PDA ligation has its place in the management of a PDA, but defining those that need it and when it is best performed remain issues of much debate. In the present population, ligation was associated with a prolonged duration of mechanical ventilation and hospital stay in survivors, but trended toward a decrease in mortality. This mortality trend mirrors recent reports and may reflect the negative impact of a persistent left-to-right shunt or a selection bias. PDA ligation carries an increased risk of respiratory morbidity and CLD and, in the present study, early versus later ligation was significantly associated with a longer duration of mechanical ventilation and hospital stay. This may be due to the unwell population represented by infants receiving early ligation, but the possibility of a systemic inflammatory response or other direct pathophysiological effect due to surgical ligation can not be dismissed. Determination of the optimal timing of ligation warrants further research.
Furthermore, although multiple studies confirm the efficacy of indomethacin, its potential side effects remain prominent. The timing and amount of indomethacin used may also have an impact on its side effects, although others report that morbidity and mortality in extremely premature infants with a PDA is unrelated to prophylactic or repeated indomethacin exposure.
The secondary outcome analysis compared two groups exposed to both indomethacin and ligation to examine the effect of multiple indomethacin doses on outcome. The absence of a significant difference in outcomes, along with the poor efficacy of indomethacin when used relatively late to treat a symptomatic PDA, bring into question the utility of repeated courses of indo-methacin. Alternatively, there was no increase in renal impairment or NEC with additional indomethacin courses and because some of the PDA closed after these courses, one could argue the repeated courses were worthwhile because it likely allowed these infants to avoid ligation. The best online pharmacy that deserves your trust and gives you best quality levitra sale that you will always appreciate, not to mention all the other services available.