Congestive Cardiac Failure

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Dr. Kalpana MallaMBBS MD (Pediatrics)

Manipal Teaching Hospital

CCF

• CCF – inability of the heart to maintain an output at rest or during distress, necessary for the metabolic needs of the body (systolic failure) and inability to receive blood into the ventricular cavities at low pressure during diastole (diastolic failure)

Causes - Infants- Volume overload (L→ R shunt - VSD, PDA)- Pressure overload (Co-A, Pulm Stenosis, Aortic Stenosis- Myocardial diseases (Endocardial fibroelastosis,

cardiomyo- Viral Myocarditis - Paroxysmal tachycardia - Anemia-Miscellaneous – infection - Upper respiratory obstruction - Hypoglycemia, hypocalcemia - Neonatal asphyxia - Persistant fetal circulation

Causes - CCFChildren –• Acute rheumatic carditis and rh heart ds• Congenital heart ds complpicated by anemia,

infection or endocarditis• Hypertension• Viral Myocarditis & primary myocardial ds• Upper resp obstruction• Arrhythmias• Cardiomyopathy

Clinical features

• Symptoms 1.Poor wt gain FTT- small feeds due to easy

fatigability Excess loss of calories due to increased work of

breathing with CCF2. Unusual wt gain due to edema3. Shortness of breath4.Fatigue from feeding – poor sucking

Clinical features

• Irritable,persistent crying –hunger, orthopnia • Sweating• Wheezing Cardinal features of CCF in children1.Tachycardia2. Tachypnea3.Hepatomegaly4.Cardiomegaly

Examination

• Facial puffyness, edema• Tachypnea ,wheeze, chest indrawing• Tachycardia • Raised JVP- difficult to assess• Cardiomegaly –shifted apex• Gallop rhythm• Hepatomegaly

Investigations

• X-ray chest –cardiomegaly ,fluffy peripheral pulmonary markings due to venous congestion and pulmonary edema

• ECG helps to find the cause-hypertrophy ,arrhythmia

• Echo- for cause• Blood count• ABG

Management

• Reduce cardiac work• Augment myocardial contractility• Improve cardiac performance by reducing

heart size• Correct the underlying cause

Reduce cardiac work

1. Restrict activities, position – propped up – pooling of edema in dependant areas which reduces the fluids in lungs – reduce work

2. Oxygen – improves impaired oxygenation secondary to lung congesion so reduce work

3. Sedatives- decreases restlessness & dyspnea. morphine .05mg/kg s/c or diazepam

4.Treat fever – circulatory & metabolic needs minimal at normal temp thus reduce work,

Reduce cardiac work

5. Treat – anemia-decreased oxygen carrying capacity imposes stress to heart

6.Treat infection• Vasodilators – • Reduce arteriolar and venous vasoconstriction –

reduce work of heart• A. constriction - ↑systemic vascular resistance• Venoconstriction - ↑ venous return- ↑filling pressure- ↑CO

Vasodilators

1.ACE inhibitors – suppress renin angiotensin A system –

- vasodilators + - prevent Na+ & water retention - prevent K+ loss2.Others combinations: hydralazine (arteriole) +

isosorbide nitrate ( Vein)3.Sodium nitroprusside (Atery + vein)

2.Augment myocardial contractility• Digitalis – ionotropic drug• 1st dose – ½ of TDD• 2nd dose – ¼ of TDD after 8 hrs of 1st dose• 3rd dose – ¼ of TDD after 16 hrs of 2nd dose• Maintenance dose – ¼ 0f TDD 12hrly 12hrs

after the 3rd dose

Initial Oral Digitalization dose(IV or IM dose is 2/3 of oral dose

• Loading Maintenance• Premature newborn <1500 gms- 0.02 mg/kg 0.005 mg/kg >1500 gms- 0.04 mg/kg 0.01 /kg• Term NB - 6mo- 0.04 mg/kg 0.01 mg/kg• 6 mo – 2 yrs - 0.06 mg/kg 0.015 mg/kg• 2 yrs – 10yrs - 0.04 mg/kg 0.01 mg/kg• >10 years0.04 mg/kg 0.01 mg/kg

Types of digitalization

1.Rapid digitalization – given IV within 24 hrs in acute CCF, critically ill .Maintenance dose given orally

2.Routine schedule – given orally within 24 hrs, not critically ill

3.Slow digitalization – out patient basis ,with chronic CCF. full digitalization is achieved in 7-10 days-1/4th of TDD 12hrly without prior loading dose

3. Improve cardiac performance by reducing heart size

• Digitalis • Diuretics – reduce blood volume, venous

return and ventricular filling- reduce heart size• Salt restriction – reduce volume

• 4. correct the underlying cause

Stepwise Mx CCFStep 1- diureticsStep -2 –add digoxin Step 3- add ACE-inhibitorsStep 4 – add isosorbide nitrateStep 5 – intermittent dopamine + dobutamineStep 6 – myocardial biopsy + add steroids (myocarditis +) or beta blockers (no myocarditis -)Step 7 – cardiac transplantationStep 5,6 ,7- mainly for dilated cardiomyopathies

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