P2.020: Standardizing PDA Care by Hemodynamic Relevance: Clinical Outcomes in Preterm Infants Before and After Protocol Implementation

Background: Prophylactic treatment of patent ductus arteriosus (PDA) in preterm infants has been a longstanding practice aimed at preventing hemodynamic instability and related complications. However, emerging evidence suggests that treatment of non-hemodynamically significant (non-HDS) PDA may not influence short-term neonatal outcomes. In May 2019, our institution implemented a protocol that standardized PDA management based on hemodynamic significance for infants ≤28 weeks estimated gestational age (EGA). This study aimed to evaluate the effect of this protocol on treatment trends and neonatal outcomes, particularly morbidity and mortality.

Methods: A retrospective chart review of infants ≤28 weeks EGA diagnosed with PDA between January 1, 2016, and June 25, 2021, was conducted at Bronson Methodist Hospital. . The PDA protocol was implemented on May 15, 2019. The pre-intervention cohort included infants born before May 15, 2019, and the post-intervention cohort included those born after. Data included demographics, clinical characteristics, PDA treatment methods (medical/surgical), timing of closure, echocardiography use, and comorbid outcomes such as bronchopulmonary dysplasia (BPD), chronic lung disease (CLD), retinopathy of prematurity (ROP), and necrotizing enterocolitis (NEC). Comparative analyses were conducted using chi-square, independent t-tests, and Mann-Whitney U tests.

Results: 133 infants met inclusion criteria (85 pre-cohort, 48 post-cohort). Post-intervention, the rate of HDS PDA diagnosis declined significantly (n=72 vs. 24; p< 0.05). In the post-cohort, there were more cases of early-onset sepsis (n=6 versus 12; p< 0.05). Management for non-HDS PDA also differed in the post-cohort as they were followed for a longer period without treatment (n=5 versus 20; P< 0.05). There was a higher proportion of non-HDS PDAs managed expectantly in the post-cohort (n=5 vs. 20; p< 0.05). The overall rate of PDA closure did not differ significantly between cohorts, nor did the method of closure (medical vs. surgical). Time to closure and number of TTEs prior to intervention were also comparable. There were no statistically significant differences in rates of pulmonary overcirculation sequelae (BPD, CLD, ROP, need for diuretics or home oxygen) or low cardiac output complications (NEC, IVH) between cohorts. Additionally, duration of respiratory support, nasogastric feeds, central line access, and inotropic therapy were not significantly different.

Conclusion: Standardizing PDA management based on hemodynamic significance safely reduced treatment of non-HDS PDA without increasing morbidity or mortality. Our findings reinforce growing evidence that non-HDS PDA may be managed conservatively with close monitoring. Implementing similar protocols in neonatal intensive care units could reduce unnecessary interventions while maintaining favorable outcomes in extremely preterm infants.