Perfil epidemiológico, morfológico e funcional de recém-nascidos prematuros com persistência do canal arterial tratados com paracetamol: estudo observacional retrospectivo

Abstract

Introduction: The persistence of the patent ductus arteriosus (PDA) is associated with increased morbidity and mortality in preterm newborns (PTNB). Objective: To identify the epidemiological, morphological, and functional parameters of the ductus arteriosusin newborns with PDA, treatment predictors. Method: This was a retrospective study conducted in the Neonatal Intensive Care Unit at a University Hospital from January 2015 to July 2020. The diagnosis of patent ductus arteriosus(PDA) was confirmed using echocardiographic parameters (Samsung ultrasound device HS40), including direct visualization of the ductus in two dimensional mode, using the parasternal short-axis view. Preterm newborns with a diagnosis of hemodynamically significant PDA (presence of diastolic flow in the descending aorta, left atrium enlargement, and increased Doppler flow velocity in the pulmonary valve) on echocardiography, who received paracetamol when treatment with ibuprofen failed or was contraindicated, were included in the study. Preterm newborns with hemodynamically insignificant PDA on echocardiography who received conservative treatment were considered as the control group. The dose of paracetamol used was 15 mg/kg/dose every 6 hours, orally, forseven days, and the cycle was repeated for a total of 14 days of treatment in case of treatment failure or reopening of the ductus arteriosus. The ROC curve was used to determine if the echocardiographic parameters, including ductus diameter, ductus diameter/weight, ductus diameter/left pulmonary branch, AE/Ao ratio, and diastolic velocity of the left pulmonary branch, were able to discriminate between patients who received conventional treatment and those who received paracetamol treatment. Results: Results: A total of 173 male and 179 female patients participated in the study. The mean birth weight in the paracetamol group was 1,090 g (970 - 1,685 g), which was significantly lower than the control group's 2,125 g (1,420 - 2,765 g). Closure of the ductus arteriosus after paracetamol treatment was 92%. In 59 preterm newborns (36%), the ductus closed after 7 days of treatment, and in 105 (64%) preterm newborns, extended treatment with two cycles of 7 days was required for remission of hemodynamic symptoms. Three preterm newborns (1,8%) were referred for surgical treatment. The following echocardiographic parameters were statistically significant in predicting the need for ductus arteriosus treatment: reverse diastolic flow in the descending aorta, non-restrictive x reverse transductal flow, AE/Ao ratio > 1.5, transmitral flow E/A ratio > 1, absence of reverse diastolic flow in the superior mesenteric arteries, and flow velocity in the left pulmonary branch. The absolute diameter of the ductus arteriosus in millimeters did not differ significantly between the control and paracetamol groups. However, the ratio between ductus diameter and weight was significantly higher in the paracetamol group. The area under the ROC curve was greater than 0.7752 for the following echocardiographic parameters: ductus diameter, ductus diameter/weight, ductus diameter/left pulmonary branch, AE/Ao ratio, and diastolic velocity of the left pulmonary branch. The highest sensitivity and specificity were observed for LA/Ao. Conclusion: In this study we identifed, for the first time, the optimal cut-off points for echocardiographic markers used to diagnose PDA, such as PDA diameter/weight, PDA diameter/left pulmonary branch, LA/Ao and diastolic velocity of the left pulmonary branch to differentiate paracetamol group compared to conventional treatment. Additionally, it was observed that the relationship between the internal diameter of the ductus arteriosus indexed to weight has a greater impact on determining the magnitude of blood flow than the absolute diameter of the ductus arteriosus in millimeters. The introduction of a screening, monitoring, and medication treatment protocol, when correctly indicated, significantly reduces the rate of surgical intervention.