Donna M. Kraus, Pharm.D.
Spring 1998

Pediatric Cardiology Case

RS is a 3 day old, 800 gram female with respiratory distress syndrome (RDS), who was born at 27 weeks gestational age. Apgar scores were 5 at 1 minute and 7 at 5 minutes. On the first day of life, RS was intubated, maintenance IV fluids were started, and antibiotics were initiated for R/O sepsis. In addition, RS received 2 doses of surfactant for treatment of her RDS.

 

Current vital signs include: HR 190 beats/minute, RR 72 breaths per minute, BP 62/25 mm Hg with an O2 saturation of 89%. RS's nurse reports that the patient also has a systolic murmur, a hyperactive precordium, and "wet" sounding lungs. ABG's include pH 7.22, pCO2 55 mm Hg, pO2 77 mm Hg, and a base deficit of 10. The ventilator settings are increased to compensate for RS's deteriorating respiratory status. The chest X-ray shows pulmonary edema and an enlarged heart and the echocardiogram reveals a moderate-sized PDA with significant left-to-right shunting. All other labs are normal.

 

MEDS and IVs

 

 

1. What risk factor(s) does RS have for the development of a PDA?

2. What signs and symptoms of RS are consistent with the presentation of a PDA?

3. Name 3 treatment options for the management of RS's PDA.

4. How should RS be acutely managed? State the rationale for your answer.

5. Despite diuretics and fluid restriction RS is still symptomatic and indomethacin therapy will be started. What are the contraindications for indomethacin therapy and what monitoring parameters should be used to assess the adverse effects of the drug?

 

Pediatric Cardiology Case: ANSWER KEY

 

RS is a 3 day old, 800 gram female with respiratory distress syndrome (RDS), who was born at 27 weeks gestational age. Apgar scores were 5 at 1 minute and 7 at 5 minutes. On the first day of life, RS was intubated, maintenance IV fluids were started, and antibiotics were initiated for R/O sepsis. In addition, RS received 2 doses of surfactant for treatment of her RDS.

 

Current vital signs include: HR 190 beats/minute, RR 72 breaths per minute, BP 62/25 mm Hg with an O2 saturation of 89%. RS's nurse reports that the patient also has a systolic murmur, a hyperactive precordium, and "wet" sounding lungs. ABG's include pH 7.22, pCO2 55 mm Hg, pO2 77 mm Hg, and a base deficit of 10. The ventilator settings are increased to compensate for RS's deteriorating respiratory status. The chest X-ray shows pulmonary edema and an enlarged heart and the echocardiogram reveals a moderate-sized PDA with significant left-to-right shunting. All other labs are normal.

 

MEDS and IVs

 

 

1. What risk factor(s) does RS have for the development of a PDA?

RS has two primary risk factors for the development of a symptomatic PDA: prematurity and RDS. As mentioned in your handout, the incidence of PDA is dependent upon infant maturity and weight at birth, with a higher incidence observed in premature neonates with a birth weight < 1000 grams. Preterm neonates are at a higher risk for PDA than term newborns because the immature ductus is more sensitive to the dilatory effects of the in utero prostaglandins and less sensitive to the constrictive effects of the increased oxygen tension that occurs after birth. RDS also increases the risk of PDA and a PDA can worsen RDS.

In addition to these 2 risk factors, RS is receiving 159 ml/kg/day of IV fluids (rather than a desired amount of 120 ml/kg/day). This fluid overload would also contribute to the development of a PDA.

2. What signs and symptoms of RS are consistent with the presentation of a PDA?

Systolic cardiac murmur, hyperactive precordium, wide pulse pressure > 35 mm Hg (BP 62/25, pulse pressure = 37 mm Hg), tachypnea (RR > 70), cardiomegaly on chest X-ray, ECHO results.

3. Name 3 treatment options for the management of RS's PDA.

Fluid management (fluid restriction and diuretics)

Pharmacologic management with indomethacin

Surgical ligation (usually reserved for infants who do not respond to indomethacin or those in whom indomethacin is contraindicated)

4. How should RS be acutely managed? State the rationale for your answer.

Rx: Give furosemide 1 mg/kg (0.8 mg) IV push immediately.

Rationale: By causing a diuresis, a decrease in intravascular volume will result, which will also decrease the workload of the heart. A decrease in left ventricular end diastolic volume (preload) and pulmonary venous pressure will also be seen. The effects of pulmonary edema will be decreased and an increase in lung compliance will be seen. Blood gases may also improve.

Rx: Decrease IV fluids to 3.3 - 4 ml/hr to restrict fluid intake to 100 - 120 ml/kg/day.

Rationale: By decreasing volume, the workload of the heart will be decreased. This will prevent congestive heart failure and avoid worsening of pulmonary edema.

5. Despite diuretics and fluid restriction RS is still symptomatic and indomethacin therapy will be started. What are the contraindications for indomethacin therapy and what monitoring parameters should be used to assess the adverse effects of the drug?

Contraindications to indomethacin include: necrotizing enterocolitis (NEC), impaired renal function (do not use if BUN > 25 or SCr > 1.0 mg/dl), intraventricular hemorrhage, active bleeding or thrombocytopenia (platelets < 80,000).

Monitoring parameter Adverse effect
BUN Nephrotoxicity
SCr Nephrotoxicity
I & O's (ins and outs) Oliguria
Urine output ml/kg/hr Oliguria
Serum sodium Hyponatremia (dilutional)
Platelet count Thrombocytopenia
CBC Bleeding
NG aspirate and stools for visual presence of blood GI Bleeding
NG aspirate and stools for occult blood (hemocult/ guaiac test) GI Bleeding
Abdominal girth NEC
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