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