can i take your opnions in this case

26 w GA infant refered to me after 3h after birth so i give him surfanta within 1/2 -3/4 h after

thin i start to lower pip and fio2 till reach to fio2 30% pip 12 peep 4 but in 2nd day IVH occur manifest by drop in HB and irritability after bl trx and plasma ,start dopamin

on 3rd day baby still on mv stable ,but with no active movement

on 4th day start to develop resp acidosis then bring pul hage.............then die

i doute about PDA but clinically there is no any murmur,active pericordium , bounding pulsation

could i start ibuprofen as regard as he is ELBW, RDS and take surfanta

or i must do ECHO first

if it is not PDA what the cause of Pul hage in this case and how can i avoid it later

It seems very difficult differential diagnosis of premature baby's clinical status.I think it will be done right first ECHO. We also think that the baby is low ventilator settings.if you are using drug I suggest you use paracetamol rather than ibuprofen for the clinical situation is not good.

http://www.clinicaltrials.gov/ct2/show/NCT01291654

http://summaries.cochrane.org/CD010061/paracetamol-acetaminophen-for-patent-ductus-arteriosus-in-preterm-andor-low-birth-weight-infants

Common scenario in day to day NICU care. Ventilation wise you should be given high PEEP like 6-7. PEEP of 4 is very low.

Most likely the cause of pulmonary haemorrahage in this case is PDA. usually very large PDA have no murmur. echo be done before any iburpofen given to rule out any structural heart lesion. Why you didnot use Volume guranttee on this baby? to give you an idea of what PIP this baby actually need? giving low PIP to treat RDS ?? is questionable.

How was the initial course of baby i.e did you exercise Golden hour for this baby, what was the admitting temperature?

the ECHO is not available in our unite , and i ask if posibility of PDA is high in this baby , can i give ```ibuprufen as i suspect or not

The answer is "No" echo to be done before ibuprofen, atleast for the first time. This is due to fact that even there is no structural heart disease, not all PDA needs treatment, only pulsatile type PDA needs to be treated if clinically condition permit and there is no contraindication. Pulmonary hypertension type do not need treatment with brufen to close rather it is contraindicated.

Even if the result is dying of this ELBW baby,

if PDA is not the cause , what is it?

what is the cause of pul hage

If baby is dying, donot bother about treating PDA with Ibuprofen, at that stage it is contraindicated. At that stage maintain BP, give inotrpes, blood products etc. Other causes beside PDA of pulmonary haemorrhage in EBW babies is immarurity and fragility of pulmonary vasculature, DIC etc

what about the pulm hemorrhage being caused by the use of surfactant??

Experts debate the role of surfactant in the pathogenesis of pulmonary hemorrhage. It is postulated that surfactant decreases pulmonary vascular resistance, thereby increasing the left-to-right shunt across the PDA. This results in increased left ventricular pressure, which can increase pulmonary capillary pressure and result in pulmonary hemorrhage. Studies have shown a strong association between pulmonary hemorrhage and high pulmonary blood flow, due in most cases to ductal shunting.

The symptoms of RDS usually peak by the third postnatal day, and they may resolve quickly when diuresis starts. Because infants who have RDS usually develop hypoxia, the ductus arteriosus may remain patent. Early in the disease, shunting is from right to left. The clinical improvement seen in this patient was accompanied by a rapid fall in pulmonary vascular resistance and rise in systemic arterial pressure, which led to the development of a large left-to-right shunt through a PDA. Therefore, the patient's recovery was interrupted by the development of congestive heart failure and pulmonary edema and, finally, pulmonary hemorrhage. When the granular pattern of RDS changes to a homogenously opaque appearance, pulmonary edema due to PDA or early chronic pulmonary changes should be suspected.

When the granular pattern of RDS changes to a homogenously opaque appearance, pulmonary edema due to PDA or early chronic pulmonary changes should be suspected....................

so in this stage i can give indomthacin or ibuprufen

I am waiting for any advice about PDA after surfactant therapy should i ttt it by suspecting or i must do echo 1st

what about prophylacting brufen??????????

As suggested above: I would not try to close the duct without ruling out structural heart disease by echocardiography.

In addition, with a fresh bleeding I feel NSAIDs are contraindicated.

So, my suggestion: wait and see.

Why are you treating PDA at all cost irrespective of even contraindication and even in dying baby , As already mentioned not all PDA needs treatment and even current evidence is going away from treating any PDA. There is nothing Prophylactic ibuprofen in literature about treating PDA, I donot know from where you quote this term? do you have any evidence????? So in short answer to your question is " NO"

Have you followed ABG while weaning?I feel that with 30% fio2 PIP/PEEP 12/4 is not appropriate and if ABG was o.k. while weaning with this setting then its a time to extubate and put on CPAP .Hypoventilation may be one of the reason for IVH,pul hemmorhage.treatment is increase peep, appropriate pip to maintain adequate ventilation(PCO2 45-50 mm of hg) and supportive care,maintain good circulating function, transfusion cautionary, FFP & vit K if PT/APT prolong .Treat PDA conservatively , restriction of fluid intake 120-130//kg maintained urin output 1-3 ml /kg ,minimum ET suction

.Ibuprofen is contraindicated with Bleeding.

Dinesh

Edited April 30, 201312 yr by Dinesh N Patel

i am not talking abou tttt of pul hage, but about cause of pul hag in this case

is PDA is blaming here or not and how can i manage this when i suspect without doing echo esp baby at high risk "as he ELBW, take surfactant" and compliance improve and pvr decresed and so increse lt to rt shunt