Elsevier

The Journal of Pediatrics

Volume 160, Issue 4, April 2012, Pages 584-589.e1
The Journal of Pediatrics

Original Article
Use of Targeted Neonatal Echocardiography to Prevent Postoperative Cardiorespiratory Instability after Patent Ductus Arteriosus Ligation

Presented in part at the Pediatric Academic Societies’ annual meeting, Denver, CO, May 2011.
https://doi.org/10.1016/j.jpeds.2011.09.027Get rights and content

Objectives

To investigate the value of targeted neonatal echocardiography (TnECHO) in predicting cardiorespiratory instability after patent ductus arteriosus (PDA) ligation, and to evaluate the impact of TnECHO-directed care.

Study design

We reviewed serial echocardiography evaluations of 62 preterm infants after PDA ligation to investigate the relationship between indices of myocardial performance and postoperative cardiorespiratory instability. A predictive model was developed based on TnECHO criteria, with targeted initiation of intravenous milrinone. A comparative evaluation was performed between matched infants in the previous era (epoch 1; n = 25) and current era (epoch 2; n = 27) of TnECHO-guided treatment.

Results

Left ventricular output <200 mL/kg/min at 1 hour after PDA ligation was a sensitive predictor of systemic hypotension and the need for inotropes, and was used for initiation of i.v. milrinone infusion in epoch 2. Infants treated with milrinone had a lower incidence of ventilation failure (15% vs 48%; P = .02) and less need for inotropes (19% vs 56%; P = .01), and showed a trend toward improved oxygenation (P = .08).

Conclusion

TnECHO facilitates early detection of infants at greatest risk for subsequent cardiorespiratory deterioration. Administration of milrinone to neonates with low cardiac output may lead to improved postoperative stability.

Section snippets

Methods

This study was conducted in 2 parts in the neonatal intensive care unit at The Hospital of Sick Children in Toronto, an outborn quaternary center providing PDA ligation services for all perinatal centers in the region. The study received Institutional Research Ethics Board approval. Study A was a retrospective evaluation of previously analyzed echocardiography markers to determine predictors of PLCS, and study B was a retrospective chart review investigating the impact of TnECHO-guided

Study A

A total of 67 preterm infants underwent PDA ligation and received preoperative and postoperative TnECHO during the study period. Five infants without 8-hour postoperative TnECHO data were excluded. The included infants had a mean gestational age of 25.5 ± 2.0 weeks and a median birth weight of 730 g (650-850 g) and had complete preoperative and 1- and 8-hour postoperative TnECHO data available for review. The median age and weight at the time of surgery were 26.5 days (20-35 days) and 945 g

Discussion

We report on a targeted cardiovascular intervention, based on echocardiography, in neonates after PDA ligation surgery. Our main findings were that (1) an LVO of <200 mL/kg/min within 1 hour of PDA ligation in preterm infants may predict subsequent cardiorespiratory compromise and the need for inotropic agents, and (2) administration of i.v. milrinone to neonates with an LVO <200 mL/kg/min after the 1-hour postligation TnECHO evaluation was associated with improved postoperative stability.

The

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  • Cited by (124)

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    Winner of the Fellow Section at 23rd Annual Canadian Pediatric Resident and Fellow Research National Competition, Winnipeg, MB, Canada, May 12, 2011.

    The authors declare no conflicts of interest.

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