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Published on : Aug 02, 2021 | Views : 2105 | Downloads : 7

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Slide 1-

Heart Failure in pediatrics Investigations & Treatment Jenan muhammed 8th term ESIC MC PGIMSR
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Chest radiography High specifity and negative predictive value Cardiomegaly- suggestive of ventricular dilatation or hypertrophy Large right to left shunts-exaggerated pulmonary arterial vessels marking towards periphery Cardiomyopathy- lung fields normal Severe HF- fluffy perihilar pulmonary markings suggestive of pulmonary edema
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Laboratory investigations Symptomatic HF- associated with perturbations of electrolyte and fluid balance, renal function, liver function, thyroid function Hyponatremia due to renal water retention (chronic Diuretic treatment still worsens tht)
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ECG Nonspecific but frequently abnormal in pediatric HF patients With findings of LV hypertrophy, low voltage QRS morphology with ST-T wave abnormalities (myocardial inflammatory disz,also pericarditis), MI patterns, AV blocks, Best tool for evaluating rhythm disorders
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Echocardiography Std technique for assessing ventricular function Commonly used parameter in children Fractional shortening- ED diametr-ES diameter ED diameter normal – 28%to 42% Ef normal – 55-65%
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Essential for identifying Causes of HF such as structural heart disease Ventricular dysfunction (both systolic and diastolic) Chamber dimensions Effusions (both pericardial and pleural)
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Biomarkers Serum B type ntriuretic peptide- elevated in HF due to systolic dysfunction(CM) as well as with volume overload Cardiac troponin-elevated in cases of mycarditis, ischemic injury due to coronary anomaly, cardiomyopathy
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Pulse oximetry or hyperoxia test- 100% oxygen given and oxygen saturation is determined Metabolic and genetic testing Endomyocardial biopsy for acute myocarditis MRI cardiac- left n right ventricular function
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treatment Underlying cause Cardiac anomaly amenable to surgery – medical treatment to prepare the patient for surgery Lesion s nt reversible- medical treatment allows the child to b back to normal activities for some period and delay need for heart transplantion
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Treatment of the precipitating events Rheumatic activity, Infective endocarditis, Intercurrent infections, Anaemia, electrolyte imbalances, Arrhythmia, pulmonary embolism..
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General measures Bed rest and limit activities Nurse propped up or in sitting position Control fever Expressed breast milk for small infants Fluid restriction in volume overloaded Pulmonary edema – positive pressure ventilation Neonates with HF- nursed in an incubator, baby s kept propped up at 30 degree Child s restless or dyspneic- sedatives r used
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Diet Usually fail to thrive- increased metabolic demands and decreased caloric intake Increase calorie intake supplement breast milk Severely ill- not able to suck, nasogastric tube Older children- no added salt diet
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Goals of medical therpay Reducing preload Enhancing cardiac contractility Reducing afterload Improving oxygen delivery Enhancing nutrition Medical management of CCF should be tailored to specific details of each case
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diuretics Diuretics afford quick relief in pulmonary and systemic congestion. 1 mg/kg of frusemide is the agent of choice. For chronic use 1-4 mg/kg of frusemide or 20-40 mg/kg of chlorothiazide in divided dosages are used. Monitor electrolytes, urea and weight Spironolactone may be added 2 divided doses of 2mg/kg/day
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Afterload reducers- ACEI and ARBs Decreases peripheral vascular resistance and thereby improving mycardial performance Especially useful-HF secondary to cardiomyopathy n severe aortic n mitral insufficiency Additional benefits on preventing cardiac remodeling Captopril-0.3 to 6mg/kg ,Enalapril-0.05to 0.5mg/kg/day Nitrates- venodilators Hydralazine arterial dilators Nitroprusside used in icu settings
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Beta blockers Used in dialated cardiomyopathy Improve symptoms n survival Metoprolol selctive beta blocker Carvediol both alpha n beta blocker CCBs Should b avoided unless indicated for systemic HTN
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Phosphodiesterase inhibitor Milrinone- refractory to std therapy n post operative period in open heart surgery Positive inotropy n peripheral vasodialtaion IV 0.25to 1 microgm/kg/min
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Augmenting myocardial contractility Digoxin- Digitalization schedule- half total immediately subsequent 2 quarters at 12 hrs intervals ECG closely monitored maintenance digitalis after 12 hrs- daily dosage one quarter of digitalising dosage s divided into 2 n given at 12 hrs intervels
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Inotropes Usually administered in ICU settings Dopamine – beta adrenergic agonists(alpha adrenergic at higher doses) Selective renal vasodilatation( useful in patients compromised kidney functions) 2 to 10 micro gm/kg/min Fenoldopam – DA1 agonists Dobutamine – causes moderate reduction in peripheral vascular resistance 2 to 20 microgm/kg/min
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Isoproterenol- pure beta agoinists in patients with slow heart rates & less commonly used( chances of arrhythmias) Epinephrine in cardiogenic shock
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Manging acute CCF Admit to ICU Neoneates nursed in incubator Baby kept propped up at 30 degree Humidified oxygen Child is restless- morphine 0.05mg/kg SC Treat precipitating factors Diuresis with furosemide Significant hypotention- given dopamine infusion Reduce preload- nitrates After stabilisation look into cause
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Electro physiologic approach Biventricular resynchronisation pacing Improves cardiac output by maintaining normal synchrony between right n left ventricle contraction Correct underlying cause Surgical approach
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Thank you