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Shared using Xodo PDF Reader and Editor Heart failure Dr.Eman Hassn Alhmairy CABP/FICMSP Consultant Pediatric  Shared using Xodo PDF Reader and Editor Heart Failure Heart failure occurs when the heart cannot deliver adequate cardiac output to meet the metabolic needs of th...

Shared using Xodo PDF Reader and Editor Heart failure Dr.Eman Hassn Alhmairy CABP/FICMSP Consultant Pediatric  Shared using Xodo PDF Reader and Editor Heart Failure Heart failure occurs when the heart cannot deliver adequate cardiac output to meet the metabolic needs of the body.  Shared using Xodo PDF Reader and Editor In children, the signs and symptoms are often similar to those in adults and include fatigue, effort intolerance, anorexia, abdominal pain, dyspnea, and cough. older children and adolescents may have primarily abdominal symptoms and a surprising lack of respiratory complaints.  Shared using Xodo PDF Reader and Editor Orthopnea basilar rales edema Cardiomegaly  gallop rhythm holosystolic murmur of mitral or tricuspid valve regurgitation may be heard.  Shared using Xodo PDF Reader and Editor In infants, heart failure may be difficult to identify. Prominent manifestations include tachypnea, feeding difficulties, poor weight gain, excessive perspiration, irritability, weak cry, and noisy, labored respirations with intercostal and subcostal retractions, as well as flaring of the alae nasi. The signs of cardiac-induced pulmonary congestion may be indistinguishable from those of bronchiolitis; wheezing is prominent.  Shared using Xodo PDF Reader and Editor Pneumonitis is common, especially in the right middle and lower lobes; it is due to bronchial compression by the enlarged heart.  Hepatomegaly usually occurs, and cardiomegaly is invariably present. gallop rhythm can frequently be recognized.  The other auscultatory signs are those produced by the underlying cardiac lesion. Edema may be generalized and usually involves the eyelids as well as the sacrum and less often the legs and feet.  Shared using Xodo PDF Reader and Editor Etiology of Heart Failure FETAL Severe anemia (hemolysis, fetal-maternal transfusion, parvovirus B19-induced anemia, hypoplastic anemia) SVT VT Complete heart block  Shared using Xodo PDF Reader and Editor PREMATURE NEONATE Fluid overload PDA VSD Cor pulmonale (bronchopulmonary dysplasia) HT  Shared using Xodo PDF Reader and Editor FULL-TERM NEONATE  Asphyxial cardiomyopathy Arteriovenous malformation (vein of Galen, hepatic) Left-sided obstructive lesions (COA, HLHS) Large mixing cardiac defects (single ventricle, truncus arteriosus) Viral myocarditis  Shared using Xodo PDF Reader and Editor INFANT-TODDLER Left-to-right cardiac shunts (ventricular septal defect) Hemangioma (arteriovenous malformation) Anomalous left coronary artery Metabolic cardiomyopathy Acute hypertension (hemolytic-uremic syndrome) SVT Kawasaki disease Viral myocarditis  Shared using Xodo PDF Reader and Editor CHILD-ADOLESCENT  Rheumatic fever Acute hypertension (glomerulonephritis) Viral myocarditis Thyrotoxicosis Hemochromatosis-hemosiderosis Cancer therapy (radiation, doxorubicin) Sickle cell anemia Endocarditis Cor pulmonale (cystic fibrosis) Cardiomyopathy (hypertrophic, dilated)  Shared using Xodo PDF Reader and Editor Diagnosis CXR cardiac enlargement. exaggeration of the pulmonary arterial vessels to the periphery of the lung fields, Fluffy perihilar pulmonary markings suggestive of venous congestion and acute pulmonary edema are seen only with more severe degrees of heart failure.  Shared using Xodo PDF Reader and Editor ECG Chamber hypertrophy Evaluation of rhythm disorders as a potential cause of heart failure.  Shared using Xodo PDF Reader and Editor Echo The most commonly used parameter is fractional shortening, determined as the difference between end-systolic and end- diastolic diameter divided by end-diastolic diameter. Normal fractional shortening is between 28 and 40%, whereas a normal ejection fraction (which measures volume) is 55-65%.  Shared using Xodo PDF Reader and Editor Treatment  Treat the underlying cause  GENERAL MEASURES: Strict bed rest is rarely necessary(the child should rest and sleep adequately). Most older patients feel better sleeping in a semi-upright position. For infants with heart failure, an infant chair may be advisable. After patients begin to respond to treatment, restrictions of activities according to the specific diagnosis and the patient's ability.  Shared using Xodo PDF Reader and Editor DIET Increasing the number of calories per ounce of infant formula (or supplementing breast-feeding) may be beneficial.  Many infants do not tolerate an increase beyond 24 calories/oz because of diarrhea or because these formulas provide too large a solute load for compromised kidneys.  Shared using Xodo PDF Reader and Editor Severely ill infants may lack sufficient strength for effective sucking So nasogastric feedings may be helpful. The use of continuous drip nasogastric feedings at night, administered by pump, may improve caloric intake while decreasing problems with gastroesophageal reflux.  Shared using Xodo PDF Reader and Editor low sodium formulas in the routine management is not recommended(poorly tolerated and may exacerbate diuretic- induced hyponatremia). Human breast milk is the ideal low sodium nutritional source. Most older children can be managed with " no added salt" diets.  Shared using Xodo PDF Reader and Editor DIGITALIS Digoxin is the digitalis glycoside used most often in pediatric patients.(half-life 36 hr) It is absorbed well by the gastrointestinal tract (60-85%), even in infants. Absorption is greater with the elixir than with tablets.  An initial effect can be seen as early as 30 min after administration, and the peak effect for oral digoxin occurs at approximately 2-6 hr.  When the drug is administered intravenously, the initial effect is seen in 15-30 min, and the peak effect occurs at 1-4 hr.  Shared using Xodo PDF Reader and Editor The drug crosses the placenta, and therefore a fetus with heart failure (secondary to arrhythmia) can be treated by administering digoxin to the mother. The kidney eliminates digoxin The rate of excretion is proportional to the GFR.  Shared using Xodo PDF Reader and Editor Rapid digitalization may be carried out intravenously. The recommended schedule is to give half the total digitalizing dose immediately and the succeeding two one-quarter doses at 12 hr intervals later.  Shared using Xodo PDF Reader and Editor DigoxinPremature: 20 μg/kg Digitalization PO (1/2 initially, followed by 1/4 q8-12h 12 × 2) Full-term neonate (up to 1 mo): 20-30 μg/kg Infant or child: 25-40 μg/kg Adolescent or adult: 0.5-1 mg in divided doses IV dose is 75% of PO dose Digoxin maintenance5-10 μg/kg/day divided q12h  Shared using Xodo PDF Reader and Editor  ECG must be closely monitored and rhythm strips obtained before each of the three digitalizing doses.  Digoxin should be discontinued if a new rhythm disturbance is noted.  Prolongation of the P-R interval is not necessarily an indication to withhold digitalis, but a delay in administering the next dose or a reduction in the dosage should be considered, depending on the clinical status.  Hypokalemia and hypercalcemia exacerbate digitalis toxicity.  Because hypokalemia is relatively common in patients receiving diuretics, potassium levels should be monitored closely in those receiving a potassium-wasting diuretic (e.g., furosemide) in combination with digitalis.  Shared using Xodo PDF Reader and Editor Maintenance digitalis therapy is started approximately 12 hr after full digitalization. The daily dosage is divided in two and given at 12 hr intervals for more consistent blood levels and more flexibility in case of toxicity. The dosage is one quarter of the total digitalizing dose. For patients who are initially given digitalis intravenously, maintenance digoxin can be given orally once oral feedings are tolerated.  Shared using Xodo PDF Reader and Editor Patients who are not critically ill may be given digitalis initially by the oral route, and in most instances digitalization is completed within 24 hr. When slow digitalization is desirable, for example, in the immediate postoperative period, initiation of a maintenance digoxin schedule without a previous loading dose achieves full digitalization in 7-10 days.  Shared using Xodo PDF Reader and Editor Digoxin toxicity Hypokalemia, hypomagnesemia, hypercalcemia, cardiac inflammation secondary to myocarditis, and prematurity may all potentiate digitalis toxicity. A cardiac arrhythmia that develops in a child who is taking digitalis may also be related to the primary cardiac disease rather than the drug. Any form of arrhythmia occurring after the institution of digitalis therapy must be considered to be drug related until proved otherwise. Succeeding doses should be withheld until the issue is resolved.  Shared using Xodo PDF Reader and Editor DIURETICS It interferes with reabsorption of water and sodium by the kidneys, which results in a reduction in circulating blood volume and thereby reduces pulmonary fluid overload Diuretics are most often used in conjunction with digitalis therapy in patients with severe HF.  Shared using Xodo PDF Reader and Editor Furosemide inhibits the reabsorption of sodium and chloride in the distal tubules and the loop of Henle. It results in rapid diuresis and prompt improvement in clinical status, particularly if symptoms of pulmonary congestion are present. It has the potential for significant loss of potassium. So KCL supplementation is usually required unless spironolactone is given concomitantly.  Shared using Xodo PDF Reader and Editor Spironolactone is an inhibitor of aldosterone and enhances potassium retention, often eliminating the need for oral potassium supplementation, which is frequently poorly tolerated. This drug is usually given orally in two to three divided doses of 2-3 mg/kg/24 hr.  Combinations of spironolactone and chlorothiazide are commonly used for convenience.  Shared using Xodo PDF Reader and Editor Chlorothiazide is used occasionally for diuresis in children with less severe chronic heart failure. It is less immediate in action and less potent than furosemide, and it affects the reabsorption of electrolytes in the renal tubules only. Potassium supplementation is often required if this agent is used alone.  Shared using Xodo PDF Reader and Editor AFTERLOAD-REDUCING AGENTS AND.ACE INHIBITORS Afterload-reducing agents and ACE inhibitors are most often used in conjunction with other anticongestive drugs such as digoxin and diuretics. Capoten Enalopril  Shared using Xodo PDF Reader and Editor The oral captopril produces arterial dilatation by blocking the production of angiotensin II, thereby resulting in significant afterload reduction. Venodilation and consequent preload reduction have also been reported. In addition, this agent interferes with aldosterone production and therefore also helps control salt and water retention. ACE inhibitors have additional beneficial effects on cardiac structure and function that may be independent of their effect on afterload.  Shared using Xodo PDF Reader and Editor  Adverse reactions includes hypotension and its sequelae (e.g., syncope, weakness, and dizziness). A maculopapular pruritic rash (in 5-8%)which is often disappears spontaneously with time. Neutropenia, renal toxicity, and chronic cough also occur. Enalopril more selective and less side effects. Shared using Xodo PDF Reader and Editor THANK YOU