Date post: | 14-Dec-2015 |
Category: |
Documents |
Upload: | braydon-ballam |
View: | 220 times |
Download: | 3 times |
Congenital Heart Disease in Congenital Heart Disease in NeonatesNeonates
EGM Hoosen
Paediatric Cardiology
Inkosi Albert Luthuli Central Hospital
How common is cardiac How common is cardiac disease in children?disease in children?
Congenital Heart Disease: 8/1000
3/1000 : cardiac disease needing intervention in the first year.
UK study UK study
More than half of babies with undiagnosed congenital heart disease which comes to light in infancy are missed by routine neonatal examination and more than one third by the 6 week examination
– Wren et al
A normal neonatal examination does not guarantee that the baby is normal and certainly does not exclude life threatening cardiovascular malformation
A persistent murmur or any other sign of congenital heart disease should warrant prompt paediatric cardiac evaluation
Antenatal diagnosisAntenatal diagnosis
– 20weeks gestation– detection rate
average: 23% range: 3 – 68%
– advantage– early detection
– delivery in high risk unit
Consequences of late/missed Consequences of late/missed diagnosisdiagnosis
Mortality
Ischemic brain injury
Multiorgan failure
Higher postoperative morbidity
Case 1Case 1
Day 7 term neonate
–severe cyanosis – Respiratory Distress
– Was discharged one day after a normal delivery – Became suddenly ill and rushed to hospital
Clinical findingsClinical findings
?Respiratory Disease– Clinical examination– CXR– Oxygen administration - – Blood gas: pH 7.18 PO2 :4kPa PCO2: 3.5kPa
BE :-16
ManagementManagement
Discusssed urgently – ?cyanotic congenital heart disease
Stabilised :– acidosis corrected– Temperature – Glucose– Commenced on prostaglandins– Iv fluids– Monitored for apneoa
Why cyanotic congenital heart Why cyanotic congenital heart disease is disease is oftenoften missed at birth missed at birth1. Cyanosis is not always apparent or always
treated seriously immediately after birth.2. Cyanosis, particularly peripheral cyanosis, is
common in newborns.3. Cyanosis that worsens on crying must be
investigated further.
4. Newborns with cyanotic congenital heart disease often look completely well initially-until the duct begins to close
Congenital heart disease Congenital heart disease presenting with cyanosis at or presenting with cyanosis at or
soon after birthsoon after birthPulmonary atresia/VSD (1:3500 live births)Transposition of Great vessels (1:3500)Pulmonary atresia /Intact ventricular septumCritical pulmonary stenosis
Prostaglandin administrationProstaglandin administration
Maintain a patent ductus arteriosusIntravenous infusion – Prostaglandin
E1(alprostadil)Oral prostaglandins: Prostaglandin E2 Side effects:
– Apneoa– Fever– Gastrointestinal etc
Management of pulmonary Management of pulmonary atresiaatresia
Careful assessment by cardiologist
Neonatal surgery – Blalock Taussig shunt
Case 2Case 2
D6 neonate: – Shock– Cardiomegaly with gallop rhythm– Severe metabolic acidosis with respiratory distress
– Normal at birth – kept in hospital as mum unwell.– Murmur noted soon after birth– thought to be VSD –
elective appointment.
ManagementManagement
InotropesAntibiotics Prostaglandin administration Acidosis correctedGlucose 1.6mmols initially – correctedReferred for cardiac evaluation
Congenital heart disease Congenital heart disease presenting with shock in the presenting with shock in the
neonateneonate Coarctation Interrupted aortic arch Critical aortic stenosis Hypoplastic left heart
syndrome
Congenital heart disease must be excluded in all neonates presenting with shock or cardiac failure
Careful comparison of upper and lower limb pulses essential in all neonates – repeat if neonate becomes ill later
Early maintenance of ductal patency can be lifesaving.
Most common differential Most common differential diagnoses of critically ill diagnoses of critically ill
neonates with congenital heart neonates with congenital heart diseasedisease
Septic shockPersistent pulmonary Hypertension of the
NewbornRespiratory disease
Pulse oxymetryPulse oxymetry
Proper use of equipment
Saturations persistently less than 96%
Differential saturations
Neonates and infants with central cyanosis or cardiac failure are an emergency – irrespective of their clinical state.
Important clinical cluesImportant clinical clues
Persistent unexplained central cyanosis or desaturation –even if mild initially.
Desaturation or cyanosis that does not improve with oxygen or ventilation
A significant persistent difference in upper and lower limb saturations
Important clinical cluesImportant clinical clues
Signs suggestive of cardiac failure– Unexplained respiratory distress– Hepatomegaly– Cardiomegaly– Poor perfusion and metabolic acidosis
Prominent or visible epigastric pulsations
Weak or absent pulses in the lower limbs Persistent murmur
small team examining predischarge + structured referral pathway – 90% detection
does not matter whether physician or registered nurse
experienced team structured referralstructured referral
Arch Dis Child Fetal Neonatal 2006;91:F263-7
Successful Outcome depends Successful Outcome depends on: on:
Obstetrics Neonatology Paediatric cardiology Paediatric Cardiac
Surgeons Anaesthetists Intensive Care
Doctor Nursing staff Technologist Perfusion
Technologists Physiotherapists etc