Patent Ductus Arteriosus

George A Gregory, MD
University of California
San Francisco
 Patent Ductus Arteriosus
• Background
• ⬆️incidence of PDA
• ⬆️survival of extremely premature infants
• ⬆️need for treatment due to problems of prematurity
• Ductus closure
• Functional closure
• 18-24 h
• Anatomic closure
• 2-3 weeks of age
• Abnormal if open >3 d of life
• Failure to close
• Immature structure and response to closure mechanisms
 Patent Ductus Arteriosus
• Closure mechanisms
• In utero
• Ductus kept open
• NO, PGE2, adenosine, atrial natriuretic peptide, CO, K+ channels
• Anatomic remodeling
• Changes at birth
• Initial ⬇️in PA constriction ➡️⬆️PBF
• ⬇️pulmonary vascular resistance
• ⬇️PGE2
• Onset of ventilation
• ⬆️O2
• ⬆️systemic vascular resistance
• ⬆️PBF and ⬇️ductal flow
 Patent Ductus Arteriosus
• Persistent PDA
• Preterm infants <28 w gestation
• Closure is inversely related to age
• Immaturity - ⬇️smooth muscle and responses to oxygen, endovascular cushion
• Persistent right-left shunting or low velocity blood flow
• More resistant to pharmacologic treatment
• Low platelet count?
• Consequences of significant hemodynamic PDA (hsPDA)
• ⬆️PBF, ⬇️lung compliance, pulmonary edema, hypoxemia, respiratory acidosis
• Ductal steal from systemic circulation - ⬇️blood flow to periphery
• Gut, brain, lungs
Ductal Steal
 Patent Ductus Arteriosus
• Effects of excess left-to-right shunt
• Pulmonary
• ⬆️lung fluid
• ⬇️oxygenation
• ⬆️respiratory support and mechanical ventilation
• ⬆️Lung injury
• BPD
• Prolonged ventilation with ⬆️pressures/oxygen
• Excessive tidal volumes
• Hemorrhagic pulmonary edema
 Patent Ductus Arteriosus
• Effects of left-to-right shunt
• Cardiovascular
• LA and LV overload ➡️dilation and dysfunction heart failure
• PA pressure ⬆️- often equals systemic
• ➡️pulmonary hypertension and ⬆️PVR (10% <1 kg)
• Mortality
• ⬆️after ≧ 7 d with moderate-to-large left-to-right PDA shunt
 Patent Ductus Arteriosus
• Effects of left-to-right shunt
• Neurologic
• Intraventricular hemorrhage
• Periventricular leukomalacia, ⬇️school performance @ 8 y in premature infants
• How much is due to PDA?
• Early indomethacin ➡️⬇️IVH but no long-term difference in outcome
• Early surgery no ⬇️IVH
• Surgery may be associated with poor outcomes
• Surgery and pharmacotherapy may result in worse outcomes than conservative therapy
• WHY?
• Steal ➡️⬇️regional cerebral blood flow
• ⬇️SaO2, ⬆️tissue O2 extraction
 Patent Ductus Arteriosus
• Effects of left-to-right shunt
• NEC or focal intestinal perforation
• ⬇️gut blood flow from steal may ➡️NEC or focal perforation
• Indomethacin + corticosteroids ⬆️NEC
• Early feeding with indomethacin administration does not ⬆️NEC
• Maternal breast milk
• When is PDA significant?
• ECHO is gold standard for diagnosis
• Ductal diameter
• ≧ 1.5 mm in ≦ 28 w gestation
• LA-to- aortic root ratio ≧ 1.4
• LV enlargement
• ⬆️PA mean and diastolic flow velocities
• ⬆️Qp/Qs ratio ➡️⬆️left heart volume load ➡️left heart failure
• Retrograde diastolic flow in descending aorta or low anti or retrograde flow in diastole
• Anterior cerebral and renal mesentery arteries
• Diagnosis of hsPDA based on clinical plus ECHO
 Patent Ductus Arteriosus
• When is PDA significant?
• Diagnosis
• History
• Symptoms and need for ventilatory support
• Physical examination
• Echocardiographic and clinical findings
• Gestational and chronologic age
 Patent Ductus Arteriosus
• Treatment
• Diagnosis
• Transthoracic echo
• Direction of shunt, systolic-diastolic flow
• Atrial and ventricular function ⬇️
• Diameter ≧ 1.5 mm during 1st 3 d of life - <28 w gestation
• L-R to aortic root ratio ≧ 1.4
• LV enlargement
• ⬆️mean and diastolic PA flow velocity
• Reversed mitral E/A echo
• ⬆️Qp/Qs ➡️⬆️in left heart volume overload
• Low-antegrade or retrograde diastolic flow in systemic arteries (cerebral artery, renal artery)
due to a steal
 Patent Ductus Arteriosus
• Pharmacologic closure of PDA
• I.V. indomethacin
• Prophylactic
• <24 h of age or 2-6 d of age
• Asymptomatic
• <72 h of age
• Watchful waiting
• Indomethacin/ibuprofen – COX inhibitors
• Less effective in very premature infants
• Indomethacin – less effect on end-organ flow than ibuprofen
• Ibuprofen ⬇️risk of PDA on d 3 of life, ⬇️need for rescue treatment, surgery
• No difference in mortality, CLD, IVH vs. expectant care
• Indomethacin often used, due to less IVH
 Patent Ductus Arteriosus
• When to treat pharmacologically
• Early treatment does not improve survival or neurologic outcome
• Longer prophylactic indomethacin treatment ➡️white matter injury
• About 40% of PDAs close spontaneously with no treatment
• May treat if <6 d of age and <28 w GA
• Significant shunt, respiratory support
• ⬇️GA ➡️⬆️hsPDA
• Catheter closure
• ≧ 700 g
• Effective 99% with experienced radiologists
• Complications – bleeding, hemolysis, aortic obstruction, tricuspid regurgitation, ruptured vessels
• Postcardiac ligation syndrome
• Improved pulmonary function
 Patent Ductus Arteriosus
• Surgical closure
• About 3% of patients
• ⬆️odds of neurodevelopmental defects, CLD, severe retinopathy
• Very sick before surgery/anesthesia
• ⬇️odds of death
• Post-ligation cardiac syndrome
• ⬇️L sided heart function, hypotension, ⬇️oxygenation, ⬆️ventilatory requirements
• Less common after catheter-based closure than after surgery
 Patent Ductus Arteriosus
• Conservative treatment
• Intentional fluid restriction (120-150 ml/kg/d), low respiratory requirements
(<2 L), diuretics – waiting for DA to close spontaneously
• No ⬆️in mortality, duration of MV, CLD, NEC, PVL, or IVH in placebo vs. no
treatment trial
• May be as effective as drug treatment in some patients
• Korean study – 23-30 w GA with hsPDA
• Nonintervention outcomes same as Ibuprofen treatment
 Patent Ductus Arteriosus
• Treatment of premature patient with PDA
• Approaches
• Prophylaxis
• Therapy at ≦ 6 d of age
• Hemodynamically significant PDA with symptoms
• Symptomatic treatment following failed previous therapy
• Early prophylaxis
• Drug toxicity – only in ICNs with low rate of spontaneous closure - <26 w gestation (<750 g)
• Early treatment of symptomatic PDA
• Moderate to large hemodynamically significant shunt @ <6 d of age (<28-week GA)
• On respiratory support - >2 L on nasal cannula – FiO2 >0.25
• ECHO of all infants <6 d of age
• If no shunt/hemodynamically insignificant shunt – conservative treatment
 Patent Ductus Arteriosus
• Treatment of premature patient with PDA
• Approaches
• Symptomatic infants
• ≧ 6 d of age
• > minimal respiratory support ➡️ECHO
• FiO2 > 0.25, failure to ween from respiratory support
• Ibuprofen if fails ➡️indomethacin
• Late rescue of symptomatic infants
• Moderate-to-large shunt + > minimal ventilatory support
• Pharmacology, ➡️catheter based, ➡️surgery
Case
• A 2-month-old boy. Preterm 36 weeks ●
• Peritonitis due to NEC + PDA
• First surgery Oct 25th: resection of jejunum, jejunostomy
• Second surgery Nov 2nd: Surgical ligation of PDA
 ●

Past medical history:

• Mother, 32-year-old lady, irregular antenatal checkup,
normotensive, nondiabetic
• 2nd baby, preterm, 36 wks, vaginal delivery, Birthweight 2.6
kg (normal for age)
• Good APGAR, meconium within 24hrs after birth
• Breast feeding with difficulty Did this improve?
Dehydrated? Starving?
• Developmentally age appropriate
• Family history: healthy 2-year-old brother
• Other members: no medical record
 ●

• A 2-month-old boy was admitted to Tien Giang hospital due to coma

& central cyanosis (glucose, calcium, drugs?)
• Condition when left hospital? PDA? Size?, Murmur? Treatment? Stable?
Eating well? If no murmur, what happened to open DA at 3 months?
• History:
• For 3 days he had mild fever, bad cough with tachypnea, poor feeding,
sometimes cyanosis, then severe vomiting , coma, cyanosis. ? Hypoxemia?
• Treatment in Tien Giang hospital for 7 days :
• Intubated, mechanical ventilated
• Fluid resuscitation
• Antibiotics : Meronem, Vancomycin, Ciprofloxacin, Metronidazol
• On the 7th day:
• He was awake, poor feeding, bilious vomiting
• Fever 38°C
• Pink/ MV, SpO2 96%
• Warm, good pulse: 168 bmp, CRT 2s (fever?)
• Regular heart sounds, systolic murmurs 3/6 precordium
• Breath sound was vesicular, equal in both lungs – Murmur?
• Abdomen: soft, moderately distended
• NG tube  10 ml dark green fluid, maroon blood in stool without
anal fissure
• Lab tests results:​
• WBC 13.7 k/uL Neu 9.5 k/uL
• Hct 38% PLT 198 K/L ​
• CRP: 60.7 mg/L Lactate: 0.05 mmol/L
• Na+ 139 mmol/L K+ 3 mmol/L Ca++ 2.19 mmol/L
• Abd US: Distension of bowel loops & small amount of free fluid in the
abdominal cavity
• Heart US: PDA: 4.6mm, L-R shunt; PFO: 3.3 mm; Mitral
regurgitation ¾, LV dilation (⬇️cardiac function)
• --> Transferred to Children’s Hospital 1
• His condition at CH1 (Oct 25, 14:00)
• Awake, pink/O2 100% via ETT with Ambu bag, SpO2 95%
• Pulse: 160 bpm, BP: 87/43 mmHg (Rt arm); RR: 30cpm
T: 38.5C CRT 2s
• Weight: 4kg Height: 51cm
• Flat fontanelle
• Chest:
• Clear heart sounds,
• Equal breath sounds, rhonchi & crepitation in both lung fields in middle
& lower zone
• Abdomen: tender, severe distension
 ●
• Lab test results:​
• WBC 20.300 /uL Neu 65.3%
• RBC: 4.700.000 /L ; Hct 39.5% (dehydration?) ; Hb: 13.5g/dl
• PLT 299.000 /L ​
• PTs: 17sPT%: 69% INR:1.31 ; aPTT: 36.7s ; Fib: 2.47 g/dl
• Lactate: 4.19 mmol/L CRP: 75.68 mg/L
• Dextrostix: 105 mg%
• Na 135; K 2.7 ; Ca 1.0; Cl 110 mmol/L
• pH: 7.49pCO2: 30.5 pO2: 88.8; HCO3: 23.5; BE: 1.2; FiO2: 40%
• Ure: 5.35 mmol/L Creatinin: 70.74 umol/L
• AST: 24.54 U/L ALT: 15.16 U/L
●
• CXR: cardiomegaly, dilatation of LV,
increased pulmonary vascular
markings
• Prominent main pulmonary artery
segment blending with a prominent
aortic knob along the upper left
heart border.
• Ground glass opacity, atelectasis in
both lungs very poor inspiration
• Follow up bone infarction

Abdominal Ultrasounds: Free air & fluid

with fibrin in the abdominal cavity

Poor inspiration
⬆️markings
Bone demineralization?
AXR: Subdiaphragmatic free air
Football sign, Rigler’s sign,
Falciform ligament sign
Extraluminal Air-fluid level
Diagnosis:
• Peritonitis due to hollow viscus perforation / Sepsis – PDA -
PFO
Treatment
• Infusion NS 10-20 ml/kg/h & (NaCl 10%, KCl 10%, CaCl2 10%, G10%)
• Antibiotics: Meronem, Amikacin, Metronidazol
• Insertion of gastric tube, rectal tube
• Blood cultures, antibiograms
• Indication for surgery
 Day Symptoms and lab tests results Treatment
Oct 25 Surgery: Resection of 30 cm of necrotic jejunum, 5cm of necrotic splenic Operation blood loss  40ml
18:00 flexure colon, a jejunostomy in the right iliac region → transfusion 40ml of PRBCs of the same ABO group
Oct 25 Arrived NICU.
20:45 -Unconscious, T: 36.6C -30° head elevation
-Mild pallor, pink/ventilator, SpO2 95% -Ventilation with SIMV + PS mode, FiO2 60%
-Warm, good pulse 114 bpm, CRT < 2s -PIP/PS/PEEP: 16/14/6 cmH20 RR 30 cpm
-IBP (Rt hand): 112/83 mmHg -Trigger: 0,5 l/min Vte: 32ml
-Clear heart sounds & equal breath sounds -Continue: Meropenem + Amikacin + Metronidazole
-Liver is palpable  2 cm from Rt costal margin -Morphin 20mcg/kg/h + Midazolam 1mcg/kg/min
-Paracetamol
-Mild pedal oedema -IV Omeprazol 4mg
-NPO
Oct 26 · Quiet, afebrile -Vitamin K1: 4mg/10ml Infusion 20ml/h x3 days
POD1 · Pink / MV, SpO2: 99% (FiO2 40%)
8:00 · Warm, good pulse 110bpm IBP: 86/42 mmHg
· Soft abdomen, gastric tube: small amount of green liquid
· Urine output: 120ml (2,7ml/kg/h)
· WBC: 20.3 Neu: 65% Hct: 33% PLT: 299.000
· CRP: 76.57 Lactate: 2.13 mmol/L Dextrostix: 113mg%
· PTs: 19.9s PT%: 55% aPTT: 33.6 INR: 1.55 Fib: 1.65
ABG:     pH: 7.37                   pO2: 285.3       pCO2: 36.8  
              HCO3: 21.1              BE: -3.4 FiO2: 60%
· Na 137; K 3.1; Ca 1.04; Cl 113; Mg 0.66
 Day Symptoms and lab tests results Treatment
Oct 27 - Awake, afebrile, pink, SpO2 99% Supplement:
POD2 - Good pulse 170 bpm, IBP 101/71 mmHg - Vaminolact 6.5%, SMOF lipid 20%, ●
8:00 - Good heart sounds, s/s 3/6 Human Albumin 20%
- Crackles in both lung fields, middle & lower zone - IV Furosemide 2mg
- Soft abdomen, ↓ distended, palpable liver 4 cm from Rt costal
margin - Nutrition before surgery?
- Pedal oedema
- Albumin 1.92 g/dl (N: 2.8-4.4 g/dl) Total protein: 3.24 g/dl (N: 5.7-8
g/dl)
Oct 28 Echocardiogram: -Digoxin 5 mg BID
POD3 -PDA: 8mm, ¾ diameter of ascending aorta, tubular, good shunt Lt → -Plan for surgical ligation of PDA
8:00 Rt
-PFO: 3mm, shunt Lt → Rt -Occlude PDA?
-Dilation of LV, mitral valve, FS 30%, preserved LV function, PAH not
clearly, no coarctation
-WBC: 13.83 Neu: 75.7% Hct: 33.7% PLT: 122.000
-CRP: 49.6 Lactate: 2.13 mmol/L Dextrostix: 113mg%
ABG:     pH: 7.358                 pO2: 113.7       pCO2: 46.9
              HCO3: 25.7              BE: -0.1 FiO2: 30%
- Na 134; K 3.2; Ca 1.09; Cl 109; Mg 0.55 mmol/L
 ●

Day Symptoms and lab tests results Treatment

Nov 1 · Awake, T°: 37.1°C (3 times > 38° yesterday) -Meronem + Vancomycin
POD7 · Pink / MV, SpO2: 98% (FiO2 30%) -Digoxin: 20 mg BID
8:00 · Warm, good pulse 156 bpm IBP: 105/66 mmHg (NBP Lt -Furosemide 4 mg, BID
hand: 95/54 mmHg) -Spironolacton 25 mg, ¼ PO, BID
· WBC: 11.12 Neu: 65% Hct: 32% PLT: 95.000 -Captopril 0.5 mg PO, TID
· CRP: 34.7 Lactate: 2.1 mmol/L
· Dextrostix: 100 mg%
ABG:     pH: 7.46                   pO2: 119       pCO2: 49.6
              HCO3: 35.1              BE: 10 FiO2: 30%
Metabolic alkalosis, diuretics
· Na 135; K 3.6; Ca 1.17; Cl 106; Mg 0.71
· Albumin: 2.77 g/dl
· Total protein: 4.04 g/dl
 ●

Oct 27 (D2) Oct 31 (D6) Oct 31 (D6)

 ●
Preoperative examination for PDA ligation (Day 9 of NEC surgery) Nov 2 , 2021
nd

Vital signs:
• Pulse: 168 bpm, regular, no radio –radial / radio femoral delay
• BP: 81/45 mmHg (right arm, IBP); 70/40 mmHg (left arm, NBP)
• RR: 30 cpm To: 37oC
Anthropometry:
• Weight: 4 kg Height: 53 cm BMI: 14.24 kg/m2
• Weight for age Z score: <–2SD to –3SD : Underweight
• Height for age Z score: <–2SD to –3SD : Stunted
• BMI for age Z score: <–1SD to –2SD

• NG tube: 15ml yellow clear fluid

• Jejunostomy: 35ml green fluid
• Urine output: 410 ml/day
 ●
Physical examination (Nov 2nd, 2021)
Awake, look ill, malnutrition, mild pallor
Flat cervical vein, pedal edema (low albumin)
CNS: Flat fontanelle, NAD
Cardiovascular system
• Shape of chest is normal; Hyperdynamic precordium
• Apex beat at Lt 6th ICS, lateral to MCL
• Clear heart sound, a continuous murmur 3/6 at Lt infraclavicular
area
 ●
Respiratory system:
• Subcostal retraction breathing
• Rhonchi & crepitation in both lung fields in middle & lower zone
Abdominal examination:
• Mildly distended, soft, non tender
• Umbilicus is centrally placed & inverted
• Liver: 4 cm from Rt costal margin along the MCL, not tender, smooth
surface, regular border
• Spleen, kidneys: not palpable
 ●
Lab tests results

• WBC: 10.75 k/uL Neu 61.8%

• RBC: 3.290 Hb: 9.4 g/dl Hct 29%PLT 65 K/L 
• PTs: 15.7s PT%: 77% INR: 1.2 aPTT: 37.7 Fib: 2.5
• CRP: 24 mg/L Glucose: 116 mg%
• AST: 39 U/L ALT: 13 U/L
• Bilirubin Total 18, Bil Direct 5.8 Bil Indirect 12 umol/L
• Ure: 4.8 mmol/L Creatinin: 50.7 umol/L
• Albumin: 2.7 g/dL Total protein: 4.0 g//dL
• Na 134 K 3.7 Ca 1.1 Cl 95 Mg 0.5 mmol/L
• pH: 7.4 pCO2: 49 pO2: 175 HCO3: 32.9 BE: 7.8FiO2: 30%
• Compensated respiratory acidosis/metabolic alkalosis
 ●
CXR

Echocardiography:
Situs solitus levocardia
PDA d= 6mm (PA) 9mm (Ao)
PG: 20 mmHg
Dilation of left heart
Regurgitation of Mitral valve 2/4 type I
Tricuspid valve ¼
PAPm: 30 mmHg
FS: 33% EF: 63%
Left Aortic arch, preserved LV function, no
coartation

Tip of tube at carina

 ●

Sinus tachycardia: 173

pbm
LV Hypertrophy
 ●

Diagnosis: 2 m old boy, PDA/ Peritonitis, NEC, jejunum resection, jejunostomy D9

Risks of
Risks of
patient’s surgery
condition

Risks of
anesthesia
 ●

Risks of patient’s condition

• 1. Large PDA with Lt -Rt shunt : risk of pulmonary hypertension/edema,
bronchopulmonary dysplasia, NEC, intraventricular hemorrhage, infective
endocarditis, neurodevelopmental delays,..
• 2. Congestive heart failure: volume overloaded, inadequate perfusion,
arrhythmias, blood clots → brain, myocardial infarction, organ damage in the
kidney or liver
• 3. Preterm, short bowel syndrome → malabsorption of nutrients, vitamins,
minerals, electrolyte/glycemic imbalance, hypothermia,..
• 4. Pneumonia, pulmonary atelectasis → hypoxia, prolonged mechanical
ventilation
 ●

Risks of surgery
• Bleeding
• Aortic clamping: renal failure, hepatic ischemia and coagulopathy, bowel infarction,
paraplegia, Aortic coarctation post-op
• Pneumothorax, pleural effusion/chylothorax
• Recurrent laryngeal nerve paralysis
• Others:
-Ligation of incorrect structures
-Infection
-Post-ligation cardiac syndrome (PLCS): systemic hypotension &
oxygenation failure often requiring vasoactive medications and prolonged
mechanical ventilation
 ●

Risks of anesthesia
• ↓SV, hypotension (due to CHF, high FiO2 → acute pulmonary vasodilation,  Lt-
Rt shunt through the duct)
• ↓ PVR, SVR → ↓ myocardial contractility, ischemia, infarction,..
• Hyperventilation, hypocapnia and ⬆️PBF → low cerebral blood flow, cerebral
ischemia, periventricular leukomalacia & adverse neurological outcomes
• Arrythmia, volume overloaded, disturbance of electrolytes, ABG,
hypothermia,..
• Transient R‐L shunts may occur (PFO) → systemic air emboli
 ●

Anesthesia plan
• Stop Captopril 24hr prior to surgery
• Blood & platelet transfusion before surgery (due to Hct 29.1% & PLT 65 K/L)
• Ventilator settings: FiO2 < 60%, volume‐limited ventilation, 5–7mL/kg,
maintain SpO2 < 96%
• Preparation of 3 good veins (22G & 24G catheters), warming devices
• Monitor: SpO2 + IBP (Rt hand) & NBP (Rt foot), ECG, EtCO2, temperature,
urine output
• Tight? glucose control, electrolytes, ABG
• Measure glucose to detect low or high concentrations
 ●

Pre-anesthesia evaluation: Patient arrived OR at 12:40 (Nov 3rd)

• 2-month-old boy, 4kg, EBV: 340 ml, MABL: 22 ml

•Pink / Oxy ventilator, SpO2: 98%, FiO2: 30%
•Pulse 134 bpm, BP 81/45 mmHg (Rt hand) , 70/40 mmHg (Rt foot)??
•RR: 30 cpm; CRT: 2s, good pulse
•Flat fontanelle
•Good heart sounds, s/s 3/6
•Mild lower chest retractions, equal vesical murmur.
•Soft abdomen
•WBC: 8k/uL Hb 10.6 g/dl Hct: 32% PLT: 300 K/L
•Glycemia 100 mg%

• ASA IV
 ●

pH – PaCO2 - BE
Improved lungbfunction
after ligation
 ●

Surgical report:
•Right lateral decubitus
•A left transaxillary thoracotomy 4 cm at the 3rd intercostal
space
•Muscular dissection, mobilized L lung anterior
•Identify the descending thoracic aorta and left subclavian artery
•Identify & dissect circumferentially the PDA, dPDA= 12mm,
dAo= 10mm
•Clamp the aorta, ligate & dissect the PDA, unclamp after 3
minutes
•The lung was then allowed to retract to its normal anatomic
position
•Chest tube w an 8-Fr pigtail catheter in the anterior axillary line
below the nipple
•Chest closing
 Day Symptoms and lab tests results Treatment
●
Nov 3 Arrived NICU. -Continue Mechanical ventilation
14:20 -Unconscious, pink with manual ventilation -Antibiotics: Vancomycin, Meronem,
-Warm, good pulse 127 bpm, IBP: 101/ 67 mmHg CRT <2s Metronidazole
-SpO2 96%, To 36.1 C -Digoxin, Furosemide, Spironolactone, Captopril
-NPO, Parenteral nutrition

Nov 4 · Extubation - Glucose 5% 5ml x 8 (Gavage)

POD1

Nov 5 · Pink / nCPAP - Start Enteral nutrition with Pregestimil 5ml x 8

POD2 · Warm, good pulse 140 bpm, BP: 98/67 (Gavage)

Nov 26 - Awake, pink, Pulse: 150 bpm, BP: 86/55 mmHg, - Jejunostomy reversal surgery
POD 23 - Weight: 3.6 kg - Stop Digoxin, Diuretics, Captopril afterwards
- Soft abdomen, no distension / tenderness
- Jejunostomy in good condition
Dec 4 Awake, stable hemodynamic - Discharged
POD 34 No vomiting - Follow-up appointment after 2 weeks
Soft abdomen, no distension / tenderness
Wound was healing good
No surgical complications
 ●
Bone demineralization
BPD
• Conclusions