A low platelet count is associated with treatment failure in preterm infants treated with ibuprofen for patent ductus arteriosus

Background: Recent studies have demonstrated that platelet count (PLTc) and function have an important role in promoting spontaneous closure of the PDA in animal models.Aimto evaluate whether response to ibuprofen in premature infants with PDA is influenced by PLTc. Methods: All infants with GA 64 28wks born in our unit between 1/1/2007 and 31/12/2009 were retrospectively studied. Exclusion criteria were: congenital malformations, death within 48 hrs and outborn. All infants had echocardiographic evaluation in 1st DoL. Patients with a hemodynamically significant PDA (HsPDA) were treated with a standard course of ibuprofen. GA, BW, antenatal steroids, gender, type of ventilatory support were analyzed along with PLTc before and after treatment. Associations with HsPDA and treatment response were assessed by univariate and multivariate analysis.Results: Data from 130 out of 162 newborns (GA 26.2w\ub11.5, BW 851.2\ub1293g) were analysed. 117 patients showed a PDA at first evaluation. 88 newborns were treated with ibuprofen for HsPDA; after treatment 60 patients had a closed ductus (responders) while 28 were non-responders. A lower PLTc was observed in infants with HsPDA but difference was not statistically significant. Among treated infants, non-responders had a lower GA, were more likely mechanically ventilated and had a PLT significantly lower than responders (111.000/ \u3bcl vs. 184.000/\u3bcl, p=0,001). In the multivariate analysis only invasive ventilation and low PLTc were independent factors for treatment failure. Conclusion: A low PLTc increases the risk of treatment failure of PDA. Further studies are needed to evaluate the prognostic and therapeutic implications of this observation

Patent ductus arteriosus : wait and see?

"Patent ductus arteriosus is one of most common problems that physicians caring for preterm infants have to face. Although medical and surgical treatment of PDA has been extensively investigated, results from the randomized controlled trials and metanalysis are still inconclusive and many authors therefore suggest a less aggressive attitude toward PDA. In the present review evidence for and against routine treatment of PDA are analyzed. A strict selection of those patients who are most likely to benefit from treatment is probably an appropriate strategy at this time but further studies, mainly targeted to long term outcomes, are needed to provide definitive indications.

A low platelet count is associated with treatment failure in preterm infants treated with ibuprofen for patent ductus arteriosus (PDA

Background: Recent studies have demonstrated that platelet count (PLTc) and function have an important role in promoting spontaneous closure of the PDA in animal models.Aimto evaluate whether response to ibuprofen in premature infants with PDA is influenced by PLTc. Methods: All infants with GA 64 28wks born in our unit between 1/1/2007 and 31/12/2009 were retrospectively studied. Exclusion criteria were: congenital malformations, death within 48 hrs and outborn. All infants had echocardiographic evaluation in 1st DoL. Patients with a hemodynamically significant PDA (HsPDA) were treated with a standard course of ibuprofen. GA, BW, antenatal steroids, gender, type of ventilatory support were analyzed along with PLTc before and after treatment. Associations with HsPDA and treatment response were assessed by univariate and multivariate analysis.Results: Data from 130 out of 162 newborns (GA 26.2w\ub11.5, BW 851.2\ub1293g) were analysed. 117 patients showed a PDA at first evaluation. 88 newborns were treated with ibuprofen for HsPDA; after treatment 60 patients had a closed ductus (responders) while 28 were non-responders. A lower PLTc was observed in infants with HsPDA but difference was not statistically significant. Among treated infants, non-responders had a lower GA, were more likely mechanically ventilated and had a PLT significantly lower than responders (111.000/ \u3bcl vs. 184.000/\u3bcl, p=0,001). In the multivariate analysis only invasive ventilation and low PLTc were independent factors for treatment failure. Conclusion: A low PLTc increases the risk of treatment failure of PDA. Further studies are needed to evaluate the prognostic and therapeutic implications of this observation

Factors Determining Late Reopening of Ductus Arteriosus in Very Preterm Infants

BACKGROUND: A significant proportion of premature infants undergoes to late reopening of ductus arteriosus after an initial functional closure. Lower gestational age, infections and excessive fluid administration are frequently considered risk factors for ductal reopening(DR)but weight of each factor is still to determine. OBJECTIVE: To evaluate the incidence of DR and to verify which risk factors are associated with late DR and what is the contribution of each of them. DESIGN/METHODS: Clinical data in all infants with a gestational age below 28 wks born between January 2006 and June 2009 were retrospectively analyzed. To document initial ductal closure and ductal reopening echocardiography was used in all cases. GA,BW, gender, twin birth, IUGR, sepsis (both culture proven and suspected), previous treatment with ibuprofen or indomethacin and excessive fluide intake were considered. We used multiple-random effects logistic regression to calculate adjusted odds ratio of ductal reopening. The final model included the variables associated with DR in univariate analysis. RESULTS: 151 infants (84/151 male) with mean GA 26,1\ub11,6 wks and BW 813\ub1251g were included. 23% were SGA and 71% were singleton. 44/151 (28%) infants experienced one or more episodes of DR after a previous echocardiographically proven closure (71 episodes in all). First episode occurred at a mean postnatal age of 12 days and never occurred beyond 26 days. We defined as sepsis-related a DR occurring within 3 days from the sepsis diagnosis. 52/71 (73%) DR were sepsis-related. DR was more frequent in infants with at least 1 episode of sepsis (OR 7,2 p<0,027). DR was also strongly positively associated with male gender (OR 10.4 p=0.037), previous course of cox-inhibitors (OR 16,6 p=0,024) and inversely related with GA (OR=0,4, p=0,015). Excessive fluid intake or excessive weight gain were related only to 7% of sepsis-related and to 18% of non-sepsis related reopenings. CONCLUSIONS: Late reopening of ductus arteriosus is associated to a systemic infection in most cases. Male gender and lower gestational age are also significative risk factors. An excessive fluid intake does not appear to be relevant

The surgical and endovascular treatment of the hepatic artery aneurysms: personal experience

OBJECTIVE: The aim of this single-institution retrospective study is to report the results of surgical and endovascular treatment of hepatic artery aneurysms. MATERIALS AND METHODS: Twenty patients with an extraparenchimal hepatic artery aneurysm made part of the study. In the first period, between February 1980 and December 1996, 12 patients were admitted and treated surgically. In the second period, January 1997 until December 2005, 8 patients were admitted. Four were treated surgically and 4 with an endovascular procedure. The aneurysms ranged from 2.3 cm to 6.2 cm Seventeen patients were asymptomatic, while three were symptomatic for pain and obstructive icterus. In 13 patients aneurysmectomy and graft interposition was performed, in three patients aneurysmectomy with dacron patch interposition was performed, and in 4 patients the aneurysm was excluded with a stent-graft. RESULTS: NO perioperative mortality was noted and no major complication occurred. All endovascular procedures successfully excluded the aneurysm without signs of endoleak. Follow-up in 4 months, 6 months and 10 months postoperatively showed patency of the stent-graft with no signs of migration or endoleak. Only in one case, in the 8th post-operative month, thrombosis of the stent-graft occurred and the patient was completely asymptomatic. CONCLUSION: The natural history of hepatic artery aneurysms is rupture, and consequently there is an indication of treatment. Actually, we consider endovascular treatment as the first-choice-treatment whenever possible. Endovascularlly treated patients need a strict follow-up surveillance by imaging means. Particular attention so be given in the preoperative study of the collateral circulation in patient treated surgically

The importance of lung recruitability: A novel ultrasound pattern to guide lung recruitment in neonates

BACKGROUND: Lung Ultrasound (LUS)-guided Lung Recruitment Maneuver (LRM) has been shown to possibly reduce ventilator-induced lung injury in preterm infants. However, to avoid potential hemodynamic and pulmonary side effects, the indication to perform the maneuver needs to be supported by early signs of lung recruitability. Recently, a new LUS pattern (S-pattern), obtained during the reopening of collapsed parenchyma, has been described. This study aims to evaluate if this novel LUS pattern is associated with a higher clinical impact of the LUS-guided LRMs. METHODS: All the LUS-guided rescue LRMs performed on infants with oxygen saturation/fraction of inspired oxygen (S/F) ratio below 200, were included in this cohort study. The primary outcome was to determine if the presence of the S-pattern is associated with the success of LUS-guided recruitment, in terms of the difference between the final and initial S/F ratio (Delta S/F). RESULTS: We reported twenty-two LUS-guided recruitments, performed in nine patients with a median gestational age of 34 weeks, interquartile range (IQR) 28-35 weeks. The S-pattern could be obtained in 14 recruitments (64%) and appeared early during the procedure, after a median of 2 cmH2O (IQR 1-3) pressure increase. The presence of the S-pattern was significantly associated with the effectiveness of the maneuver as opposed to the cases in which the S-pattern could not be obtained (Delta S/F 110 +/-47 vs 44 +/-39, p = 0.01). CONCLUSIONS: Our results suggest that the presence of the S-pattern may be an early sign of lung recruitability, predicting LUS-guided recruitment appropriateness and efficacy

Effect of Domperidone on QTc Interval in Term and Preterm Newborns: Is It Really Unsafe?

BACKGROUND: Domperidone is a prokinetic drug widely used in newborns for motility disorders. Sporadic cases of QTc prolongation and ventricular tachyarrhythmia related to intravenous domperidone have been reported. Small studies with variable methodology have reported conflicting effects of oral domperidone on QTc in newborns. OBJECTIVE: To evaluate the effect of domperidone on QTc interval in term and preterm newborns. DESIGN/METHODS: A retrospective analysis of QTc changes in newborns treated with domperidone was performed. Only patients for whom at least 2 ECG recordings were available, one taken while on therapy and one while off therapy, were included. QT interval was measured on lead II according to standard methods and corrected for heart rate by the formula of Bazett. Staistically univariate analysis were performed using paired t-test. Subgroup analysis was performed for preterm and term newborns. RESULTS: Data for 80 patients (mean GA 32wks, BW 1735g) were collected and 91 ECG pairs were available (52 before starting therapy and while on treatment, 39 on treatment and after discontinuation). Domperidone was administered in the mean oral dose of 1.6 mg/kg*d (range 0.8-2.4) at a median postnatal age of 29 days. During therapy mean QTc was 0.394\ub10.034msec. The dosage of domperidone did not affect absolute QTc values neither QTc variations. In 3 pts QTc exceeded the upper normal limits of 440ms. No episodes of ventricular arrhythmia or life-threatening events were observed. No significant changes in QTc were detected before starting and while on treatment (p=0,52); a slight decrease in QTc was observed after domperidone discontinuation (p=0,03). In the subgroup analysis this effect was only seen in preterm (GA< 36wks, p=0,02) and not in term infants (p=0,7). CONCLUSIONS: Oral domperidone administered in the recommended dose range seems to be safe in preterm and term newborns. In preterm infants minor changes in QTc intervals may be detected but they do not seem to be clinically significant

Near-Infrared Spectroscopy Measurement of Cerebro-Somatic Oxygenation Ratio (CSOR): May We Predict a Hemodynamically Significant Patent DuctusArteriosus (PDA)?

BACKGROUND: Definition of hemodynamically significant PDA (HS-PDA) is still controversial and its effects on cerebral and somatic tissue oxygenation (cSO2 and sSO2) as well as on fractional oxygen extraction (FOE) are not well known. OBJECTIVE: To use non invasive NIRS-technology in pretem infants 6433 wks GA to evaluate differences in cSO2, postductal sSO2 and FOE according to the presence of PDA. DESIGN/METHODS: cSO2 and thoraco-lumbar sSO2 were measured simultaneously using the INVOS oximeter (Somanetics) in clinically stable preterm babies and the mean values, over a 10-min period, were expressed as CSOR (=sSO2/cSO2). Cerebral and somatic FOE (cFOE and sFOE) were calculated according to the formula=(SaO2-regionalSO2)/SaO2. The presence and the flow pattern through PDA were assessed by echocardiography.Unpaired t-test was used. RESULTS: 21 measurements were performed in 14 preterm infants (mean GA 29.6\ub13.9wks, BW 1230\ub1460g, postnatal age 7.1\ub15.9 days). Mean CSOR was 1.101\ub10.127. No statistically significant differences were observed between babies with and without PDA for all parameters. Infants with pulsatile flow pattern at echocardiography (defined HS-PDA) showed an \u201cinverted\u201d CSOR<1 (mean value 0.874\ub10.076) mainly related to decrease in sSO2 while cSO2 was relatively spared. cFOE did not seem to be affected whereas a significant increase in sFOE was observed.[table1] CONCLUSIONS: Our results confirm previous studies\ub9 showing higher oxygenation of somatic compared with cerebral tissue in preterms and suggest that an \u201cinverted\u201d CSOR<1 might represent a sign of HS-PDA. NIRS technology could be routinely used as a trend monitor for cSO2 and sSO2 and might help in early detection of babies who would benefit from PDA closure. Due to the small sample size further studies are needed to confirm these data and adjust results for confounders. \ub9Petrova A PediatrCritCareMed 200