206 PDA in preterm babies should be managed conservatively: the need for surgical ligation is questionable

• Published in: BMJ paediatrics open Vol. 5; no. Suppl 1; p. A58
• Main Authors: Jain, Ankita, Jenkins, Sian, Uzun, Orhan
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group LTD 01-04-2021; BMJ Publishing Group
• Subjects: Babies; Gastrointestinal diseases; Morbidity; Mortality; Necrosis; Pediatrics; Premature babies; Premature birth; Surgery
• ISSN: 2399-9772
• DOI: 10.1136/bmjpo-2021-RCPCH.111

BackgroundHaemodynamically significant PDA in preterm babies are traditionally associated with higher incidence of IVH (intraventricular haemorrhage), NEC (necrotising enterocolitis) and CLD (chronic lung disease), and longer duration of ventilation. In practice, there is wide variation in PDA management, particularly the need for surgical or medical intervention. The management strategies include pharmacological therapy with cyclooxygenase inhibitors and surgical ligation or device closure. In some infants with failed extubation, surgical management has often been considered to be the only option. There is growing opinion that aggressive management of PDA may not have much impact on reducing mortality and severe morbidity hence conservative management should be preferred treatment.ObjectivesThe primary aim was to compare the need for surgical or catheter closure of haemodynamically significant PDA since introduction of the conservative management guideline and secondary aim is to look at the differences in mortality and morbidity in preterm babies with haemodynamically significant PDA before and after implementation of the guidelines.MethodsThis is a single centre review of all preterm infants admitted to a tertiary neonatal unit between 1992–2017, who had a haemodynamically significant PDA. Data on sex, gestation, birth weight, length of stay, treatment of PDA and incidence of NEC, IVH, CLD and death were analysed by using department digital records.We compared the clinical outcomes of all preterm babies with haemodynamically significant PDAs managed medically or surgically before 2014 versus conservative management, following a change in local guideline in 2014. This comprised of significant fluid restriction, optimum diuretics, early steroid use and restricted use of ibuprofen and paracetamol.ResultsOver the 22-year period general trend showed lower referral rates for surgical ligation in the last 5 years. Hence analysis was restricted to 2010–2013 and post 2014, to minimize the bias due to changes in neonatal management strategies. Fewer babies were referred for surgical management after 2013. There was no significant difference in the incidence of CLD, IVH, NEC or mortality between the two periods. The change in guidelines mitigated the need for unnecessary transfer of these vulnerable infants to the cardiac surgical centre, this was less disruptive for the families too. Also the study shows that conservative management of PDA has huge cost saving incentives for NHS, not only the cost of surgery but also on duration of NICU stay without compromising care and long term outcomes.ConclusionsChanges to the PDA management guideline, promoting conservative management, resulted in fewer patients being referred for surgery, without affecting mortality or morbidity. This study raises the question about the need for surgery in the management of preterm PDAs. Long term prospective multicentre studies are required to address this question fully.