management of ccf in pediatric patients

1. (pediatric age group) by
Dr. smilu mohanlal

2.  Thorough history taking and physical
examination
 Regardless of the etiology, the first
manifestation of congestive heart failure is
usually tachycardia. An obvious exception to this
finding occurs in congestive heart failure due to
a primary bradyarrhythmia or complete heart
block,
 As the severity of congestive heart failure
increases, signs of venous congestion usually
ensue. Left-sided heart failure is generally
associated with pulmonary venous congestion,

3.  right-sided heart failure is associated with signs
of systemic venous congestion. Marked failure of
either ventricle, however, can affect the
function of the other, leading to systemic and
pulmonary venous congestion.
signs of congestive heart failure vary with the
age of the child tachypnea, respiratory distress
(retractions), grunting, and difficulty with
feeding. Often, children with congestive heart
failure have diaphoresis during feedings, which is
possibly related to a catecholamine surge that
occurs .

4.  Right-sided venous congestion is characterized
by hepatosplenomegaly and, less frequently, by
edema or ascites. Jugular venous distention is
not a reliable indicator of systemic venous
congestion in infants, because the jugular veins
are difficult to observe.
 Uncompensated congestive heart failure in an
infant primarily manifests as a failure to thrive.
In severe cases, failure to thrive may be
followed by signs of renal and hepatic failure.

5.  left-sided venous congestion causes tachypnea,
respiratory distress, and wheezing (cardiac
asthma).
 Right-sided congestion may result in
hepatosplenomegaly, jugular venous distention,
edema, ascites, and/or pleural effusions.
Older children with uncompensated congestive
heart failure may have fatigue or lower-than-
usual energy levels. Patients may complain of
cool extremities, abdominal pain,
nausea/vomiting, exercise intolerance,
dizziness, or syncope.

7.  CBC
 Renal function tests
 Liver function tests
 brain natriuretic peptide
 12 lead ecg
 pulse oximetry
 Arterial blood gases
 chest x ray
 Echocardiography

9.  The management of congestive heart failure
(CHF) is difficult and sometimes dangerous
without knowledge of the underlying cause.
Consequently, the first priority is acquiring a
good understanding of the etiology. The goals
of medical therapy for congestive heart
failure include the following:

10.  Reducing the preload
 Enhancing cardiac contractility
 Reducing the afterload
 Improving oxygen delivery
 Enhancing nutrition

11.  Preload reduction can be achieved with oral (PO) or
intravenous (IV) diuretics (eg, furosemide, thiazides,
metolazone).
 Venous dilators (eg, nitroglycerin) can be
administered, but their use is less common in
pediatric practice.
 Contractility can be supported with IV agents (eg,
dopamine) or mixed agents (eg, dobutamine,
inamrinone, milrinone).
 Digoxin appears to have some benefit in congestive
heart failure, but the exact mechanism is unclear.
 Afterload reduction is obtained orally through
administration of angiotensin-converting enzyme
(ACE) inhibitors or intravenously through
administration of other agents, such as hydralazine,
nitroprusside, and alprostadil.

12.  Admit the patient
 Basic investigations
 Establish i.v access, start i.v fluids,
antibiotics. Low dose dopamine if decreased
cardiac output.
 Echocardiography to confirm the lesion
 if ductus dependent then start PGE1
 if non structural then cardioversion by
chemical or electrical.

13.  In older children with acute congestive heart
failure, admit to the ICU for diuresis with IV
furosemide. For patients with significant
hypotension, IV dopamine (5-10 mcg/kg/min) or
milrinone (0.3-1 mcg/kg/min) infusion is
appropriate until stabilization is achieved. Older
children may require the placement of a central
venous or pulmonary artery catheter to monitor
venous pressure and cardiac output during
stabilization.

14.  After load reducing agents- ACE inhibitors, ATI
antagonists.
 For more severe congestive heart failure,
diuretic therapy with oral furosemide may be
increased to 2 mg/kg/dose orally 3 times daily or
a second agent, such as hydrochlorothiazide or
metolazone, can be added. To be most effective,
hydrochlorothiazide and metolazone are best
administered simultaneously with furosemide to
achieve their synergistic effect.

15.  Cautious supplementation of sodium and
potassium
 Nutrition to be taken care of
 Correction of anemia.
 Recent modalities: cardiac resynchronisation
therapy, ventricular assist devices.