Congestive Cardiac Failure

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

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 Restrict activities, position – propped up – pooling of edema in dependant areas which reduces the fluids in lungs – reduce work 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 1 st dose – ½ of TDD 2 nd dose – ¼ of TDD after 8 hrs of 1 st dose 3 rd dose – ¼ of TDD after 16 hrs of 2 nd dose Maintenance dose – ¼ 0f TDD 12hrly 12hrs after the 3 rd 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 years 0.04 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-1/4 th 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 Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]