Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Cardiac Failure Treatment PowerPoint PPT presentation
CARDIAC FAILURE
Inability of heart to maintain an output,
necessary for metabolic needs of body
(systolic failure) &
inability to receive blood into ventricular
cavities at low pressure during diastole
(diastolic failure)
INVESTIGATIONS
X ray chest
--to assess cardiac size& pulmonary congestion
--exclude pulmonary etiology
--detect congenital heart disease
ECG
-may show nonspecific T & ST segment changes
-tal P wave
-specific patterns of congenital&aquired heart dis
Echocardiography
--most useful,widely available,low cost test
--provides immediate data on
cardiac morphology& structure,
chamber volumes/diameters,
wal thickness,
ventricular systolic/diastolic function,
pulmonary pressure
OTHERS
Hemogram
Serum electrolytes
Blood gas analysis
Renal function test
Blood culture
AIM OF TREATMENT
Correction of inadequate cardiac output
1.Correction
2.Reduce
of underlying
cardiac work
cause
3.Augment
4.Improve
myocardial
cardiac
contractility
performance
CORRECTING THE UNDERLYING CAUSE
Important when CCF is caused or precipitated by:
? Anemia
? Nephrosis
? Overloading of circulation
? Severe chest infection
? Hypertension
? Fever
? Arrhythmias
? Pulmonary embolism
? Infective endocarditis
? Thyrotoxicosis
? Drug toxicity etc.
Surgical y treatable causes:
? Valvular lesions
? Obstructive lesions
? Shunts
Conditions that might be missed :
? sustained tachyarrhythmias,
? coarctation of aorta.& obstructive aortitis,
? anomalous origin of LCA from pulm artery,
? hypocalcemia
Uncommon causes of CCF in children:
- upper respiratory obstruction
-hypoglycemia
-hypocalcemia
-neonatal asphyxia
REDUCTION OF CARDIAC WORK
Restrict patient activities
Sedatives
Rx of conditions causing stress to heart
Vasodilators
Mechanical ventilation
Mx of NEONATE WITH HEART FAILURE
? Nursed in an incubator & handled minimal y
? Baby is kept propped up at an incline of about 30.
(Pooling of edema fluid in the dependant areas fluid
col ection in lungs reduce work of breathing)
? Temp ? 36-37 C (overal circulatory and metabolic needs
are minimal reduce work of heart)
? Humidified oxygen to maintain a conc.of 40-50%
(improves impaired oxygenation due to pulm congestion)
SEDATIVES
If infant or child is restless or dyspneic
Opiates (morphine)
Benzodiazepine(midazolam)
To reduce anxiety & lower catacholamine secretion
Reduce ?physical activity ,
-- respiratory rate ,
--heart rate
RX OF CONDITIONS CAUSING STRESS TO HEART
Fever
Infection
Anemia
Obesity
Thyrotoxicosis
Repeated pulmonary emboli
RX OF CONDITIONS CAUSING STRESS TO HEART
INFECTIONS
In infants & smal children,presence of
superadded pulmonary infection is difficult to
recognise. Therefore , antibiotics administered
emperical y
In older children, antibiotics are used only if
evidence of infection is present
RX OF CONDITIONS CAUSING STRESS TO HEART
Anemia
stress on heart bcoz of decreased oxygen carrying
capacity of heart
Anemia leads to tachycardia &hyperkinetic
circulatory state
Correction of anemia decrease cardiac work
Packed cel volumes of 10-20 mL/kg are required
to correct severe anemia
(single dose furosemide iv is given prior to
transfusion)
VASODILATORS
Counteract inappropriately excessive
compensatory mechanisms in heart failure&
improve cardiac output
VASODILATORS
VASODILATORS
Nitrates are used as preferential venodilators
In acute care setting, sodium nitroprusside is
used since it is a mixed arterio & venodilator
Phospho diesterase inhibitors (milrinone) &
Calcium sensitisers(levosimendan)
---popular especial y in post op period
---have powerful vasodilatory and inotropic
effects
VASODILATORS
SPECIFIC INDICATIONS
q Acute mitral or aortic regurgitation
q Ventricular dysfunction due to myocarditis
q Anomalous coronary artery from pulmonary
artery
q Early postoperative setting
ACE INHIBITORS
Eg: Captopril, Enalapril
Effective for treating heart failutre in infants and
children
Prevent cardiac remodel ing
They suppress RAAS
Reduce vasoconstriction& salt and water retention
reduce work of heart
By suppressing catacholamines,they prevent
arrhythmias and other adverse effects on myocardium
S/E--- Cough
(persistent coughuse angiotensin receptor blocker-
Losartan)
BETA BLOCKERS
Improve symptoms especial y in patients with
dilated cardiomyopathy,who continue to have
tachycardia
Metoprolol ,Carvedilol
Carvedilol ?preferred----since it has properties
of beta blockers with peripheral vasodilation
Treatment- started at low dose & increased
depending on tolerability
Dose--0.08 - 0.4 mg/kg/day
Maximum--1 mg/kg/day
AUGMENTING MYOCARDIAL CONTRACTILITY
INOTROPIC AGENTS
DIGOXIN
Rapid onset of action
Eliminated quickly
Available as oral & parenteral
Oral digoxin---available as 0.25 mg tablets&
digoxin elixir(1 ml=0.05 mg)
Parenteral---(0.5 mg/2 ml)
---dose- 70% of oral dose
Beneficial for symptom relief
Can be combined with ACE inhibitors for
synergistic effect
DIGOXIN- MECHANISM OF ACTION
DOSAGE
Children are digitalised within 24 hour period
1/2 of calculated digitalising dose is given
initial y
Fol owed by ? in 6-8 hours
Final ? after another 6-8 hours
Maintenance dose is usual y 1/4 of digitalising
dose
DIGITALIS TOXICITY
Rx --
DIGIBIND
? before 3rd daily dose an ECG is done to rule out digitalis
toxicity
? Toxicity can be control led by omitting next one or two doses
? PR interval is a useful indicator; if it exceeds initial interval
by 50%,digitalis toxicity is present
Digitalis is used with caution in:
1. Premature neonates
2. Heart failure due to myocarditis
3. Very cyanotic patients
New Intravenous inotropic agents
1. Catacholamine inotropes:
Dopamine,Dobutamine, Adrenaline
2. Phosphodiesterase inhibitors:
Amrinone,Milrinone
3. Levosimendan (calcium sensitiser)
4. Xamoterol ( agonist- cardiac stimulant)
5. Flosequinan
DOPAMINE
Used if B.P is low
At a dose less than 5 g/kg/minperipheral
vasodilation& increase myocardial contractility
DOBUTAMINE
Dose--2.5- 15g/kg/min
In pts with dilated cardiomyopathy,it is used as 24 hr
infusion once or twice a week
MILRINONE
Infusion 0.3-0.7g/kg/min fol owing a loading dose of
50g/kg
LEVOSIMENDAN
6- 12g/kg loading dose over 10 minutes fol owed by
0.05-0.2g/kg/min
IMPROVING CARDIAC PERFORMANCE
BY REDUCING SIZE OF HEART
q DIURETICS
q DIGOXIN
q DIET
IMPROVING CARDIAC PERFORMANCE
BY REDUCING VENOUS RETURN(PRELOAD)
DIURETICS
(first line of management in congestive failure)
MECHANISM OF ACTION
(i) Reduce blood volume,reduce venous return &
ventricular fil ing
Reduce heart size& volume
Wal tension decrease
Improves myocardial function & cardiac output
(ii) reduce total body sodium
Reduce B.P & peripheral vascular resistance
Increase cardiac output & reduce work of heart
DOSAGE OF DIURETICS
Furosemide
1 -3 mg/kg/day oral y OR
1 mg/kg/dose IV
Spironolactone
1 mg/kg oral y every 12 hr
DIET
Sodium restriction is recommended ;but
difficult to implement in infants and young
children
Since heart failure increases calorie
requirements,adequate intake is adviced
(150 kcal/kg/day)(smal and frequent meals
are given)
Severely ill- not able to suck,nasogastric tube
NEW THERAPIES
Ivabradine
Neprilysin inhibitor & valsartan
Device therapy
1. Implantable cardioverter defibrillator
2. Cardiac resynchronisation therapy
STEPWISE RX OF PEDIATRIC CCF
REFRACTORY CCF
Children with CCF that is refractory to above
mentioned measures need:
Re-evaluation with a special search for
unrecognised precipitating/underlying factor
Therapy with a -vasodilator nitroprusside
-iv inotropic(dopamine)
-beta blocker(propranolol)
under strict hemodynamic monitoring
Ultrafiltration or dialysis in the presence of renal
shutdown
Cardiac transplantation
8 wks old baby with fast breathing and resp
distress.O/E, resp rate -78, HR-172, temp-
103,SPO2-84, BP-94/60,MODERATE
RETRACION,cardiomegaly wiyh pan systolic
murmer of grade 5 in lower left sternal
border,tender hepatomegaly present
8 month old baby with ,admitted with resp
distress. O/E, severe pal or
,tachypnea,tachycardia,cardiomegaly &tender
hepatomegaly.on evaluation, hb was found to
be 3
4 month old baby admitted with 3 days upper
resp tract infection,O/E,there is
tachypnea,tachycardia,hypotension,
cardiomegaly
ECG showed ST-T CHANGES and
echocardiogram showed dilated cardiomyopathy
with LV dysfunction
This post was last modified on 12 August 2021