772 - Instituting Indomethacin Prophylaxis for Patent Ductus Arteriosus in Extremely Low Birthweight Infants: Evaluation of a Practice Change

Poster Number: 772
Publication Number: 772.247

Luke A.. Wessler, Medical University of South Carolina College of Medicine, Charleston, SC, United States; William W. Shugart, MUSC College of Medicine, Charleston, SC, United States; Anthony M. Hlavacek, Medical University of South Carolina College of Medicine, Charleston, SC, United States; David J. Annibale, Medical University of South Carolina, Charleston, SC, United States; Rita M. Ryan, Case Western Reserve University, Cleveland, OH, United States; Heidi J.. Steflik, Medical University of South Carolina College of Medicine, Charleston, SC, United States

Background: Indomethacin can be used as patent ductus arteriosus (PDA) prophylaxis (PPX) in premature newborns. In 2019, our large Level IV neonatal intensive care unit (NICU) implemented indomethacin PPX for all neonates < 28 weeks gestational age (GA) and < 1,000 grams at birth (extremely low birth weight, ELBW).

Objective: We aimed to determine if implementation of a clinical practice guideline for indomethacin PPX for PDA in our NICU was associated with changes in subsequent PDA occurrence, management, and outcomes.

Design/Methods: Single center retrospective cohort study of ELBW neonates < 28 weeks GA treated before (Cohort 1 [C1]: 3/15/16-3/14/19) and after initiation of protocolized PPX (Cohort 2 [C2]: 3/15/19-3/14/22). PPX consisted of indomethacin 0.1mg/kg IV q24 hours, up to 3 doses in those without contraindications.
C1 and C2 were compared using Chi-square or Wilcoxon rank sum test as appropriate. Details of PPX prescription and receipt were examined in C2. Primary outcome: subsequent need for PDA medical treatment. Secondary outcomes: early (< 7 postnatal days) spontaneous intestinal perforation (SIP), intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), survival, length of stay (LOS), PDA disposition, need for surgical ligation or transcatheter PDA closure, and number of echocardiograms (ECHO) performed.

Results: Of 483 infants, 382 met inclusion criteria (C1: n=173; C2: n=189; Figure). Baseline demographic characteristics were similar between cohorts (Table 1).
In C2, 98 (52%) received PPX, most completing a full course (1 dose: 16.3%; 2 doses: 10.2%; 3 doses: 73.5%). The most frequent contraindication to the 1st dose was bleeding or coagulopathy while the most frequent contraindication for the 2^nd and 3^rd doses was anticipated need for steroids.
PPX was associated with decreased subsequent medical PDA treatment (Table 2) compared with the historical cohort, C1. Of those requiring subsequent treatment (1-4 courses), most in both cohorts received 2 courses, but the distribution of courses varied between groups (p=0.02).
PPX was associated with decreased incidence of IVH (C1: 64.2% vs. C2: 41.8%) and LOS (C1: median 118 days [IQR 84-146] vs. C2: 100 days [80-123]; all p< 0.05). SIP, BPD, survival, PDA disposition, need for surgical ligation or transcatheter PDA closure, and number of ECHOs did not differ between cohorts.

Conclusion(s): In our Level IV NICU, implementation of PPX was associated with reduced subsequent need to medically treat a PDA and reduced IVH and LOS without associated increases in SIP, BPD, or mortality, suggesting potential benefit in our patient population.