446 - Fluid Restriction During First Three Days of Life Lowers Risk of Hemodynamically Significant Patent Ductus Arteriosus in Extremely Preterm Infants: A Quality Improvement Cohort Study

Publication Number: 3431.446

Hussnain S. Mirza, AdventHealth for Children, Longwood, FL, United States; Melissa Tyree, AdventHealth for Children, Winter Park, FL, United States; Jorge A. Garcia, AdventHealth for Children, Orlando, FL, United States; Maha Batool, UCF, Winter springs, FL, United States; William NMN. Oh, Women and Infants' Hospital, Barrington, RI, United States

Background: In extremely preterm infants, renal prostacyclin production increases by excessive IV fluids intake preventing ductal closure. We reported a significant association between higher fluids intake and prolonged duration of hemodynamically significant PDA (hsPDA) in extremely preterm infants

Objective: To decrease the risk of hsPDA in extremely preterm infants by preventing excessive IV fluids administration in the first week of life

Design/Methods: This is a quality improvement project to optimize the daily fluid intake in extremely preterm infants. Historically, we were prescribing higher daily IV fluids. Clinical practice guidelines were revised in July 2020 in favor of restricted IV fluids intake (Figure 1-A). Infants born at < 29 weeks and treated in neonatal ICU at Advent Health, were included if they had no major congenital anomaly or genetic syndrome and an echocardiogram is performed within the first 7+3 days of life. Electronic Medical Records (EMR) were retrospectively reviewed for infants in the historic cohort (EPOCH-1) admitted from January 2013 to June 2016. Historical data revealed an association between higher risk for prolonged hsPDA among infants receiving higher IV fluids in the first 2 days of life. New practice guidelines were implemented in July,2020 to restrict IV fluid intake in the first 72 h of life. Daily serum sodium levels were monitored, and screening echocardiograms performed at 7+3 days of life. Definition of hsPDA was based on a combination of echocardiographic and clinical characteristics as reported in our original paper (Figure-1-B). Clinical and demographic data were retrieved from EMR for infants in the post-intervention cohort (EPOCH-2) from July 2020 to December 2022. Data analysis was completed to compare the two groups and their clinical outcomes.

Results: We enrolled 306 & 378 infants in EPOCH 1 & 2 respectively. Infants with major congenital anomalies or genetic disorder were excluded. Clinical and demographic characteristics of the two groups were comparable. For infants in EPOCH-1, total daily fluid intake in first 3 days of life was significantly higher compared to the infants in EPOC-2 (Figure 2-A). Serum sodium was significantly higher on day 1 in EPOCH-2 (139 vs 136), but no clinically significant hypernatremia was noted by restricting daily fluid intake (Figure 2-B). Infants in EPOCH-1 have higher incidence of hsPDA & PDA that required medical treatment. However, overall incidence of other clinical outcomes remained unchanged (Table 1)

Conclusion(s): Restricted IV fluids intake in first 3 days of life is associated with lower risk for hsPDA in preterm infants

Figure 1-A & 1-B
Revised Practice Guidelines & Modified PDA Scoring System

Figure 2-A & 2-B
Actual Daily Fluids Intake and Daily Serum Sodium Levels; EPOCH-1 vs EPOCH- 2

Table 1
Demographic & Clinical Characteristics