CARDIAC FAILURE

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Last Updated : 1/10/2012
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N C Joshi
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Management of CHF

In pediatrics, majority of

patients with CHF

are due to congenital heart disease who will need corrective surgery. The medical

treatment of CHF

is necessary for three reasons:
- To correct hemodynamic aberrations due to CHF.
- To allow the patient to reach the operating room in a better hemodynamic and metabolic state.
- To give an opportunity for spontaneous improvement of the defect - PDA in premature and VSD closure.

Medical management
As a rule, infants first seen in CHF should be hospitalized because:
- CHF is a life threatening in infants.
- The administration of therapeutic agents, selection of drugs, determination of appropriate dosage can be done in an inpatient setting.
- A complete anatomic and physiologic understanding should be obtained as soon as possible to decide about surgery.

Once the patient is admitted, a chest film PA view and an electrocardiogram should be taken and blood for blood count, gases, and chemistries should be obtained. A careful history and physical examination and a working diagnosis should be made and treatment is started. If the patient is very ill, two-dimensional echocardiography, intravenous line, delivery of oxygen by mask and therapy should be done simultaneously.

Once a working diagnosis is made and no emergency surgery is indicated, intravenous diuretic is used, provided serum potassium is normal. Frusemide, a loop diuretic known as high - ceiling diuretic due to the high intensity of its effects is used to improve ventricular function by its preload reduction due to pulmonary vasodilatation. The only contraindication for frusemide is CHF due to tachyarrhythmia.

Along with the diuretic, in desperately ill infant- parenteral inotropics (digoxin or dopamine) is given. See Table 3.

Drug therapy and
dosage schedule for treatment of CHF


Drug
Initial Oral Digitalization dose
(IV or IM dose is 2/3 of oral dose)
Maintenance
Digoxin  
Premature
  
<1500 gms
0.02 mg/kg
0.005 mg/kg
>1500 gms
0.04 mg/kg
0.01 mg/kg
Newborns and up to six months
0.04 mg/kg
0.01 mg/kg
6 months - 2 years
0.06 mg/kg
0.015 mg/kg
2 years - 10 years
0.04 mg/kg
0.01 mg/kg
>10 years
0.04 mg/kg
0.01 mg/kg
 
Dopamine
5-10-mcg/kg/min in 5% glucose
 
 
Morphine
0.1 mg/kg/dose
 
 
Chloral hydrate
20 mg/kg/dose
 


Fig 1: Sites of action of
drugs used to treat heart failure


Sites of action of drugs used to treat heart failure



Other aspects of management:
- Maintain infant's temperature in euthermic range.
- Posture: An infant in CHF has cardiomegaly and congested lungs. Both diminish the volume available for air exchange. In addition hepatomegaly will limit diaphragmatic excursion in recumbent posture so keep the patient in a suitable chair in inclined posture.
- Oxygen administration: If there is respiratory distress, pulmonary venous desaturation is pronounced so increase inspired oxygen concentration will benefit the patient.
- Sedation: Restlessness is very common in infants and children with CHF which raises oxygen demands. Sedation with chloral hydrate is useful in infants and children. Morphine is the sedative of choice in acutely ill patient and in postoperative period when pain is an additional factor.

In the second 24 hours: if the patient has good diuresis, respiratory distress has lessened and heart rate has slowed down, maintenance digoxin and diuretics are switched over to the oral route.

But if inotropics and preload reducers do not produce the desired effect, search for additional problem is made because digoxin has got dynamic action depending upon the pH of blood, electrolyte normality, abnormal blood sugar level and hemoglobin concentration. If child is very anemic, packed blood cells are given which increase oxygen carrying capacity. Attempt is made to maintain electrolyte balance, normal blood sugar and proper blood pH. If child has got pulmonary infection adequate antibiotic treatment is given. If inspite of above variables being normal, after load reducers are considered.

Two more therapeutic principles that can be followed both in the hospital as well as at home are:
- Salt restriction should not interfere with baby's eating. Infants should eat enough.
- Restriction of physical activity is not the issue in pediatrics. It may be counter productive because it increases oxygen consumption.

When the baby improves, can tolerate room air and develops an appetite sufficient to gain weight - maintenance of inotropics & diuretics should be decided and further investigation for proper surgical management should be carried out.



Contributor Information and Disclosures N C Joshi
Consultant Pediatrician and Pediatric Cardiologist, Nanavati Hospital, Mumbai, India


First Created : 1/12/2001
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