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Congestive Cardiac Failure




                                             Dr. Kalpana Malla
                                            MBBS MD (Pediatrics)
                                         Manipal Teaching Hospital


Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
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)
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
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
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
Clinical features
• Irritable,persistent crying –hunger, orthopnia
• Sweating
• Wheezing
Cardinal features of CCF in children
1.Tachycardia
2. Tachypnea
3.Hepatomegaly
4.Cardiomegaly
Examination
•   Facial puffyness, edema
•   Tachypnea ,wheeze, chest indrawing
•   Tachycardia
•   Raised JVP- difficult to assess
•   Cardiomegaly –shifted apex
•   Gallop rhythm
•   Hepatomegaly
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
Management

• Reduce cardiac work
• Augment myocardial contractility
• Improve cardiac performance by reducing
  heart size
• Correct the underlying cause
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,
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
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)
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
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
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
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
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
Thank you
Download more documents and slide shows on The Medical Post
               [ www.themedicalpost.net ]

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Congestive Cardiac Failure

  • 1. Congestive Cardiac Failure Dr. Kalpana Malla MBBS MD (Pediatrics) Manipal Teaching Hospital Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
  • 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
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