mahatma

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.

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

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.

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

We do sometimes use bicarbonate in cases of persisting metabolic acidosis, especially when ionotropes (suprarenine, noradrenaline etc) are not working properly (inotropic support). In acidemia changes in ligand binding and pharmacological effects of inotropes may occur, therefore our goal is to ascertain a ph > 7,15.

Well as a basic principle we try to maintain oyxgenation above SpO2 95%, avoid any acidosis (use hydrogencarbonate if necessary), ascertain normothermia, and try to keep systemic blood pressure slightly above normal. Achieving these goals may include the use of HFOV and the use of different inotropes like dobutamine, low-dose adrenaline (0.05µg/kg/min), noradrenaline or milrinone followed by hydrocortisone. We also include iNO (starting 20 ppm) if inotropes are ineffective. We rarely use sildenafil primarily. I would be interested to know how you combine inotropes? Start dobutamine first? Then add noradrenaline (to what max. dosage)?

Apparently there was a trial published in NEJM which showed no significant difference between preterms (<1000g) who received either CPAP or nIPPV as non-invasive ventilation, primary outcome was death or BPD at 36 weeks gestational age. (Kirpalani et al, "A trial comparing noninvasive ventilation strategies in preterm infants", NEJM Aug ´13)