Transcript My Girls - NCCPeds

HI! I’m Emily
and here to
tell you to
pay
attention...this
is a
really great
talk!!!!!!!!!!
Have you seen
my
brother?…he’s
sooooa
annoying
Congestive Heart Failure in
Children
Thomas R. Burklow, MD
LTC, MC
Asst C., Pediatric Cardiology
Odenwald mountains
Case Presentation
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4 month old presents to ER with cc: “cold sx”
5 day history of increasing cough; afebrile, no rhinorrhea, no ill contacts.
PMH: unremarkable. vigorous feeder (25-30oz/d) until the last couple of
days.
FHx: father had a “leaky valve” but was cleared to join the Marines
Physical Examination
VS: HR 165, RR 60, Nl BPs throughout; RA O2 sat
mid 80’s, increases to 97% on 1/4 L/ O2
 Small for age male, nondysmorphic, mild cyanosis,
moderate increased work of breathing
 Left chest prominent
 Prominent PMI, RRR, S2 obscured by murmur, gr III
pansystolic SRM over apex to left axilla
 Liver edge 4 cm below RCM
 1+ pulses throughout

Electrocardiogram
Chest X ray
Neckargemund
Cause of Congestive Heart Failure
 Excessive
work load: pressure or volume
 Normal workload faced by a damaged
myocardium
Etiologies

Neonate
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
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
dysfunction
volume
pressure
Infant
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
Volume
Dysfunction

Child


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Palliated congenital heart
disease
AV valve regurgitation
Acute rheumatic fever
Myocarditis
Endocarditis
Clinical manifestations

Infant
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feeding difficulties
failure to thrive
diaphoresis
tachycardia
tachypnea

Child

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
breathlessness
tachycardia
tachypnea
peripheral edema
cardiomegaly
Treatment
 Digitalis
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oral: 8-10 mcg/kg/day
I.V.: 80% of oral dose
Because of varying metabolism, appropriate dose varies
by age
Rapid digitalization
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
May be performed over 12-24 hours, 6-12 hours in dire situations
Calculate TDD (varies by age); administer 1/2 of TDD, followed by
1/4, then 1/4 of TDD
 Case
example: patient weight is 5.5 kg
Effiel Tower at Dusk
Case example
5.5 kg in a 4 month old
 Oral TDD for 1 month-2 years is 30-50 mcg/kg
 TDD is 220 mcg


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
Administer 110 mcg now, then 55 mcg in 12 hours, then 55 mcg in 6
hours
IV dose is 80% of the above amounts
Maintenance digoxin is approximately 1/4 of TDD,
divided b.i.d., or at 50 mcg/cc, 0.1 cc/kg per dose b.i.d.
Digoxin toxicity
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Levels are helpful only in cases of suspected toxicity, not for
management
GI symptoms are common presenting symptoms: nausea,
vomiting, anorexia
Most common sign of cardiac toxicity is arrhythmia:
bradycardia, AV block, PVCs
Treatment includes holding doses for 1-2 half lives, atropine for
sinus bradycardia, and “FAB” fragments in cases of significant
toxicity
Nutrition
 What
are maintenance calories for a normal
infant?
 What is the metabolic state of an infant in
congestive heart failure?
 What are the caloric requirements for an infant
in congestive heart failure?
Other medications
 Diuretics
 Furosemide (Lasix); 0.5-1.0 mg/kg/dose
 Chlorothiazide (Diuril); 20-50 mg/kg/day
 Spironolactone (Aldactone); 1-2 mg/kg/day
 Afterload reduction
 Captopril (Capoten); 0.1-0.5 mg/kg/dose t.i.d.
 Enalapril (Vasotec); 0.1 mg/kg/day
 Beta-blocker
 Labetolol
Wasn’t my dad great!?!?