Treatment and Nontreatment of the Patent Ductus Arteriosus: Identifying Their Roles in Neonatal Morbidity

Clyman, Ronald I.; Liebowitz, Melissa

doi:10.1016/j.jpeds.2017.06.054

Cited by 22 publications

(20 citation statements)

References 55 publications

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“…[56][57][58][59] Fluid restriction is included in our care practices, but its value in preventing or treating BPD has not been well established. 60,61 Interventions we minimized that may increase BPD were treatment of PDA [62][63][64] and antibiotic use. 65 The decrease in BPD <33 associated with the changes we implemented highlights the importance of a more fully delimited and implemented system of care over individual interventions, that is, the whole was greater than the sum of its parts.…”

Section: Discussionmentioning

confidence: 99%

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Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle

et al. 2021

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IMPORTANCE Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade. OBJECTIVE To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019).INTERVENTIONS A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable. MAIN OUTCOMES AND MEASURESThe primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge.Balancing measures were adjusted mortality and adjusted mortality or specified morbidities. RESULTSThe study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly. CONCLUSIONS AND RELEVANCEA sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.

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Section: Discussionmentioning

confidence: 99%

“… 56 , 57 , 58 , 59 Fluid restriction is included in our care practices, but its value in preventing or treating BPD has not been well established. 60 , 61 Interventions we minimized that may increase BPD were treatment of PDA 62 , 63 , 64 and antibiotic use. 65 …”

Section: Discussionmentioning

confidence: 99%

Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle

et al. 2021

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“…Forty-four infants were surgically treated for PDA (Ligated group). Each infant in the Ligated group was matched to an infant in the Control group from the Swedish Neonatal Quality Register (44 out of 101 eligible infants), blindly as to any other outcomes except for ( 1 ) not having undergone surgery for PDA, ( 2 ) being born within +/−1 month of the birthdate, and ( 3 ) within +/−1 week of the gestational age of the infant in the Ligated group. Infants with congenital anomalies or heart conditions other than PDA or foramen ovale were excluded from both groups in this study.…”

Section: Methodsmentioning

confidence: 99%

“…Patency of the ductus arteriosus in newborn pre-term infants continues to be one of the most challenging problems in neonatal intensive care units. Despite extensive research efforts, there are still uncertainties about the diagnostic criteria and treatment strategies for patent ductus arteriosus (PDA) in pre-term infants, and specifically in extremely pre-term newborn infants ( 1 , 2 ).…”

Section: Introductionmentioning

confidence: 99%

A Matched Case Control Study of Surgically and Non-surgically Treated Patent Ductus Arteriosus in Extremely Pre-term Infants

et al. 2021

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Introduction: There are still uncertainties about the timing and indication for surgical ligation of patent ductus arteriosus (PDA) in pre-term infants, where lower gestational age (GA) usually is predictive for surgical treatment.Objective: Our aim was to assess differences in clinical characteristics and outcomes between surgically treated and matched non-surgically treated PDA in extremely pre-term infants.Methods: All extremely pre-term infants born 2010–2016 with surgically treated PDA (Ligated group; n = 44) were compared to non-surgically treated infants (Control group; n = 44) matched for gestational age (+/−1 week) and time of birth (+/−1 month). Perinatal parameters, echocardiographic variables, details of pharmacological PDA treatment, morbidity, and mortality were assessed.Result: Mean GA and birthweight were similar between the Ligated group (24+5 ± 1+3 weeks and 668 ± 170 g) and the Control group (24+5 ± 1+3 weeks and 704 ± 166 g; p = 1.000 and p = 0.319, respectively). Infants in the Ligated group had larger ductal diameters prior to pharmacological treatment, and lack of diameter decrease and PDA closure after treatment (p = 0.022, p = 0.043 and 0.006, respectively). Transfusions, post-natal steroids and invasive respiratory support were more common in the Ligated group. Except for a higher incidence of severe bronchopulmonary dysplasia (BPD) in the Ligated group there were no other differences in outcomes or mortality between the groups.Conclusion: Early large ductal diameter and reduced responsiveness to pharmacological treatment predicted the need for future surgical ligation in this matched cohort study of extremely pre-term infants where the effect of GA and differences in treatment strategies were excluded. Besides an increased incidence of severe BPD in the Ligated group, no other differences in morbidity or mortality were detected.

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“…PDA closure can be performed pharmacologically or, in case of failure or contraindication, with surgical ligation or transcatheter closure (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18).…”

Section: Introductionmentioning

confidence: 99%

Early Urinary Metabolomics in Patent Ductus Arteriosus Anticipates the Fate: Preliminary Data

et al. 2020

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Introduction: In premature neonates, the persistence of hemodynamically significant ductus arteriosus (hsPDA) can be associated with short- and long-term consequences, impairing their outcome. The correct strategy of management for such condition is under debate, especially regarding contraindications and/or side effects. In recent years, metabolomics was applied to several perinatal, pediatric, and adult conditions to investigate potential biomarkers of disease, which have become useful for early diagnosis and/or therapeutic management.Aim of the Study: The main purpose of our exploratory study was to asses, through 1H-NMR metabolomics analysis of urinary samples at birth, possible metabolic pathways differentiating, with a significant predictive power, those preterm neonates who will subsequently develop hsPDA and neonates of comparable gestational age (GA) who will undergo spontaneous ductal closure or the persistence of an irrelevant PDA (no-hsPDA). Moreover, we investigated potential prenatal or perinatal clinical factors potentially influencing the development of hsPDA.Materials and Methods: We enrolled n = 35 preterm neonates with GA between 24 and 32 weeks; urinary samples were collected within the first 12 h of life. Patients were closely monitored regarding intensive care, respiratory support, fluid balance and administered drugs; an echocardiogram was performed at 48–72 h.Results: Our results reported a significant correlation between lower GA at birth and the development of hsPDA. Moreover, neonates with GA ≤ 30w developing hsPDA were characterized by lower Apgar scores at 1′ and 5′, higher rates of perinatal asphyxia, higher need of delivery room resuscitation and subsequent surfactant administration. Interestingly, metabolomics analysis at birth detected a clear separation between the 1H-NMR urinary spectra of subjects GA ≤ 30w not developing hsPDA (n = 19) and those of subjects born at GA ≤ 30w in which hsPDA was confirmed at 48–72 h of life (n = 5).Conclusions: This is the first study applying metabolomics to investigate the PDA condition. Although preliminary and conducted on a limited sample, our results reveal that metabolomics could be a promising tool in the early identification of hsPDA, potentially superior to the clinical or laboratory predictive tools explored to date and even to the clinical observations and correlations in our sample, through the detection of specific urinary metabolites.

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Treatment and Nontreatment of the Patent Ductus Arteriosus: Identifying Their Roles in Neonatal Morbidity

Cited by 22 publications

References 55 publications

Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle

Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle

A Matched Case Control Study of Surgically and Non-surgically Treated Patent Ductus Arteriosus in Extremely Pre-term Infants

Early Urinary Metabolomics in Patent Ductus Arteriosus Anticipates the Fate: Preliminary Data

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