Heart failure in pediatrics sandip

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ppt on approach to pediatric heart failure

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Heart failure in pediatrics sandip

  1. 1. DR. SANDIP GUPTA PGT,PEDIATRICS B.S.M.C.H. HEART FAILURE IN PEDIATRICS
  2. 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. 3. Causes of heart failure  congenital  acquired
  4. 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. 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. 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. 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. 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. 9. APPROACH TO PATIENT  HISTORY  PHYSICAL EXAMINATION  INVESTIGATION  TREATMENT
  10. 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. 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. 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. 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. 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. 15. Treatment of heart failure state • General measures • Medical management • Treatment of precipitating factors • Treatment of special condition
  16. 16. General measures • Propped –up position • Oxygen • Adequate calories • Salt restriction • Bed rest • Daily wt • Mx respiratory failure
  17. 17. Precipitating factors • Hypertension • Anemia • Arrhythmia • Hyperthyroidism • Infection • Fever
  18. 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. 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. 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. 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. 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. 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. 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. 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. 26. HEART FAILURE IN SPECIAL CONDITION  Ductus dependent circulation  Rheumatic carditis  Kawasaki’s disease  Anthracycline toxicity  Preterm PDA
  27. 27. THANK YOU

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