Patent Ductus Arteriosus
|Reviewed by David Knight
- PDA is a problem in
ventilated very low birth weight infants. About 40% of these will have a
large PDA at 3 days of age.
- Early: Mostly silent, with no murmur. BP may be low (systolic, diastolic and mean) with normal
- Late: Murmur. Hyperactive precordium.
- Increased pulses. Wide pulse
pressure. These are not reliable signs in the first few days.
- Congestive Heart Failure
- Pulmonary congestion/oedema/plethora
- Clinical respiratory deterioration.
- Rising PaCO2.
Usually diagnosed late. Most babies treated before this stage.
- Usually done at 3 days in infants <28 weeks' gestation or <1000g.
- Other babies are investigated on clinical suspicion.
- Rules out (most) congenital heart
- It is important to rule out duct dependent lesions, especially
- Pulmonary stenosis may be masked by a large PDA.
- Establishes ductal patency and size.
- Indicates the size of the shunt (ductus shunt
is best assessed by its physical size, then by descending aortic flow
- Assesses atrial shunt and size.
- To look at heart size and lung fields.
- The ECG is usually normal.
- It is rarely done in preterm infants.
Indications for treatment
- Significant shunt in a small baby with ongoing lung
- Closure of the ductus is aimed mainly at improving lung
<28 weeks or <1000gms, and on IPPV or CPAP
- Echocardiogram at 3 days.
- Significant PDA: Consider
Other babies on IPPV
- Investigate if clinical suspicion.
- Monitor creatinine, electrolytes, urine output &
platelets before and at least daily initially. If these parameters
remain normal, then they do not need to be routinely checked
after the 3rd dose.
- Review baby and results before each dose.
Poor renal function
Pulmonary haemorrhage (note: may
occur because there is a PDA)
- While on
indomethacin, reduce by 20-40ml/kg/day.
- There is no evidence that fluid restriction per se
results in closure of the duct but there are studies suggesting that early,
liberal fluid intakes are associated with a higher incidence of PDA.
- If PDA is still clinically significant after
indomethacin, or if
indomethacin is contraindicated.
usually be performed on NICU.
- Note that a increase in
respiratory support is often required immediately after surgery.
- Referral Process
- Drain to be removed the day after surgery if no drainage or bubbling.
- Dressing / Glue will peel off
- A variety of sutures are used for closure and are usually dissolvable.
If there are knots to be trimmed this is done at 14 days. Call the surgical
fellow or nurse assist on 021380548 for any queries.
- Diuretics for one week post-op and then stop (unless otherwise indicated
for non-cardiac reasons)
- Follow up with Paediatrician in 1 month, no need for cardiology follow
up unless there is a new issue
The treatment of patent ductus arteriosus in preterm infants. A
review and overview of randomized trials. Seminars in Neonatology.
2001; 6: 63-73.
Steer P, Woodgate P. Indomethacin for asymptomatic patent ductus
arteriosus in preterm infants. Cochrane Database of Systematic
Reviews 2003, Issue 1.
Holberton J, Davis P. Prolonged versus short course of indomethacin
for the treatment of patent ductus arteriosus in preterm infants.
Cochrane Database of Systematic Reviews 2001, Issue 4.
Travadi JN et al. Is surgical ligation of patent ductus Arteriosus
necessary? The Western Australian experience of conservative
management. Arch Dis Childh. 2005; 90: F235-F239.
Current controversies in the diagnosis and treatment of patent
ductus arteriosus in preterm infants. Advances in Neonatal Care.
2003; 3: 168-177.