Cardio Exam 1: Yang

• _______ (CHDs) arise from the abnormal formation of the heart or major blood vessels. (most popular with pediatric patients)

• At least 21 specific anatomic or hemodynamic lesions have been identified.

• Many infants have _______.

  • ~25% require invasive treatment during the _______

• Associated with significant morbidities (e.g arrhythmias, infective endocarditis, thrombotic disorder, congestive HF).

• Infants _______

  • Account for almost 50% of the deaths associated with CHD

Congenital heart diseases, more than 1 lesion, 1st year of life, <1 y/o

Acyanotic (PINK → adequate oxygen supply (_______%, not all blood goes to systemic), but not optimal) KNOW!!

• _______ (_______)

• _______ (_______)

• _______ (_______)

• _______ (_______)

Cyanotic (BLUE → not enough sufficient oxygen supply (<_______%))

• Transposition of Great Arteries (TGA)

• Hypoplastic Left Heart Syndrome (HLHS)

• Tetralogy of Fallot (ToF or Tet)

LV → _______ pressure (than RV) → aorta

• High pressure (_______) → Low pressure (_______)

85-90, Atrial Septal Defect, ASD, Ventricular Septal Defect, VSD, Coarctation of Aorta, CoA, Patent Ductus Arteriosus, PDA, 60, higher, LV, RV

Which is this?

Acyanotic CHD: Ventricular Septal Defect (VSD)

Which is this?

Acyanotic CHD: Patent Ductus Arteriosus (PDA)

Patent Ductus Arteriosis (PDA)

• PDA in term infants is reported to be _______ live births and around 5%-10% of all CHDs.

• Female:male = _______

• Much _______ rate in pre-term neonates (_______)

• Ductus Arteriosus

  • Fetus: allows blood _______

    • Oxygen exchange through _______ (_______)

  • After birth (KNOW):

    • In response to _______ and _______, the newborn ductus will functionally close during the first few days after delivery.

      • Closed about _______ after birth with permanent destruction at about _______

  • PVR drops

1 in 2000, 2:1, higher, 37 weeks, bypass lungs, placenta, mother, increased O2, removal of placental prostaglandins, 96 hours, 2 weeks

Patent Ductus Arteriosis (PDA)

• What if DA is not closed?

  • PDA

    • _______

      • Aorta PA and lungs pulmonary over-circulation pulmonary edema reduced gas exchange  reduced oxygenation

    • _______

      • Pulmonary _______ and _______

Acyanotic Left-to-Right Shunt, Increasing pulmonary blood flow, HTN/edema, CHF

Patent Ductus Arteriosis (PDA)

• Why is PDA not closed?

  • _______ infants

    • Ductal tissue _______ respond to high levels of circulating _______ like term _______ does.

  • Genomic/family history??

    • Family history is a predictor of _______

      • Spontaneous preterm birth in the current pregnancy was significantly associated with a maternal family history of preterm birth among female relatives within 3 generations and notably sisters.

      • Am J Obstet Gynecol MFM, 2021

    • No consistent conclusions

  • _______

  • Being born at a high altitude.

Premature, does not, oxygen postpartum, newborn, current preterm birth, female sex

• Closure of PDA → _______ (_______) + _______ (_______)

• _______: push or pull (a train or part of a train) from the main line to a siding or from one track to another.

increases O2, Ventilator, decreases prostaglandins, NSAID, Shunt

KNOW IMAGE

Indomethicin

• MOA: Decrease prostaglandins through _______ of _______

• Dose: Based on _______ age at time of _______ and _______ after _______

• Indication

  • Landmark Clinical Study in Premature Infants:

    • __% of patients achieved ductal closure.

    • Patients receiving indomethacin experienced significantly _______ episodes and _______

  • Given _______ (_______)

reversible inhibition, COX-1 and COX-2, postnatal, 1st dose, urine output, 1st dose, 79, more bleeding, increasing SCr, IV, 3-dose series

Ibuprofen

• MOA: Decrease prostaglandins through _______ of _______ 

• DOC

  • Based on birth weight

    • _______ age ≤ _______ (_______ at birth)

      • ___ mg/kg/dose IV, followed by ___ mg/kg/dose IV _______ and _______ (_______→ if closure didn’t work, then _______ → if not, then _______)

  • Oral solution: ___ mg/ml; _______ solution: ___ mg/ml or _______

• Indication

  • _______

    • As effective as indomethacin

    • Reduced risk of necrotizing enterocolitis and transient renal insufficiency

• Contraindication

  • Do NOT initiate ibuprofen for ductal closure with _______

  • If DA does not close or reopen after the initial course, a second course may be considered versus indomethacin or surgical closure.

  • _______ ibuprofen: at least as effective as _______ administration

Reversible inhibition, COX-1 and COX-2, Gestational, 32 weeks, 500-1500 g, 10, 5, 24 hours, 48 hours after 1st dose, 3-dose course, do another 3-dose course, surgical closure, 20, IV, 10, PO, drug of choice for the closure of PDA, renal impairment, Enteral, IV

Acetaminophen

• MOA: Decrease prostaglandins through _______ of _______

• Indication

  • FDA approves _______ of acetaminophen in 2010

    • _______ risk

      • Ok for _______ patients

    • _______

      • Ofirmev

  • Suggest that acetaminophen is an _______ to ibuprofen or indomethacin

reversible inhibition, COX-1 and COX-2, IV formulation, reduced GI bleeding, renal insufficient, expensive, alternative

What’s the C/I of Ibuprofen for PDA treatment?

•  Severe _______ impairment

What’s the C/I of Acetaminophen for PDA treatment

•  Severe _______ impairment

renal, hepatic

Patient Case:

C.P. is a 25-weeks post-conceptional age baby boy (current body weight=680 g) who remains ventilator-dependent. He was born at 24 weeks gestational age with a birth weight of 650 g. 

He has a continuous murmur and bounding peripheral pulse, and his chest radiography shows evidence of pulmonary over-circulation with mild cardiomegaly consistent with patent ductus arteriosus (PDA). 

He has no evidence of intra-ventricular hemorrhage on cranial ultrasonography

For patient CP, what would you recommend for his PDA management?

•  Requires _______ (requires _______)

Urine output during the past 24 hours was 4 ML/kg/hr. As a clinical pharmacist, which is the best treatment option for CP at this time?

•  Give _______ 6.5 mg followed by 3.3 mg at _______ after the 1st dose (USE: _______)

Before starting PDA treatment, you noticed the patient’s urine output during the past 24 hours was reduced from 1.4 mL/kg/hr. As a clinical pharmacist, which is the best treatment option for CP at this time? (urine output >1 mL)

• Give _______ 6.5 mg _______ depending on the _______ after the 1st dose

pharmacological closure, ventilator, IV ibuprofen, 24 and 48 hours, 10 mg/kg, IV ibuprofen, 1st with holding the 2nd and 3rd doses, urine output

As a clinical pharmacist, which is the best treatment option for CP at this time?

• _______ + _______

• Need further workup + assess the patients _______ before making a recommendation

hold ibuprofen, start IV APAP, liver function

• _______ is the DOC (Drug of Choice); less _______ toxicity compared to indomethacin

Indomethacin + Ibuprofen (_______)

• If anuria or marked oliguria (urinary output < ___ ml/kg/hr) is evident at the scheduled time of the _______ dose, _______ until renal function returns to normal.

• C/I in _______ with significant _______.

Ibuprofen, renal, kidney impairment, 0.6, 2nd or 3rd, hold dose, preterm infants, renal impairment

T/F: Closing PDA is always beneficial for patients with CHD

False

What is this?

Cyanotic CHD: Transposition of Great Arteries (TGA)