Persistent pulmonary hemorrhage in a preterm

[mahatma]

Dear members,

I would like to discuss a case concerning pulmonary hemorrhage in a preterm of 26+2 weeks of gestational age.
This little fellow had to be intubated at day 2 after CPAP due to increasing oxygen requirements and dyspnea, he received one dose of surfactant and responded pretty good. During very gentle ventilation he encountered a pulmonary hemorrhage and needed transfusion of erythrocytes and thrombocytes (min. 100/nl). He got vitamin K at the very beginning, blood clotting was unsuspicious, no signs of infection. We treated him with Terlipressin intratracheal and put him on high-frequency oscillation. Despite our efforts the bleeding recurred a couple of times. He still does´t need to much oxygen (about 30%) and HFO ventilation is still moderate. additionally he has a PDA of hemodynamic significance which I would like to start treating with indomethacin, but i am in doubt because of the enduring pulmonary bleeding.

Any suggestions in this case??? Would you start treating the PDA?? Any other therapy options?

 

Thanks!

Mahatma

[livesynapse]

Our protocol for pulmonary hemorrhage includes intratracheal epinephrine, an extra dose of surfactant, and like you did HFOV.

In these cases, when there is active bleeding, we treat the PDA with paracetamol: 15 mg/k/dose every 6 hours for three to six days. 

Good luck!

Patricia

Here's a link

J Pediatr. 2016 May 20. pii: S0022-3476(16)30176-7. doi: 10.1016/j.jpeds.2016.04.066. [Epub ahead of print]

Paracetamol Accelerates Closure of the Ductus Arteriosus after Premature Birth: A Randomized Trial.

Härkin P¹, Härmä A¹, Aikio O², Valkama M¹, Leskinen M¹, Saarela T¹, Hallman M¹.

[rehman_naveed]

What is the Day of life now?how is the XR looks like ? I would treat with indomethacin before it is too late and we are left only with surgical closure .

[Fayrouz Essawi]

Significant PDA need closure so use paracetamol instead of indomethacin in this case with pulm. Hge.also you did right with HFO but also you need to check bleeding profile and platelete in order to give plasma or platelete If you need to control pulm hge.

[Cat]

Greetings from Ecuador. We use paracetamol protocol to close de PDA instead of indometacin (15 mg/k/dose every 6 hours for three days). Also the use of epineprine for the pulmonary hemorrage. My suggestion is to add a new dosis from Vitamin K1 IV and check For Pulmonary hypertension may be you need sildenafil.

Atte

Cat

[yuriyko]

I agree with paracetamol and epinephrine suggested. Additionally, pulmonary hemorrhage may be evaluated in some cases as a high degree of congestive heart insufficiency. Consider fluid restriction, furasemid and probably inotropes. This may help PDA to close as well. To stop bleeding sometimes we have to rise mean airway pressure (of course carefully in such a tiny baby). If the clotting process is disturbed we use plasma because it works immediately. Wish you success.

[emad shatla]

In our unit we are using paracetamol in dose 10-15 mg every 6-8 hours for 3 days

HFO can be used or you can increase PEEP TO 6-7 

intratracheal adrenalin can be used

FFP can be used

cover of antibiotics 

surfactant can be used

dr Emad Shatla 

senior consultant neonataolgy

MD/ MRCPCH

[Ghodstehrani]

In my unit I use daily FFP for at least three days, frequent doses of IT epinephrine and if plt more than 50000 and not severe hemorrhage a full course of Ibuprofen.

 

dr Ghodstehrani  senior specialist neonatologist Iranian hospital Dubai

 

[mghabour]

This is likely hemorrhagic pulmonary edema that follows significant PDA. Symptomatic support is high PEEP(like pressing on a bleeding point). Specific therapy is closing it or al least reducing its size, medically with Indomethacin. or  ligating it surgically. Those used to die in the 90s. Good job

[mahatma]

Dear colleagues, thanks for all this useful information. that´s what this board is for, I really appreciate this.

He is still stable on ventilation, although pulmonary bleeding happens once or twice a day, but it´s not fatal, no transfusion or red cells necessary, so i also think this is most likely due to pulmonary edema. That´s why we decided to close the PDA with Ibuprofen now. hope this helps. HFO and intratracheal vasoconstrictors didn´t. 

[Guest safaa5@hotmail.com]

hope your patient is better  now

our routine is to increase PEEP , FFP ,platelet transfusion if needed .if repeated we may use  intratracheal epinephrine

For  PDA  you can use  Paracetamol as mentioned by first  colleague Patricia ,

consideration for heart failure and CHD  

Surgical correction if severe as prove by Echo 

[heshamomar]

I agree with a trial of paracetamole or ibuprofen

How big the duct is?

[mahatma]

We started Ibuprofen which didn´t show a real benefit, PDA still is approx. 3mm wide. That´s why we decided to do a surgical procedure tomorrow morning.
Elevated PEEP, HFO, platelets, FFP, intratracheal vasoconstrictors etc. were without effect....

Well pulmonary bleeding occurs once in while and usually we can control it doing the above mentioned things...but this time it really is tenacious..... :-/
 

[rehman_naveed]

Thanks for update. 3mm PDA will never close by medication. Good that surgical closure decision was taken early.

but make sure to have ENT to have look on vocal cords before discharge to rule out VC paresis even if everything goes well.

regards

naveed

[mahatma]

Surgical closure went well, since then no more bleeding appeared. switched from HFO to conventional ventilation today.

 

regards,

mahatma

[Guest fatema]

HI dear :

i would like to know if there is in experience to ipubrufen  for PDA closure 

thanks 

[mahatma]

On 3. Juni 2016 at 7:43 PM, fatema said:

HI dear :

i would like to know if there is in experience to ipubrufen  for PDA closure 

thanks 

http://www.cochrane.org/CD003481/NEONATAL_ibuprofen-for-the-treatment-of-patent-ductus-arteriosus-in-preterm-or-low-birth-weight-or-both-infants

 

Best regards,

M. 

[Stefan Johansson]

@mahatma - great to read this thread! And hope the infant is recovering well now.
( I was on vacation in Sardinia last week but managed to get a member's email out, glad it worked from the free wifi at www.badus.it, BTW a simple but nice place)  

[Nadya]

Does anyone know of any literature supporting the use of Intra ETT epinephrine in case of pulmonary heamorrhage?

[tarek]

Ibuprufen orally can be used to treat hemodynamically significant PDA the dose is 10 mg/kg OD in D1                        5 mg/kg OD in D2.                                 5mg/kg OD in D3.

Also check your total fluid intake regarding management of pulmonary hge. 

My question is IT epinephrine any evidence based practice for that

Also question for the people who are using FFP you are using regardless of PT and PTT

[tarek]

Conclusion

Preterm infants frequently experience IVH or pulmonary hemorrhage, which usually occur within 72 hours after birth and can lead to long-term neurological impairments and mortality. As these serious hemorrhagic complications are closely related to perinatal hemodynamic changes, delayed umbilical cord clamping or umbilical cord milking to maintain optimal blood pressure and SBF, careful assessments to maintain the afterload at an acceptable level, and a strategy of early targeted treatment of significant PDA to improve perfusion during this critical time period may reduce or prevent these serious complications.

REVIEW ARTICLE Circulatory Management Focusing on Preventing Intraventricular Hemorrhage and Pulmonary Hemorrhage in Preterm Infants Bai-Horng Su a,b,*, Hsiang-Yu Lin a,b, Fu-Kuei Huang a, Ming-Luen Tsai a, Yu-Ting Huang