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Critic 16:3:12
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Critic 16:3:12

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  • 1. + CRITICAL APPRAISAL PEARLS IMMUNIZATION CASE II DR Saptharishi L G
  • 2. + Diagnostic Issues
  • 3. + Does it fit into AFM??  Libermann et al (1991)  Clinical & Echocardiographic criteria for ‘Acute Fulminant Myocarditis’   Developed acute and severe heart failure during this illness  Evidence of Left ventricular dysfunction on Echo (EF< 40%)   Recent history of viral prodrome with fever lasting < 2 weeks No previous or family history of cardiomyopathy Acute heart failure:  Fatigue, breathing difficulty or edema developing during a 1-2 day period and within 7 days prior to hospitalization
  • 4. + Non- Obstructive TAPVC ?? Why not ??  Short history with a ‘not-so-impressive’ fever  CXR – Bilateral white-out  ECHO (on D1 hospital stay)  RA & RV grossly dilated  12 mm ASD with R L shunt  Mild TR and PR  Almost all ABGs (except one) showing PaO2 < 80  Clinical SpO2 – fluctuating; ?Pulmonary reactivity
  • 5. + What we could have done?  12 lead ECG  ECHOCARDIOGRAPHY  Caveats of echocardiography in TAPVC  One of the most difficult-to-diagnose conditions on ECHO  Serial Echo evaluations required – most often  Specific expertise in pediatric echocardiography required CLARIFICATIONS REGARDING ECHOCARDIOGRAPHY • Consultant Echo could have been considered in this case? • Echo done for myocarditis ? Information regarding contractility/ Ejection fraction ? If normal, how does that correlate with our clinical picture?
  • 6. + Positives  SEPSIS: Points in favor  High counts  Pneumonia (bilateral infiltrates) + Myocarditis + elevated OT/PT  Nosocomial sepsis – COEXISTING?  Outside hospital stay – 1 day    Multi-drug resistant Acinetobacter Isolated from Blood c/s within 48 hours of admission What precipitated the illness in the first place??  Rickettsial infection / Leptospirosis ruled out  Viral causes more likely?
  • 7. + What does available literature say? 1. Coxsackie virus 2. Adenovirus 3. Enteroviruses Can produce this kind of a clinical presentation Most important causative agents for Acute Fulminant Myocarditis
  • 8. +
  • 9. +
  • 10. + How do elevated AST/ALT fit in??
  • 11. + Management Issues
  • 12. + Management of shock  First documentation of CVP at 26 hours of hospital stay  Refractory to most measures (Fluid + Ionotropes)  Cause of refractory shock ?  Most precipitating causes ruled out  Hydrocortisone shock dose given  Acute Fulminant Myocarditis Most of the recent reviews on Myocarditis in Infants and neonates – report use of LVAD or ECMO for refractory cardiogenic shock secondary to Acute fulminant Myocarditis
  • 13. + Is IVIG the answer to MYOCARDITIS ??
  • 14. + No evidence to support routine IVIG or steroids
  • 15. +
  • 16. + Post Mortem Biopsies  Was Myocardial biopsy considered?    AHA recommendation in all clinically suspected myocarditis* EMB Vs Cardiac MRI Was any other biopsy carried out? If yes, what do the findings suggest?
  • 17. + Summary of queries  Was TAPVC considered as a possibility in this child?  Why was 12 lead ECG not considered?  How do we explain the echocardiographic picture in the setting of AFM ? (Apparently normal ejection fraction)  Shock management – Comments?  Post mortem biopsy reports