PATENT DUCTUS ARTERIOSUS

Description

The ductus arteriosus is an accessory fetal structure that connects the pulmonary artery
to the aorta. If it fails to close at birth (closure begins with the first breath, and is usually
complete between 7 to 14 days of age, although full closure may not occur until 3 months of
age), blood will shunt from the aorta (oxygenated blood) to the pulmonary artery
(deoxygenated blood) because of the increased pressure in the aorta. The shunted blood
returns to the left atrium of the heart, passes to the left ventricle, out to the aorta, and shunts
back to the pulmonary artery. This causes increased pressure in the pulmonary circulation from
the extra shunted blood; this leads to right ventricle hypertrophy and ineffective heart action.

Causes

Failure of the ductus to close is common in premature infants but rare in full-term
babies. In most children, the cause of PDA isn't known. Some children can have other heart
defects along with the PDA.

 Prematurity. PDA is most prevalent in premature neonates, probably as a result of

abnormalities in oxygenation.
 Prostaglandin E. The relaxant action of prostaglandin E prevents ductal spasm and
contracture necessary for closure.
 Other congenital defects. PDA commonly accompanies rubella syndrome and may be
associated with other congenital defects, such as coarctation of the aorta, ventricular
septal defect, and pulmonary and aortic stenoses.

Risk Factor

1. PDAs are twice as common in girls as boys and occur at a higher incidence at
higher altitudes.
2. In preterm infants, the incidence may be as high as 20% to 60% and accounts
for about 10% of all heart disease.
3. It's also common among babies with neonatal respiratory distress syndrome,
babies with genetic disorders (such as Down syndrome), and babies whose
mothers had rubella (also called German measles) during pregnancy.

Physical Examination

The child usually has a wide pulse pressure (the difference between systolic and
diastolic blood pressures). The diastolic pressure, a measure of peripheral resistance, is low
because of the shunt or runoff of blood, which reduces resistance. A typical continuous (systolic
and diastolic) “machinery” murmur can be heard at the upper left sternal border or under the
left clavicle in older children. In newborns, the murmur may not be quite so characteristic,
perhaps a short grade II or III harsh systolic sound.
Diagnostic/ Laboratory test

1. An ECG is generally normal, although it may show ventricle enlargement if the shunt is
large.
2. Echocardiography provides good visualization of the patent ductus.
3. Cardiac catheterization is generally not necessary for diagnosis but may be performed to
rule out associated defects

Pharmacological management

 Prostaglandin analogs. The ductus arteriosus can be induced to remain open by

administering prostaglandin analogs such as alprostadil (a prostaglandin E1 analog).
 Antibiotics. Before surgery, children with PDA require antibiotics to protect against
infective endocarditis.
 Indomethacin. Indomethacin is a prostaglandin inhibitor that’s an alternative to surgery
in premature neonates and induces ductus spasm and closure.
 Ibuprofen inhibits prostaglandins therefore allowing closure of the PDA

Nursing Implications
• Administer reconstituted solution intravenously over 5 to 10 seconds.
• Space doses at specified intervals.
• Observe the child closely for adverse effects. Check the infusion site carefully for signs
of oozing or bleeding indicative of impaired clotting. Also assess vomitus or urine for
bleeding (Karch, 2009).

Medical Procedure

 Cardiac catheterization. In cardiac catheterization, a plug or coil is deposited in the

ductus to stop the shunting.
 Ligation. The DA may be closed by ligation, wherein the DA is manually tied shut, or
with intravascular coils or plugs that leads to formation of a thrombus in the DA.
 Insertion of Dacron-coated stainless-steel coils by interventional cardiac
catheterization when the child is 6 months to 1 year of age. Exceptionally large
defects can be closed surgically by ductal ligation, the surgery is performed using
only three small thoracotomy incisions on the chest.
 If surgery is not done by one of these techniques, the child is at risk for heart failure
from the increased amount of blood pouring back into the pulmonary artery and
infectious endocarditis developing from the recirculating blood and potential stasis in
the pulmonary artery.

Nursing Intervention

The major goals for the patient are:

  Maintain adequate cardiac output.
 Reduce the increase in pulmonary vascular resistance.
 Maintain adequate levels of activity.
 Provide support for growth and development.
 Maintain appropriate weight and height development.

Patent ductus arteriosus necessitates careful monitoring, patient and family teaching, and
emotional support.
 Signs and symptoms. Watch carefully for signs of PDA in premature infants.
 Monitoring. Frequently assess vital signs, ECG, electrolyte levels, and intake and output.
 Adverse effects of indomethacin. If the infant receives indomethacin for ductus closure,
watch for possible adverse effects, such as diarrhea, jaundice, bleeding, and renal
dysfunction.
 Preoperative instructions. Before surgery, carefully explain all treatments and tests to
parents, including the child, and tell them about expected IV lines, monitoring
equipment, and postoperative procedures.
 Postoperative procedures. Immediately after surgery, the child may have a central
venous pressure catheter and an arterial line in place, so careful assessment of vital
signs, intake and output, and arterial and venous pressures are needed, as well
as pain relief.

Therapeutic Management.

One reason that the ductus arteriosus remains open in fetal life is stimulation by prostaglandins,
particularly PGE1, from the placenta and the low oxygen level of fetal blood. After birth, when
the PGE1 level falls and the oxygen level increases, the ductus arteriosus is stimulated to close.
If it does not close spontaneously, an infant may be prescribed IV indomethacin or ibuprofen,
prostaglandin inhibitors. These lower the PGE1 level and encourage ductus closure. If
indomethacin is given, assess for possible side effects, including reduced glomerular filtration,
impaired platelet aggregation, and diminished gastrointestinal and cerebral blood flow (Box
41.5). Because it has much fewer side effects, ibuprofen is becoming the drug of choice; it can
even be used as prophylaxis in preterm infants (Thilo & Rosenberg, 2008). If medical
management fails to bring about closure of the ductus arteriosus, the disorder can be closed by
insertion of Dacron-coated stainless-steel coils by interventional cardiac catheterization when
the child is 6 months to 1 year of age. Exceptionally large defects can be closed surgically by
ductal ligation. This involves major surgery because opening the chest (thoracotomy) and
manipulating the great vessels is necessary. However, it is not open-heart surgery and so does
not involve the use of extracorporeal circulation; rather, it may be performed using only three
small thoracotomy incisions on the chest. If surgery is not done by one of these techniques, the
child is at risk for heart failure from the increased amount of blood pouring back into the
pulmonary artery and infectious endocarditis developing from the recirculating blood and
potential stasis in the pulmonary artery