1000 g) who is at very high risk of developing a symptomatic ductus, a prophylactic strategy starting indomethacin on the first day of life can be used. The major side effect of indomethacin is transient oliguria, which can be managed by fluid restriction until urine output improves. Transient decreases in intestinal and cerebral blood flow caused by indomethacin can be ameliorated by giving the drug as a slow infusion over 1–2 hours. The drug should not be used if the infant is hyperkalemic, if the creatinine is greater than 2 mg/dL, or if the platelet count is less than 50,000/µL.
1 comments:
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