Your SlideShare is downloading. ×
Heart failure in pediatrics sandip
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Heart failure in pediatrics sandip

3,710
views

Published on

ppt on approach to pediatric heart failure

ppt on approach to pediatric heart failure

Published in: Health & Medicine

1 Comment
5 Likes
Statistics
Notes
No Downloads
Views
Total Views
3,710
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
383
Comments
1
Likes
5
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. DR. SANDIP GUPTA PGT,PEDIATRICS B.S.M.C.H. HEART FAILURE IN PEDIATRICS
  • 2. DEFINITION  HEART FAILURE: It is syndrome in which heart is unable to provide the output required to meet the metabolic demands of the body(systolic failure) and/or inability to receive blood in to the ventricular cavities at low pressure during diastole (diastolic failure).
  • 3. Causes of heart failure  congenital  acquired
  • 4.  Volume overload  Left-to-right shunting  Ventricular septal defect  Patent ductus arteriosus  Valvular insufficiency  Aortic regurgitation in bicuspid aortic valve  Pulmonary  Pressure overload  Left sided obstruction  Severe aortic stenosis  Aortic coarctation  Right-sided obstruction  Severe pulmonary stenosis Causes of Heart Failure in Children congenital heart disease
  • 5. Cont.  CYANOTIC CHD WITH INCREASED PBF  TGA  TAPVC  TRUNCUS ARTERIOSUS  TRICUSPID ATRESIA WITHOUT PS  OTHRES  Single ventricle  Hypoplastic left heart syndrome  Atrioventricular septal defect  Systemic right ventricle  L-transposition (“corrected transposition”) of the great arteries
  • 6. TIMING OF ONSET OF HEART FAILURE • At birth: HLHS, large A-V fistula, pulmonary atresia • 1st wk: TGA, TAPVR, preterm PDA, critical AS or PS • 1-4 wk: COA with associated anomalies, critical AS, PretermVSD/PDA • 4-6 wk: endocardial cushion defect • 6 wk-4 mth: large VSD, large PDA,ALCAPA.
  • 7. 2.Acquired Heart Disease  Primary cardiomyopathy Dilated Hypertrophic Restrictive  Viral myocarditis  Acute rheumatic carditis & RHD  Anthracycline induced cariomyopathy  Post-op repaired cyanotic CHD  Cardiomyopathy with muscular dystrophy & friedrich’s ataxia  Myocarditis in Kawasaki’s disease  Hypertensive heart failure in PSGN
  • 8. WHEN TO SUSPECT CCF • Poor wt gain • Difficulty in feeding • Breathes too fast • Persistent cough and wheezing • Excessive perspiration, irritability, restlessness • Puffiness of face • Pedal edema • Diaphoresis
  • 9. APPROACH TO PATIENT  HISTORY  PHYSICAL EXAMINATION  INVESTIGATION  TREATMENT
  • 10. ClinicalHistory NEONATES & INFANTS • Poor feeding • Tachypnoea worsening during feeding • Cold sweet on forehead • Poor weight gain OLDER CHILDREN • Fatigue • Exercise intolerance • Dyspnoea • Puffy eyes & pedal edema • Growth failure
  • 11. Physical examination Initial investigations Right sided failure: •Hepatomegaly •Facial & pedal edema •Jugular venus engorgement Left sided failure: •Tachypnoea •Tachycardia •Cough •Wheezing & Rales Either side failure: •Cardiomegaly •Gallop rhythm •Cyanosis •Low vol.pulse •Absence of wt.gain •CXR •Cardiac enlargement •Pulmonary edema •12-lead ECG •Pulse-oximetry, CBG, hyperoxia test •Echocardiography •CBC, U&E, calcium, creatinine, and LFT •Blood tests •Thyroid function
  • 12. Clinical diagnosis of CHF E c h o c a r d i o g r a m Structural diagnosis (eg myopathic, valvular) Pathophysiological diagnosis Systolic dysfunction (LVEF < 40%) Diastolic dysfunction (LVEF > 40%) Proceed to treatment guidelines
  • 13.  MODIFIED ROSS CLASSIFICTION.  Class I Asymptomatic  Class II Mild tachypnea or diaphoresis with feeding in infants Dyspnea on exertion in older children  Class III Marked tachypnea or diaphoresis with feeding in infants Marked dyspnea on exertion Prolonged feeding times with growth failure  Class IV Symptoms such as tachypnea, retractions,grunting, or Diaphoresis at rest
  • 14. NYHA CHF classification for infants  NYHA I - NO SIGN  NYHA II - RR>50 , WITH OR WITHOUT HEPATOMEGALY  NYHA III- ALL ABOVE WITH RIB RETRACTION  NYHA IV- RR>60/min H/R>160/ min, WITH HEPATOMEGALY,RIB RETRACTION WITH OR WITHOUT POOR PERFUSION.
  • 15. Treatment of heart failure state • General measures • Medical management • Treatment of precipitating factors • Treatment of special condition
  • 16. General measures • Propped –up position • Oxygen • Adequate calories • Salt restriction • Bed rest • Daily wt • Mx respiratory failure
  • 17. Precipitating factors • Hypertension • Anemia • Arrhythmia • Hyperthyroidism • Infection • Fever
  • 18. Medical management 1.Diuretics - 1st line of drugs - ↓ pre-load - Do not improve CO or myocardial contractility - Hypokalemia and hypochloremic alkalosis 2.Inotropic agents -Digoxin -Dobutamine -Dopamine -Amrinone /milrinone 3.Afterload ↓ agents Dilators: Arteriolar- Veno- Mixed- 4.B -blockers
  • 19. DIURETICS  Act by ↓venous return ,end diastolic volume, ↓ pulmonary edema & work of breathing.  Furosemide is diuretic of choice.  Spironolactone(2-4mg/kg/d) may be used as add on drug.  Metolazone(0.1-0.2mg/kg) has been tried in frusemide resistant edema.
  • 20. Mechanism of action DIGITALIS : special role in heart failure by ↑ contractility at the same time depressing SA node & AV node. •Its half-life of 36hrs, so given once or twice daily. •Its absorbed well by GIT,60- 85%.even in infants,elixir>tablets. •Initial effect can be seen within 30min after oral administration and within 15min after IV. •Adjust the dose in patients with renal failure.
  • 21. How to dizitalize the heart ? 1. Baseline ECG & Serum electrolytes 2. Calculate the oral digoxin dosage : Age Total dizitalizing dose(μg/kg) Maintenance dose(μg/kg/D) Prematures 20 5 Newborns 30 8 < 2yrs 40-50 10-12 > 2yrs 30-40 8-10 Maintenance dose is 25% of the total dig.dose in 2 divided doses I.V. dose is 75% of the oral dose. 3. Give one half of the TDD immediately ,then 1/4th & then the final 1/4th at 6- to 8-hr intervals. 4. Start the maintenance dose 12hrs after the final TDD but before this do ECG
  • 22. Other ionotropes: Phosphodiesterase inhibitors: Milrinone/amrinone • Low cardiac output refractory to standard therapy • After open heart surgery • Adjunct to DA / Dobutamine • S/E-thrombocytopenia Adrenergic agents: Dopamine • Inotropic,peripheral vesodilatation, increased renal blood flow- natriuresis • 5-10mcg/kg/min • In higher doses- peripheral vesoconstriction Dobutamine •2.5-40mcg/kg/min •Dose is gradually increased
  • 23. Afterload ↓ agents • Long term trials with Captopril(0.5-6mg/kg) & Isosorbide dinitrate(0.1mg/kgq6hr) shown improvement in symptoms & exercise capacity. • Used as add on with diuretics & digoxin.
  • 24. ß BLOCKERS  Effacious in CHF in children due to CHD, Anthracycline induced cardiomyopathy , dilated cardiomyopathy.  Improved left ventricular function & exercise tolerance, decreased need for heart transplant.  It has been shown to improve clinical symptoms & neurohormonal markers in infants with CHF due to Lt to Rt shunts.  Dose should titrated upwards  Avoid in decompensated heart failure.  Carvedilol(initial dose0.08→0.46mg/kg)
  • 25. Nonpharmacological treatment modalities Cadiac resynchronization therapy: BiVP • cardiomyopathy • LBBB LV assist device Surgery: (depends on the type of defect)  Blalock Taussig shunt  Balloon septoplasty  Mustard Senning  Jatene’s switch
  • 26. HEART FAILURE IN SPECIAL CONDITION  Ductus dependent circulation  Rheumatic carditis  Kawasaki’s disease  Anthracycline toxicity  Preterm PDA
  • 27. THANK YOU