Cardiology Exam 3 - PDA

PAD: which physcial connections prevent fetal blood from going to the lungs (which aren’t needed for oxygen exchange)

1. foramen ovale (move blood from Right Atria to left Atria bc/ dont need to go to pulmonary artery) BUT some stays in right atria and gets to pulmoary artery

2. ductus arteriosus (whatever blood does make it to pulmonary artery —> will move into aorta)

explain the difference between a fetal and newbrown heart in terms of

• pulmonary vasccular resistance/ perfusion

• systemic vascular resistance / perfusion

• pressure in left vs right lung

decrease in ______ allows for the closure of the Ductus Arteriosis

Fetus:

• high PVR (blood wont flow to lung)

• low SVR (blood will flow to rest of body)

• low pressure on left side, high pressure in right —> blood flow from right side of hear to left

decrease in prostoglandins (prostaglandins vasodilate allowing for high perfusion to rest of body—> but now without it experience vasoconstriciton—> increase SVR so now blood WILL flow to lung

does the ductus arterius remain open for longer for babies born earlier or later?

the earlier you are born, the longer your ductus arterious remains open after birth

what allows the Ductus Arteriosis to remain open even after birth?

persisting levels of PGE2 allows for vasodilation between pulmonary artery and aorta

why would PDA lead to increased

• increased pulmonary blood flow

• pulmonary vascular congestion

• pulmonary edema

• systemic HYPOperfusion

after you are born peripheral vascular resistance decreases dramatically and systemic vascular ressistance increases

blood isnt supposed to be able to flow from aorta into pulmonary artery BUT since ductus arterius remians open blood gushes from aorta which is now high pressure into pulomary artery which is low pressure

leading to fluid buildup in pulmonary artery and hypoperfusion to the rest of the tissues

does PDA lead to left sided volume overload or decrease load?

what structural changes are seen in the left side of the heart?

leads to INCREASED left volume overload because all of that blood that left throught the pulmonary artery is going to come back through the pulmonary vein

• left ventricular dilation and hypertrophy (overworked)

• left atrium dilation (to account for higher volume)

overworked left heart due to PDA may lead to

1. heart failure

2. tachypnea

3. poor feeding

4. hepatomegaly

What are 7 consequences of PDA?

1. prolonged _____ ______ (so much blood is now in the lung)

2. necrotizing _________

3. _____ dysfunction

4. pulmonary ________

5. bronchopulmonary ______

6. intraventicular and pulmonary _____

7. _____ ______

1. prolonged mechanical ventilation

2. enterocolitis

3. renal

4. hypertension

5. dysplasia

6. hemmorage

7. cerebral palsy

Besides prematurity what can increase your risk of PDA?

what would decrease your risk?

1. increased fluids >170ml/kg /day

2. furosemide

3. respiratory distress syndrome

4. prolonged rupture of membranes

MATERNAL ANTENATAL STEROIDS WOULD DECREASE UR CHANCES

how are you able to determine if a babies PDA is still open?

true/false: there is no accurrate or prescisie definition of a hemodynamically significant PDA

1. EKG

2. physical examination

3. serum biomarkers

TRUE. you cant tell based off of the distribution of blood alone

clinical signs and symptoms of PDA:

• continous or hollisitc ________

• what are some respiratory signs?

• renal dysfunction (what labs should you look out for)?

• _____ intolerance

• what is different about the liver?

• hyper/hypo tension

• ____ pulse pressure

• murmur

• tachypnea (fast breathing)

• frequent desaturations

• creatinine clearance and oliguria (low urine)

• HYPOtension (blood isnt making it to tisues blood from aorta is directed to pulmonary artery)

• widened pulse pressure

What can you see from the echocardiogram of a patient with PDA?

• ductal diametter greater than ______ or ______

• shunting of blood from ___-____

• ____ ___—> aortic root diameter ratio >1.6

• left/right atrial and ventricular dilation

• __________ flow reversal in the descending aorta

• ductal diameter >1.5mm or >1.4mm/kg

• left to right shhunt

• left aterium to aortic root

• LEFT atrial and ventricular dilation

• holodiastolic

lab markers:

metabolic or respiratory acidoses?

increase in _____

elevated _______ protein (inflammation)

BOTH metabolic and respiratory acidosis

increase in CO2 unable to exchange increasing levels of blood in the lungs

increased C-reactive protein due to inflammation

would you still ventilate a new born that has their PDA open BUT isn’t experiencing abnormal blood flow?

YES still ventilate BUT don’t put them on any medications and make sure fluids are low

can early routine treatment such as indomethecin, ibuprophen, acetominophen (Early routine treatment) decrease

• necrotizing enterocholitis

• bronchopulonary dysplasia

in infant who are NOT hemodynamically impacted by the PDA?

what did it lead to?

did NOT decrease necrotizing enterocholitis or brunchopulmonayr dysplasia

better to let the DA close on its own then expose new born to drugs

Early therapy actually lead to delayed feeding and late onset sepsis

what are possible therapy options for new borns with hemodynamically SIGNIFIICANT PDAS who are having

• tachypnea (palpable widened pulse)

• hypotension

• kidney damage (oliguria)

• pulmonary overcirculation

indomethacin

ibuprophen

acetaminophen

which step of PGE2 synthesis does acetaminophen block vs ibuprophen

ibuprophen block COX (arachadoic acid —> PGG2)

acetaminophen block POX (PGG2—>PGH2)

what formulations do ibuprofen come in?

when should you discontinue treatment?

IV (ibuprofen lysine) and oral suspension

discontinue if urine output is less than 0.6ml/hr

can indomethacin be given orally and IV?

when would you give babies medication every 12 hours compared to every 24 hours?

NO only IV (given in 3 doses)

if they are barely peeing you should given them the medication every 24 hours so levels dont get toxic so UOP between 0.6-1ml/kg/hr

if they are peeing often UOP >1ml/kg/hr they are also peeing out drug so give them dose every 12 hours

contraindications for taking ivermectin and ibuprofen

contraindications:

• renal dysfunction

• active bleeding

• thrombocytopenia

• coagulation defects

• congenital heart disease where patency of ductus arteriosus os mecessary for pulmoonary and systemic blood flow

Precautions IF

• untreated active infection

• necrotizing enterocolitis

• ibuprofen can displace billirubin if they already have alot of billirubin

which drug has WORSE adverse effects (indomethacin vs ibuprofen):

• renal dysfunction

• intestinal preforation

• increased billirubin

• intraventricular hemmorage

• GI bleeds

• indamethacin

• indamethacin

• IBUPROPHEN INCREASE BILLIRUBIN

• indamethacin (better at low dose)

• indamethacin

Administration and Drug Administration:

Rapid infusion of medications can cause ________ and comproomise blood flow to ________increasing the risk of _____ preforation

Might want to consider witholding _____ during treatment

increased risk of ______ ______ or _____ _____ with concomitant administration of steroids

vasoconstriction —> compromise blood flow to intestine—> increase risk of intestinal preforation (hole in intestine!)

DONT GIVE FOOD DURING TREATMENT

steroids can increase risk of necrotizing enterocolitis and intestinal preformation

Acetaminophen

• why would a baby be put on acetaminophen instead of ivermectin or iburpprofen

• what are the dosage forms available for acetaminophen?

• what are some contraindications

LESS DATA ON EFICACY AND ADVERSE EFFECTS

• if they have contraindication or cant be on NSAIDS

• BOTH IV and oral

• severe acute liver disease and increase in liver enzymes

Prophylactic Treatment:

• PDA is silent for the first ___-___ hours

for who is prophylactic treatment given to?

what beenefits have been seen?

which drug is used as prophylactic treatment?

is it recommended?

• silent for 2-3 days (48-72 hours)

• low weight preterm babies qualify for prophylactic treatment during first 3 days

• decreased hemorage and SHORT TERM benefits

indomethacin

NO bc/ PDA should close on its own not worth risk and doesn’t increase chance of survival (no mortality benefit)

NP is an 8- day old neonate born at 34 weeks and 2 days old on
mechanical ventilation since birth. On rounds the nurse reports
increasing Fi02 requirements over the past 2 days. In the chart you
notice widening pulse pressures. An echo reveals a ductus that is 1.9
mm. The team wants to initiate treatment for this patient’s PDA.
Nurses reported no wet diapers for 18 hours. Is NP a candidate for
NSAID therapy?

Yes bc/

• widened pulse pressure

• needs ventilation

• needs increased saturation

• ductus greater than 1.5mm or 1.4mm/kg

How can you tell if treatment has been working?

• shrinkage in size of _______

• does an increased age decrease efficacy

• can therapy be repeated? what is the max amounts of times?

• shrinkage of ductus arterioles

• yes increased age is decreased efficacy

• therapy can be repeated max 2x

what is considered 1 couse of therapy for

• ivermectin

• ibuprofen

• acetaminophen

• ivermectin = 3 doses

• ibuprofen = 3 doses

• acetaminophen= 3 days (every 6 hours each day) = total 12 doses

Indomethacin and ibuprofen very simmialr NSAIDs

• adverse effects favcor _______

  • less renal dysfunciton and incidence of intestinal preforation with

which is WHY

_________ is the preffered agent and ____ and ________ are used as acceptable alternatuves

adverse effects favor indomethacin

less effects w/ ibuprofen

ibuprofen is preffered with indamethacin and aceptaminophen as alternatives

BA is a 17 old infant treated for a hemodynamically significant PDA with
one course of ibuprofen.
● A repeat ECHO shows a PDA that is still 1.7 mm and persistent shunting
from left-to-right. The patient’s oxygen requirements have not decreased
after ibuprofen therapy.
● There are no significant clinical changes in the patients' course since the
ibuprofen was administered, and the patient's basic metabolic panel and
complete blood count are all within normal limits

acetaminophen bc/ clearly NSAIDs aren’t working

when is surgery by closing duct with clip or typing off vessel considered?

what are risks?

considered if

• cardiac dysfunction

• renal failure

• respiratory failure

even after medication

risks:

• vocal chord and diaphragm paralysis

• postoperative hypotension

• bronchopulmonary dysplasia

• problems with neurodevelopment if done with older baby

transcatheter closure:

• is it considered invasive?

• _____ insertd into the blood vessel to place a plug to block flow from aorta to pulmonary artery

requires _____ device at an institution

complication in 5% of patients

• device ______ requires retrieval

• unplanned cardiac or vascular surgery

• minimally invasive

catheter put in place to block connection of artery and aorta

• FDA device

Which of the following is not a contraindication to use of NSAID therapy?
A. Renal dysfunction
B. Necrotizing enterocolitis
C. Liver disease (bilirubin)
D. Ductal dependent lesion

ductal dependent lesion

Which of the following statements are true?
A. There is no set criteria to determine hemodynamic significance of a PDA
that dictate treatment
B. Preterm infants are at higher risk of having a PDA than term infants
C. Acetaminophen can be used as an alternative agent in patient who fail
or have contraindications to NSAID therapy
D. All of the above are true

all of the above