1. Congestive Cardiac Failure
Dr. Kalpana Malla
MBBS MD (Pediatrics)
Manipal Teaching Hospital
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2. CCF
• CCF – inability of the heart to maintain an
output at rest or during distress, necessary for
the metabolic needs of the body (systolic
failure) and inability to receive blood into the
ventricular cavities at low pressure during
diastole (diastolic failure)

3. Causes - Infants
- Volume overload (L→ R shunt - VSD, PDA)
- Pressure overload (Co-A, Pulm Stenosis, Aortic Stenosis
- Myocardial diseases (Endocardial fibroelastosis,
cardiomyo
- Viral Myocarditis
- Paroxysmal tachycardia
- Anemia
-Miscellaneous – infection
- Upper respiratory obstruction
- Hypoglycemia, hypocalcemia
- Neonatal asphyxia
- Persistant fetal circulation

4. Causes - CCF
Children –
• Acute rheumatic carditis and rh heart ds
• Congenital heart ds complpicated by anemia,
infection or endocarditis
• Hypertension
• Viral Myocarditis & primary myocardial ds
• Upper resp obstruction
• Arrhythmias
• Cardiomyopathy

5. Clinical features
• Symptoms
1.Poor wt gain FTT- small feeds due to easy
fatigability
Excess loss of calories due to increased work of
breathing with CCF
2. Unusual wt gain due to edema
3. Shortness of breath
4.Fatigue from feeding – poor sucking

6. Clinical features
• Irritable,persistent crying –hunger, orthopnia
• Sweating
• Wheezing
Cardinal features of CCF in children
1.Tachycardia
2. Tachypnea
3.Hepatomegaly
4.Cardiomegaly

7. Examination
• Facial puffyness, edema
• Tachypnea ,wheeze, chest indrawing
• Tachycardia
• Raised JVP- difficult to assess
• Cardiomegaly –shifted apex
• Gallop rhythm
• Hepatomegaly

8. Investigations
• X-ray chest –cardiomegaly ,fluffy peripheral
pulmonary markings due to venous
congestion and pulmonary edema
• ECG helps to find the cause-hypertrophy
,arrhythmia
• Echo- for cause
• Blood count
• ABG

9. Management
• Reduce cardiac work
• Augment myocardial contractility
• Improve cardiac performance by reducing
heart size
• Correct the underlying cause

10. Reduce cardiac work
1. Restrict activities, position – propped up – pooling
of edema in dependant areas which reduces the
fluids in lungs – reduce work
2. Oxygen – improves impaired oxygenation
secondary to lung congesion so reduce work
3. Sedatives- decreases restlessness & dyspnea.
morphine .05mg/kg s/c or diazepam
4.Treat fever – circulatory & metabolic needs minimal
at normal temp thus reduce work,

11. Reduce cardiac work
5. Treat – anemia-decreased oxygen carrying capacity
imposes stress to heart
6.Treat infection
• Vasodilators –
• Reduce arteriolar and venous vasoconstriction –
reduce work of heart
• A. constriction - ↑systemic vascular resistance
• Venoconstriction - ↑ venous return- ↑filling
pressure- ↑CO

12. Vasodilators
1.ACE inhibitors – suppress renin angiotensin A
system –
- vasodilators +
- prevent Na+ & water retention
- prevent K+ loss
2.Others combinations: hydralazine (arteriole) +
isosorbide nitrate ( Vein)
3.Sodium nitroprusside (Atery + vein)

13. 2.Augment myocardial contractility
• Digitalis – ionotropic drug
• 1st dose – ½ of TDD
• 2nd dose – ¼ of TDD after 8 hrs of 1st dose
• 3rd dose – ¼ of TDD after 16 hrs of 2nd dose
• Maintenance dose – ¼ 0f TDD 12hrly 12hrs
after the 3rd dose

14. Initial Oral Digitalization dose
(IV or IM dose is 2/3 of oral dose
• Loading Maintenance
• Premature newborn
<1500 gms- 0.02 mg/kg 0.005 mg/kg
>1500 gms- 0.04 mg/kg 0.01 /kg
• Term NB - 6mo- 0.04 mg/kg 0.01 mg/kg
• 6 mo – 2 yrs - 0.06 mg/kg 0.015 mg/kg
• 2 yrs – 10yrs - 0.04 mg/kg 0.01 mg/kg
• >10 years0.04 mg/kg 0.01 mg/kg

15. Types of digitalization
1.Rapid digitalization – given IV within 24 hrs in
acute CCF, critically ill .Maintenance dose
given orally
2.Routine schedule – given orally within 24 hrs,
not critically ill
3.Slow digitalization – out patient basis ,with
chronic CCF. full digitalization is achieved in 7-
10 days-1/4th of TDD 12hrly without prior
loading dose

16. 3. Improve cardiac performance by
reducing heart size
• Digitalis
• Diuretics – reduce blood volume, venous
return and ventricular filling- reduce heart size
• Salt restriction – reduce volume
• 4. correct the underlying cause

17. Stepwise Mx CCF
Step 1- diuretics
Step -2 –add digoxin
Step 3- add ACE-inhibitors
Step 4 – add isosorbide nitrate
Step 5 – intermittent dopamine + dobutamine
Step 6 – myocardial biopsy + add steroids
(myocarditis +) or beta blockers
(no myocarditis -)
Step 7 – cardiac transplantation
Step 5,6 ,7- mainly for dilated cardiomyopathies

18. Thank you
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