WS PDA Case-Based

Discussion
Ahmad Kautsar
Devatri Hudayari
Adhi Teguh
UKK Neonatologi IDAI
 Case-1
• Very preterm baby, Twin 1, 28+3 weeks, DCDA
• Ruptured membrane 4 hours prior to delivery, threatened
preterm labour, suspected chorioamnionitis (WCC 23,270/uL,
high maternal crp 194), no antenatal steroid coverage
• Poor ANC, maternal antibiotics 1 hour prior to delivery
• Spontaneous vaginal delivery, BW 897 gram
• Poor tone, PPV at birth, Apgar 3/5/7
• Intubated in DR due to increased WOB and high FiO2 (40%),
surfactant at delivery room
• Ventilator setting on admission PC/AC 20/6 RR 60 FiO2 30%
• Initial blood gas : pH 7.43 pCO2 41 HCO3 28 BE 3.8
Case – RDS
• 1st cardiac scan screen was done at 6 hours after birth à PDA 4.5 mm,
bidirectional, FS 28%
• Started dobutamine at 5 mcg/kg/min
• Baby was kept intubated due to concern of large PDA
• Baby was stable from admission up to 12h. Vital signs HR : 123 BP :
69/53 (60) SpO2 96% on PC/AC FiO2 21%
• Initial Head US : no IVH
• 2nd Cardiac scan was done at 12 h of age
Apical view

PG 38.86 mmHg
Suprasternal View - PDA

Large PDA 3.8 mm

 Suprasternal View

LPA flow diastolic velocity

• Conclusion :
• Large PDA bidirectional Plan: repeat scan
• Pulmonary pressure still high (baby was stable ventilated with room air)
What is your action?
a. Observe and do another scan
b. Treat PDA with medication
c. Treat PPHN
Case - Continued
• Baby was stable ventilated until 22 hours of age, in air
• At 22 hours, sudden bleeding from ET tube, FiO2
gradually increase into 100%
• HR : 157 BP : 72/58 (63) SpO2 85-90%
• pH :7.35 pCO2 43.8 HCO3 24.6 BE -1.2
• Blood transfusion was given
• Cardiac scan was done at 25 hours
• Mechanical ventilation was planned to change into
HFOV but delayed due to availability (~ 6 hours)
PDA-View

Large PDA 3.5 mm

 Case – continued

PDA still bidirectional

SMA: forward flow
Plan : second dose surfactant,HFOV, iNO if not responding
Case – Continued
• 2nd dose surfactant was given at 27 hours of life
• Limited resources: HFOV availability, problems with incubator
• Clinical condition deteriorated afterwards - hypotension
• Dobutamin 10 mcg/kg, NE titrated until 0.1 mcg/kg/min
• Epinephrine added due to ongoing hypotension
• Head ultrasound : bilateral IVH gr 3-4
• At 32 hours
• Baby started bradycardia, Profound desaturation, resuscitated
Points for discussion
• In stable preterm infant, when is the first time to do cardiac scan?
Policy for cardiac scan.
• Large PDA, bidirectional shunt à when to repeat scan?
• Interpretation of cardiac scan post pulmonary hemorrhage –
bidirectional shunt, with sub systemic PH, what is the appropriate
treatment?
Case
• Extremely preterm infant, 26 weeks, 670 gram
• Born with emergency c-section (due to reversed end diastolic flow on US)
• Mother : maternal preeclampsia, oligohydramnios, partial coverage of antenatal
steroid, no risk factor of infection.
• Poor tone and bradycardia at birth, PPV initiated with 20/5 fiO2 30%
• Apgar 1/4/7
• Difficult intubation. SpO2 at 5 min 66% with 100% FiO2, HR 95 bpm. ventilated w/ T-
Piece 25/5
• Intubated at 15 min, surfactant was given
• At 30 min more stable with SpO2 98% HR 105 bpm, ventilated with transport
ventilator PC/AC 25/5 FiO2 40%
Case
• At 1 hr, he was suspected to have pneumothorax due to
asymmetrical chest rise and +ve transillumination à needle
decompression, aspirated 30 ml
• Initial blood gas at NICU (1hr) : pH 6.875 pCO2 101.5 pO2 199
BE -15 HCO3 18.8 Lactate 13.54 (pneumothorax)
• Initial ventilator setting at NICU PC/AC 21/6 RR 60 FiO2 80%
• Difficult oxygenation and ventilation at 2 hour à ventilation
escalate to HFO Paw 11 Amp 30 Fio2 went down to 50%
• Blood gas : pH 7.216 PCO2 32.8 BE-14 HCO3 13.3 lactate 14.02
• HR 90-95 bpm, BP: 46/21 (31) SpO2 92-96% (1-4 hr of age)
• Dobutamin started at 4 hr (5 mcg/kg/min)
• Adrenaline started at 5 hr (0.05 mcg/kg/min)
 Case
• 6-11 hr • Echo at 14 hr
• Dobutamine 5 mcg/kg/min • 24 hr
• PDA 2.2 mm
and adrenaline 0.05 • Growing pattern
• FiO2 increase in 1 hour
mcg/kg/min • Qp > Qs from 30% to 100%
• HR increase to 120-122 • Lung overflow • 3rd dose surfactant was
• 2nd dose surfactan • LA/Ao 2.2 given
• BP 49/30 (36)
• Paracetamol was given • Still on dobutamine 5
• FiO2 on HFO 40%
• Bicarbonate correction • FiO2 30% Paw 11 amp 25 mcg
• Dobutamine 5 mcg/kg/min fr 12 • Adrenaline 0.05 mcg
• Adrenaline 0.05 • Paw increase to 12
mcg/kg/min • Fio2 gradually
• Head US : bilateral IVH gr 1 decrease into 21% (25-
30 hr)
Echo at 14 hrs
Echo at 14 hrs
 Case

• 36 hr • Echo : Pulmonary
• Bleeding from ETT, low • 4 days of life
hypertension, PDA R to L • iNO was able to wean and
platelet count 72.000/uL
• Marked desaturation, 2 mm, PG 40 mmHG, D- stop at day 4 of life (total
shaped LV duration 48 hrs)
sudden increase in 1 hr
• Still on dobutamine 5 • Echo : PPHN resolved, PDA
into 100% L to R, PDA 2.2 mm
• Lung recruitment Paw mcg/kg/min • Head US : IVH Gr 2 and
24 Amp 40 fr 10 • Adrenaline 0.05 PVL gr 1
• Inhaled NO 10 ppm mcg/kg/min • Leucopenia (1290),
• FiO2 was able to wean thrombocytopenia
down into 55% after iNO (28000), antibiotic was
(not readily down after escalated
lung recruitment)
• Stop Paracetamol
Echo at 36 hrs
Points to discuss
• Baby with presumed perinatal asphyxia and bradycardia at birth,
inotropes were given initially.
• Echo at 14 hrs PDA growing pattern with low RVO, paracetamol was
given, would it be better to withhold?
• PPHN in preterm, how to predict responsiveness to NO?
TERIMA KASIH