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Heart failure in pediatrics
- 1. Heart Failure inpediatrics Investigations & Treatment Jenan muhammed 8th term ESIC MC PGIMSR
- 2. Chest radiography • Highspecifity and negative predictive value • Cardiomegaly- suggestive of ventricular dilatation or hypertrophy • Large right to left shunts-exaggerated pulmonary arterial vessels marking towards periphery • Cardiomyopathy- lung fields normal • Severe HF- fluffy perihilar pulmonary markings suggestive of pulmonary edema
- 4. Laboratory investigations • SymptomaticHF- associated with perturbations of electrolyte and fluid balance, renal function, liver function, thyroid function • Hyponatremia due to renal water retention (chronic Diuretic treatment still worsens tht)
- 5. ECG • Nonspecific butfrequently abnormal in pediatric HF patients • With findings of LV hypertrophy, low voltage QRS morphology with ST-T wave abnormalities (myocardial inflammatory disz,also pericarditis), MI patterns, AV blocks, • Best tool for evaluating rhythm disorders
- 6. Echocardiography • Std techniquefor assessing ventricular function • Commonly used parameter in children Fractional shortening- ED diametr-ES diameter ED diameter normal – 28%to 42% Ef normal – 55-65%
- 7. Essential for identifying •Causes of HF such as structural heart disease • Ventricular dysfunction (both systolic and diastolic) • Chamber dimensions • Effusions (both pericardial and pleural)
- 8. Biomarkers • Serum Btype ntriuretic peptide- elevated in HF due to systolic dysfunction(CM) as well as with volume overload • Cardiac troponin-elevated in cases of mycarditis, ischemic injury due to coronary anomaly, cardiomyopathy
- 9. • Pulse oximetryor hyperoxia test- 100% oxygen given and oxygen saturation is determined • Metabolic and genetic testing • Endomyocardial biopsy for acute myocarditis • MRI cardiac- left n right ventricular function
- 10. treatment • Underlying cause •Cardiac anomaly amenable to surgery – medical treatment to prepare the patient for surgery • Lesion s nt reversible- medical treatment allows the child to b back to normal activities for some period and delay need for heart transplantion
- 11. • Treatment ofthe precipitating events • Rheumatic activity, • Infective endocarditis, • Intercurrent infections, • Anaemia, electrolyte imbalances, • Arrhythmia, pulmonary embolism..
- 12. General measures • Bedrest and limit activities • Nurse propped up or in sitting position • Control fever • Expressed breast milk for small infants • Fluid restriction in volume overloaded • Pulmonary edema – positive pressure ventilation • Neonates with HF- nursed in an incubator, baby s kept propped up at 30 degree • Child s restless or dyspneic- sedatives r used
- 13. Diet • Usually failto thrive- increased metabolic demands and decreased caloric intake • Increase calorie intake supplement breast milk • Severely ill- not able to suck, nasogastric tube • Older children- no added salt diet
- 14. Goals of medicaltherpay • Reducing preload • Enhancing cardiac contractility • Reducing afterload • Improving oxygen delivery • Enhancing nutrition • Medical management of CCF should be tailored to specific details of each case
- 15. diuretics • Diuretics affordquick relief in pulmonary and systemic congestion. 1 mg/kg of frusemide is the agent of choice. • For chronic use 1-4 mg/kg of frusemide or 20-40 mg/kg of chlorothiazide in divided dosages are used. • Monitor electrolytes, urea and weight • Spironolactone may be added 2 divided doses of 2mg/kg/day
- 16. Afterload reducers- • ACEIand ARBs • Decreases peripheral vascular resistance and thereby improving mycardial performance • Especially useful-HF secondary to cardiomyopathy n severe aortic n mitral insufficiency • Additional benefits on preventing cardiac remodeling • Captopril-0.3 to 6mg/kg ,Enalapril-0.05to 0.5mg/kg/day • Nitrates- venodilators • Hydralazine arterial dilators • Nitroprusside used in icu settings
- 17. Beta blockers • Usedin dialated cardiomyopathy • Improve symptoms n survival • Metoprolol selctive beta blocker • Carvediol both alpha n beta blocker • CCBs • Should b avoided unless indicated for systemic HTN
- 18. Phosphodiesterase inhibitor • Milrinone-refractory to std therapy n post operative period in open heart surgery • Positive inotropy n peripheral vasodialtaion • IV 0.25to 1 microgm/kg/min
- 19. Augmenting myocardial contractility •Digoxin- • Digitalization schedule- half total immediately subsequent 2 quarters at 12 hrs intervals • ECG closely monitored • maintenance digitalis after 12 hrs- daily dosage one quarter of digitalising dosage s divided into 2 n given at 12 hrs intervels
- 20. Inotropes • Usually administeredin ICU settings • Dopamine – beta adrenergic agonists(alpha adrenergic at higher doses) • Selective renal vasodilatation( useful in patients compromised kidney functions) • 2 to 10 micro gm/kg/min • Fenoldopam – DA1 agonists • Dobutamine – causes moderate reduction in peripheral vascular resistance 2 to 20 microgm/kg/min
- 21. • Isoproterenol- purebeta agoinists in patients with slow heart rates & less commonly used( chances of arrhythmias) • Epinephrine in cardiogenic shock
- 22. Manging acute CCF •Admit to ICU • Neoneates nursed in incubator • Baby kept propped up at 30 degree • Humidified oxygen • Child is restless- morphine 0.05mg/kg SC • Treat precipitating factors • Diuresis with furosemide • Significant hypotention- given dopamine infusion • Reduce preload- nitrates • After stabilisation look into cause
- 23. Electro physiologic approach •Biventricular resynchronisation pacing • Improves cardiac output by maintaining normal synchrony between right n left ventricle contraction Correct underlying cause Surgical approach
- 24.