Neoprofin and Indomethacin Worksheet

Our NICU is developing an ever increasing culture of conservative ductul management (in favor of more aggressive, early feeding guidelines). For that reason, the following guidelines should be worked through before considering use of NSAID therapy in a neonate.

1) A cardiac echo should not be done soley for a PDA evaluation prior to day of life five, unless the infant is unstable.

2) The infant should be on mild fluid restricti0n if they are on any IV fluids (total fluids = 120 ml/kg day)

3) the infant shoud not be receiving diuretics (furosemide is known to inhibit the phosphodiesterases that break down PGEs)

4) Infants with moderate to small PDAs that are asymptomatic should be managed with fluid restriction only (so that their feeding advances can be optimized as the first priority)

5) Infants with large to moderate PDAs that are symptomatic may have their feeds held to 50 ml/kg/day (or reduced to that amount) during NSAID therapy, but feedings do not  have to be and should not be routinely stopped unless the infant is exhibiting ongoing feeding intolerance).

6) Infants with a moderate PDA whose primary symptom is persistent metabolic acidosis due to loss of renal bicarbonate, should have acetate therapy optimized (including adequate cations in the TPN, reductions in phospate supplementation and reductions of trophamine to 2-2.5 to reduce the acid load) while steadily advancing feeds per our guidelines as safely and quickly as possible. On occasion, some of the infants will require NSAIDs because the combination of stupid kidneys and ductal steal cannot be managed in this way, but MOST can be managed with smart TPN management in the interim while advancing feeds to ultimately minimize the effects of trophamine.

7) if the ductus is large, or if it is moderate and persistent after all of the above criteria have been  satisfied and the infant still warrants NSAID therapy, the doses are below (Indomethacin is slightly more potent, Neoprofin may have less affect upon splanich blood flow):

Indomethacin:

1st dose: 0.2 mg/kg IV
2nd dose: 0.2 mg/kg IV 24 hours after 1st dose if PDA persists.
3rd dose: 0.2 mg/kg IV 24 hours after 2nd dose if PDA persists.

  • Indomethacin is given IV over 30 minutes
  • Noeprofin:

    1st dose: 10 mg/kg IV
    2nd dose: 5 mg/kg IV 24 hours after 1st dose if PDA persists.
    3rd dose: 5 mg/kg IV 24 hours after 2nd dose if PDA persists.

    • Neoprofin is given IV over 30 minutes

    Dr Gordon’s foot note: the primary problem with NSAID therapy is interruption of the feeding advance and delay in getting the infant onto it’s growth curve, (when most infants can managed without it). This is especially true when we get stuck in the spin cycle of two or three courses, because we try to get it all the way closed (instead of down to moderate and asymptomatic or small). On the other hand, infant’s who need their ductus closed really need it closed, because they’re symptomatic and are not going to get better until we do. This is one of the greatest challenges we face today in neonatology. This call, whether or not we treat a ductus, is second only to amount of time spend on a ventilator in prognostic value. On the other hand, infants not on a vent, seldom need their ductus closed by pharmaceuticals, period. In this new year (2011), I would like to see us have the lowest use of NSAIDs ever. Why, because it’s low hanging fruit. The faster we get them to grow, the faster they get better, go home and the more likely they are to have a normal outcome. In terms of our total numbers, I know that this is the right approach.

    • NICU Code Meds and Drips

    • E.D. Quick Guidelines for the Newborn

    • Antibiotic Guidelines (Cheat-sheet)

    • Go to NICU Brain

    • Go to NICU Library

    • Go to NICU Vault (Guidelines)

    • Go to Follow Up Clinic

    • Dr Gordon believes in using the right tool for the job

    • Flow Diagram of Neonatal Resuscitation

    • NICU Common Med List (Cheat Sheet)

    • General NICU Formulary (limited)

    • Drug Reference Tool I

    • Drug Reference Tool II

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