ccf in neonates dr rajesh kumar md (pgi), dm (neonatology) pgi, chandigarh, india rani children...
Post on 26-Mar-2015
239 Views
Preview:
TRANSCRIPT
CCF in Neonates
Dr Rajesh Kumar
MD (PGI), DM (Neonatology) PGI, Chandigarh, India
Rani Children Hospital, Ranchi
Aim
What are the causes of CCF in neonate?
How to diagnose CCF in a neonate? What are the different investigations
required? What is the treatment?
Definition
Heart is unable to meet the metabolic demands of the tissues
Stress on heart
HR Contractility catecholamine
autonomic input
Preload renal preservation
venous constriction
Decompesation
HRPul edema, hepatomegaly
Cardiac output
Diagnosis of CCF
Clinical Radiographic findings Laboratory findings
Signs and symptoms of CCF
Venous congestion Right side
• Hepatomegaly• Ascitis• Pleural effusion• Edema
Left side• Tachypnea• Retactions• Crepitations• Pul. edema
Low cardiac output Acute
• Pallor• Sweating• Cool extremities capillary refill• Altered sensorium
Chronic• Feeding difficulty• Fatigue• Poor growth
Tachycardia
Diagnosis of CCF: X-ray
To rule out primary pulmonary disease
Magnitude of pulmonary blood flow Cardiac size Cardiac shape: (boot shaped, egg on
side, snow man)
Diagnosis of CCF: ECG More useful in D/D of cyanotic
newborn with pul blood flow
Tricuspidatresia
Pul atresia with intact vent septum
TOF, Pul stenosis
0
+90
-90
180
Diagnosis of CCF: Echo
Rules out associated significant heart disease in pt with pulmonary disease
Doppler echo is preffered Operator dependant Examination of extracardiac
structure is limited
Diagnosis of CCF: Cardiac catheterisation
Necessary to delineate vascular anatomy before surgery in some cases
Causes of CCF
Cardiac
Structural
Arrythmia
Myocardial dysfunction
Extracardiac compression
Non-cardiac
Preload (ARF)
Afterload (HT)
O2 carrying
capacity (anemia)
Demand (sepsis)
Case study
Term newborn well for first 2-3 hours, developed respiratory distress, gradually worsening
CPAP for 3 days, gradually improved but continues to have problem, Day 1 echo ?? coarct
Day 5 echo showed significant coarct Dischraged on day 7, worsened in next 4-5
days Operated for coarct at day 25 of life, now
(5 months) doing well
Case study
33 weeks, infant of diabetic mother Had respiratory distress since birth,
suspected to have HMD, had murmur Echo showed PDA with Co-actation
of aorta Medical management tried, Surgery
done in third week, Now asymptomatic
Causes of CCF: Cardiac-structural heart disease Left ventricular outflow tract
obstruction Aortic stenosis, co-arctation of aorta
Ductus dependant lesions Critical aortic stenosis, preductal coarctation
of aorta, interrupted aortic arch, hypoplastic left heart syndrome, TGA
Left to right shunt VSD, PDA, ASD
Regugitant lesions ECD, truncus arterioisus
Case study
Term newborn, Wt 3.0 Kg Antenataly suspected congenital heart
block At birth heart rate 50 per minute, Echo:
normal, ECG: s/o CHB Developed tachypnea and retraction on day
3 Required temporary pacing followed by
permament pace maker implant Well till 1 year of life
Congenital heart block Supraventricular tachycardia Ventricular tachycardia
Causes of CCF: Cardiac-arrythmia
Cardiomyopathy Perinatal asphyxia
Myocardial infarction
Sepsis Acute LVF
Causes of CCF: Cardiac-myocardial dysfunction
Treatment
Treatment of underlying cause Reversing metabolic derangements Improving cardiac performance Altering preload / afterload burden Improved oxygen delivery Enhanced nutrition
Improving cardiac performance
Sympathomimetics Dopamine Dobutamine Phenylephrine Adrenaline, Noradrenaline
Phosphodiasterase inhibitors Amrinone, Minrinone
Digoxin
Naturally acting catecholamine Low dose direct stimulation of dopamine
receptors, higher dose works through release of norepinephrine
Premature babies require lesser dose than term babies Dose (g/kg/min) Effects
1-5 HR, UOP, contractility5-10 HR, contractility, BP10-20 HR, contractility, BP, SVR
Dopamine
Dopamine
40 mg per ml (1mg per unit by insuline syringe)
Neonate: In Pediadrip set:
2mg /kg/ 6hrs fluid (5.5 g/kg/min) to 6mg/kg/6hours fluid
By infusion pump: 15 mg (15 units) dopamine + 50 ml NS, Infuse
@ 1ml/kg/hour ( 5g/kg/min) to 4 ml/kg/hour
Dobutamine
50 mg per ml (1.25mg per unit by insuline syringe)
Neonate: In Pediadrip set:
2mg /kg/ 6hrs fluid (6.87 g/kg/min) to 6mg/kg/6hours fluid
By infusion pump: 15 mg (15 units) dopamine + 50 ml NS, Infuse
@ 1ml/kg/hour ( 6.87 g/kg/min) to 4 ml/kg/hour
Dobutamine
Synthetic catecholamine Does not depend on NE stores Effects: contractility, SVR, HR Often used with dopamine to
contractility and to avoid extreme vasoconstriction associated with high dose dopamine
Amrinone
Positive inotropy + Vasodilator Can be combined with sympathomimetics Precautions: not in hypovolumic, not in pt
with fixed systemic outflow tract obstruction
Dose: Neonate: loading: 3-4.5 mg/kg, folowwed by infusion of
3-5 g/kg/min Infant: loading: 3-4.5 mg/kg, folowwed by infusion of 10
g/kg/min
Amrinone
5 mg per ml, 20 ml ampoule, dilute only with saline, never with dextrose
Neonate: 10mg (2ml) + NS 48 ml Infuse @ 1ml/kg/hr (3.3 g/kg/min) to
1.5ml/kg/hr
Infant: 30mg (6ml) + NS 44 ml Infuse @ 1ml/kg/hr (10 g/kg/min)
Epinephrine
myocardial contractility, SVR Useful in sepsis induced cardiac
failure as second or third line drug Dose: Starting- 0.05-0.1 g/kg/min
can be rapidly Preparation: 0.3ml(12 units)+ 50 ml
NS, Start with ML in kg /hr (0.1 g/kg/min ) and then increase
Digoxin
Inotropic agent Loading dose:
Premature neonate:20-30 g/kg Term neonate: 30-40 g/kg
Schedule for loading: ½, ¼, ¼ 8hours apart
Maintanance dose: Premature neonate: 5-10 g/kg/day BD Term neonate: 10 g/kg/day BD
Route: IV, IM, oral Injection: 1ml ampoule, 250 g /ml
1unit = 6.25 g ; 10 g /kg = 1.5units/kg
Oral (Digoxin Paed elixir): 1ml = 0.05 mg Maintenance dose: 0.01 mg/kg/day Wt in kg /10 ml twice daily
3 kg: 0.3 ml twice daily
Digoxin
Alteration of preload
Fluid retention due to low cardiac output and renal perfusion
Ventricular contractility is compromised due to massive volume overload
Diuretics: Acute diuresis: Furosemide 1-4 mg/kg/dose Chronic diuresis: Furosemide + potassium
sparing diuretics
Alteration of afterload
Precaution: Do not use in hypovolumic condition and in pt with fixed left ventricular outflow obstruction
Effective in Regurgitant lesions(ECD, Cardiomyopathy) and left to right shunts (VSD)
Acute: Nitroprusside, Dobutamine, amrinone
Chronic: ACE inhibitors Enalapril: 0.1 mg/kg /day OD or BD ( 5 kg: ¼ tab OD)
Prostaglandin E1
Useful in ductal dependant CHD Best before 96 hours after birth Dose: 0.5 –0.2 g/kg/minute Presentation: ALPOSTIN, 1 ml
ampoule, 1ml=500mg C/I: PFC, infradiafragmatic TAPVC Side effects: Apnea
Correction of metabolic derangements
Correct metabolic acidosis 2 ml/kg bolus, later by ABG report
Correct hypoglycemia 2 ml/kg of 10% dextrose
Correct hypocalcemia 2 ml/kg calicium gluconate over 5 minutes
Improved oxygen delivery
Oxygen content of blood= Hb X %saturation X 13.6 + 0.0031 X PaO2
Start oxygen Blood transfusion if HB <10-13 gm% Iron supplementation
PDA in premature babies
Prophylactic indomethacin or ibuprofen in <1500 gms and < 34 weeks
Fluid restriction Diuretics: lasix Therapeutic:
Indomethacin: 0.2 mg/kg per dose 8 hourly three doses Ibuprofen: 5-10 mg/kg per dose 8 hourly three doses
Summary
Treat metaboloic derangements aggresively
Get echo done whenever in doubt Many of the structural heart disease
is treatable is our setup
Thank You
top related