CONGESTIVE CARDIAC FAILURE PEDIATRICS.pptx

CONGESTIVE CARDIAC FAILURE

1. CONGESTIVE CARDIAC FAILURE Dr Poonam Trivedi

2. DEFINITION: Inability of heart to deliver adequate cardiac output to meet metabolic demands of the body. PATHOPHYSIOLOGY: FRANK-STARLING PRINCIPLE Cardiac output r/t filling volume & systemic vascular resistance. As Ventricular end-diastolic volume increases, C.O. increases & reaches a maximum (^ stroke volume – result of stretching of myocardial fibres -- ^ wall tension & ^ myocardial oxygen demand)

3. CARDIAC OUTPUT = H.R. X STROKE VOLUME . DETERMINANTS OF S.V. – PRELOAD, AFTERLOAD & CONTRACTILITY. INCREASED PRELOAD: Left to right shunts, valvular insufficiency. INCREASED AFTERLOAD: AS, PS & COA. MYOCARDIAL INSUFFICIENCY: Cardiomyopathies. HIGH OUTPUT C.F.: Anemia, Hypoxemia.

4. COMPENSATORY M/C: ^ secretion of Epinephrine(Adrenals) & Norepinephrine(NM junc.) >> ^H.R. & Myocardial contractility(B- adre . Receptors) Vasoconstriction( A- adrenergic receptors). Redistribution of blood flow: skin, renal, visceral>>> heart & brain. Chronic exposure: decreased B- adre receptors & myocardial cell damage.

5. CLINICAL MANIFESTATIONS : INFANTS: Feeding difficulties(SRS cycle/ forehead sweating), tachypnea, Poor wt gain, ICR, SCR, NF, WHEEZE. CHILDREN: Fatigue, effort intolerance, anorexia, dyspnea & cough, abdominal pain. SIGNS: Tachypnea, tachycardia, ^JVP, B/L crepts / rales , wheeze, edema, hepatomegaly, cardiomegaly, gallop rhythm, murmur(MR/TR)

6. DIAGNOSES Chest X-ray: Cardiomegaly, ^ perihilar fluffy shadows. ECG: prolonged QTc ( hypocalcemia ), lateral wall infarction(ALCAPA), Tachycardia with abnormal p wave axis, low voltage QRS ( tachycardiomyopathy ) Echocardiography: fractional shortening (end sys dia - end dias dia / end dias dia , N= 28-42%), Ejection fraction(55-65%), regional wall motion abnormality), structural heart lesions. MR ANGIOGRAPHY- Ventricular function, volume, mass , cor. a rt anatomy. ABG,CBC, LFT, RFT, S.E., BNP.

7. TREATMENT 1)CORRECTION OF UNDERLING CAUSE: Mostly imp priority , has direct impact on survivalTachyarrhythmia , correctable cardiac defects, COA, Hypocalcemia . 2) SUPPORTIVE MEASURES: POP, OXYGEN SUPPORT/MECH VENTILATION SUPPORT, SEDATIVES, RESTRICTION OF STRENOUS ACTIVITIES, T/T OF ANEMIA, FEVER, INFECTIONS,DIET.

8. 3)REDUCING PRELOAD: 1 ST LINE Mx Diuretics: reduces blood volume>>decreased venous return>>decreased ventricular filling. Frusemide with K+ sparing diuretics. 4)AFTERLOAD REDUCTION ACE-inhibitors/ARBs Peripheral Vasodilatation/suppresses Renin-Angiotensin-Aldosterone M/c. Enalapril , Captopril, Losartan.

9. 5)IMPROVING MYOCARDIAL CONTRACTILITY: Currently used less frequently Digoxin(half life- 36hrs, oral- OOA-30mis, peak 2-6hrs, IV- OAA 15-30mins, peak 1-4hrs) 25-40mcg/kg… Rapid digitalisation : IV…half of total digitalisation dose f/b 1/4 th at 12 hrs interval twice. Hypokalemia, hypercalcemia - increase digitalis toxicity. ECG(PR int / ST-T wave changes), Sr electrolytes & RFT monitoring.

10. A & B ADRENERGIC AGONISTS: Dopamine:inotropic effect, decrease PVR Selective renal vasodilatation. At higher dose(15mcg/kg/min), A-adrenergic effecr >>vasoconstriction. .. Dobutamine : direct inotropic effect, per. Vasodilatation. Epinephrine: used in cardiogenic shock, Increases blood pressure. PHOSPHODIESTERASE INHIBITORS : decreased degradation Camp, positive inotropic effect& per. Vasodilatation.adjunct drug.

11. 7)MANAGING CO-MORBIDITY: Anemia, fever, infections. CHRONIC T/T WITH B-BLOCKERS: Improves exercise intolerance, decreases hospitalisations & overall survival rates, in dilated cardiomyopathy. ELECTROPHYSIOLOGIC APPROACHES: Biventricular synchronization pacing :in dilated cardiomyopathy, repaired TOF, complex CHD. Implantable cardioverter-debrillator - high risk of ventricular arrhythmias.

12. THANK YOU!!