Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Cardiac Failure Treatment PowerPoint PPT presentation
![](73abde7f-ed05-4954-9557-6db316ac093f-1_1.jpg)
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)
![](73abde7f-ed05-4954-9557-6db316ac093f-2_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-4_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-5_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-8_1.jpg)
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)
![](73abde7f-ed05-4954-9557-6db316ac093f-10_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-11_1.jpg)
RX OF CONDITIONS CAUSING STRESS TO HEART
Fever
Infection
Anemia
Obesity
Thyrotoxicosis
Repeated pulmonary emboli
![](73abde7f-ed05-4954-9557-6db316ac093f-12_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-13_1.jpg)
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)
![](73abde7f-ed05-4954-9557-6db316ac093f-14_1.jpg)
![](73abde7f-ed05-4954-9557-6db316ac093f-14_2.jpg)
VASODILATORS
Counteract inappropriately excessive
compensatory mechanisms in heart failure&
improve cardiac output
![](73abde7f-ed05-4954-9557-6db316ac093f-15_1.jpg)
VASODILATORS
![](73abde7f-ed05-4954-9557-6db316ac093f-16_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-17_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-18_1.jpg)
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)
![](73abde7f-ed05-4954-9557-6db316ac093f-19_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-20_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-21_1.jpg)
DIGOXIN- MECHANISM OF ACTION
![](73abde7f-ed05-4954-9557-6db316ac093f-22_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-24_1.jpg)
![](73abde7f-ed05-4954-9557-6db316ac093f-24_2.jpg)
![](73abde7f-ed05-4954-9557-6db316ac093f-24_3.jpg)
![](73abde7f-ed05-4954-9557-6db316ac093f-24_4.jpg)
![](73abde7f-ed05-4954-9557-6db316ac093f-24_5.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-28_1.jpg)
IMPROVING CARDIAC PERFORMANCE
BY REDUCING SIZE OF HEART
q DIURETICS
q DIGOXIN
q DIET
![](73abde7f-ed05-4954-9557-6db316ac093f-29_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-32_1.jpg)
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
![](73abde7f-ed05-4954-9557-6db316ac093f-33_1.jpg)
NEW THERAPIES
Ivabradine
Neprilysin inhibitor & valsartan
Device therapy
1. Implantable cardioverter defibrillator
2. Cardiac resynchronisation therapy
![](73abde7f-ed05-4954-9557-6db316ac093f-34_1.jpg)
STEPWISE RX OF PEDIATRIC CCF
![](73abde7f-ed05-4954-9557-6db316ac093f-35_1.jpg)
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