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Pediatric Cardiovascular Assessment
Lynn Boyle RN, MSN, CCRN
Statistics
♥ In the US, a child is born with a CHD every 15 minutes.
♥ Nearly one of every 100 babies is born with a CHD.
♥ Congenital heart defects are the #1 cause of birth defect related deaths.
♥ Congenital heart defects are the leading cause of all infant deaths in the United States.
Statistics
♥ Each year approximately 40,000 babies are born in the United States with a congenital heart defect.
♥ Thousands of them will not reach their first birthday and thousands more die before they reach adulthood.
♥ However, with recent changes in both medical and surgical management outcomes have improved dramatically.
Think Congenital Heart Defect When…..
♥ Murmur and cyanosis♥ Cyanosis without respiratory
distress♥ Crying worsens cyanosis♥ Abnormal weight loss, poor
feeding with tachypnea♥ Discordant upper/lower pulses♥ Infants appear septic♥ Diagnosed with a syndrome
When thinking about the defects, look carefully at the name...
ATRESIA = missing, not developed STENOSIS = narrowed, stiff, not flexible HYPOPLASTIC = small, not developed SEPTAL = either atrial or ventricular wall which
divides the chambers right & left ANOMALOUS = wrong connection or direction TETRALOGY = four
THE TERMINOLOGY GIVES YOU CLUES...
And more terminology…
♥ Vasoactive → raise or lower HR and BP♥ Vasopressors → typically act to raise BP♥ Inotropic → work through and receptors
to vasodilate, vasoconstrict and / or enhance contractility
♥ Chronotropic → change HR by affecting nerves controlling the heart OR
by changing the rhythm from the SA node
Cardiac Output
♥ Cardiac Output (CO) = HR x SV
volume of blood ejected from the LV / min
♥ Good CO = good tissue perfusion
♥Examples of good cardiac output??
Cardiac Output
♥ Stroke Volume
♥ Heart Rate
♥Influenced by:♥ Preload ♥ Afterload♥ Compliance♥ Contractility
Stroke Volume
♥ Volume of blood ejected from the LV with each contraction / ventricular beat
♥60-75% of ventricular volume
♥Stroke volume = Preload + Contractility + Compliance + Afterload
Summary of Clinical Manifestations
♥ Left Heart Failure- dyspnea
- tachycardia
- S3 sound
- crackles, frothy sputum,
- oliguria
- decreased SaO2, PaO2
- increased PAWP, SVR
- decreased CO
♥ Right Heart Failure- jugular venous distension
- hepatojugular reflux
- dependant pitting edema
- hepatomegaly
- anorexia, nausea
- weight gain
- increased CVP
- increased PVR
Treatment of Heart Failure
Goals of treatment include:♥ Maximize cardiac performance♥ Decrease myocardial oxygen demand♥ Improve cardiac contractility ♥ Optimize preload♥ Decrease afterload
It all starts here……
Fetal Heart Development
Fetal Circulation
♥ Heart development @ 4-7 weeks
♥ Fetus tolerates sats due to cardiac output
♥ PVR high in fetus, and starts to fall after the 1st week of life
(www.chop.edu/consumer/your_child/condition_section_index.jsp?id=-9306&printable=1)
Fetal Circulation: Shunts Foramen Ovale
Opening in the mid-atrial wall
Fetus: right to left shunt
Neonate: left to right shunt
Functional closure versus anatomic closure
www.clevelandclinic.org
Fetal Circulation: Ductus Arteriosus
http://www.nhlbi.nih.gov/health/dci/Diseases/pda/pda_what.html
A word about shunting...
© Left to right♥ Oxygenated blood
from systemic side flows to pulmonic side
♥ body receives oxygenated blood
♥ RedBlue=Pink
♥ Acyanotic
Right to left♥ Deoxygenated
blood from the pulmonic side flows to the systemic side
♥ body receives deoxygenated blood
♥ BlueRed=Blue
♥Cyanotic
Another word about shunting…vascular resistance to flow
♥ PVR: Pulmonary Vascular Resistance♥ Increased= vasoconstriction/decreased flow♥ Decreased = vasodilation/increased flow
♥ SVR: Systemic Vascular Resistance♥ Increased = vasoconstriction/decreased flow♥ Decreased = vasodilation/increased flow
Why is this important?
Why is this important?
♥ In addition to the adjusting newborn’s transitional circulation….♥ PVR falls and SVR increases, closing the functional
shunts…..
♥ What we, as NURSES, do at the bedside, both to and for the patient, will affect the pattern of both systemic and pulmonary blood flow.
Why is this important?Nursing Considerations
What do we do at the bedside that affects SVR? Medications-vasoactive infusions Pain control Temperature Regulation
♥ What do we do at the bedside that affects PVR?♥ Suction♥ Hyperventilate/hyperoxygenate♥ Pain control♥ Acidosis
Why is this important?♥ Oxygen is a vasodilator♥ CO2 is a potent pulmonary vasoconstrictor
These are key points to remember when attempting to control where the blood will “want” to go.
Always keep the PATH of LEAST
RESISTANCE in mind.
How we care for our patients WILL
dramatically affect their hemodynamics.
Classification of CHD
♥ Increased Pulmonary Blood Flow♥ Decreased Systemic Blood Flow♥ Decreased Pulmonary Blood Flow♥ Mixed Lesions
Classification of CHD
Obstruction to systemic blood flow Coarctation of the Aorta Aortic stenosis Interrupted Aortic Arch
Acyanotic
Obstruction to pulmonary blood flow Tetralogy of Fallot/TOF
Pulmonary stenosis/PS Pulmonary Atresia/PA
Cyanotic
Classification of CHD
Increased pulmonary blood flow VSD ASD PDA CAVC
Acyanotic
♥ Variable
pulmonary blood
flow (Mixed
Lesions)
♥ HLHS
♥ Truncus
Arteriousus
♥ TGA
Cyanotic
Decreased Pulmonary Blood Flow♥ Cyanotic heart disease
♥ Obstruction of blood flow to the lungs♥ Embryonic developmental failure: stenosis or atresia of
pulmonary valve and/or artery
♥ Degree of cyanosis♥ Dependent upon the degree of shunting or obstruction
♥ Development of long term problems:♥ Polycythemia, clotting abnormalities, pulmonary
vascular disease♥ High risk for CVA/stroke
♥ Supportive therapy: PGE1 (Prostaglandins)
♥ Surgical interventions: Palliation or correction
Prostaglandins♥ PGE1, Prostin VR, Alprostadil
♥ Maintains the patency of the ductus arteriosus♥ Infusions: 0.01 - 0.4 mcg/kg/min♥ Reduce rate when desired effect achieved♥ Side Effects:
• flushing• bradycardia • tachycardia• hypotension • fever
• APNEA-greatest risk in the first four hours
Decreased PBF: TOF• 1. PULMONARY
STENOSIS/RIGHT VENTRICULAR OUTFLOW TRACT (RVOT) OBSTRUCTION (RVOTO)
• 2. RIGHT VENTRICULAR HYPERTROPHY (RVH)
• 3. AORTA “OVERRIDES” or “sits over” the VSD (ventricular septal defect)
• 4. VENTRICULAR SEPTAL DEFECT (VSD)
(http://cincinnatichildrens.org)
Decreased PBF: TOFWhen pulmonary vascular resistance(PVR) is
high: right to left shunt across the VSD
When systemic vascular resistance (SVR) is high: left to right shunt across the VSD
Mild to severe cyanosis depends upon the degree of infundibular stenosis (the area under the pulmonary valve)
Boot shaped heart on CXR
“Tet Spell” “Hypercyanotic Spell” “Hypoxic Spell”
Treatments Knee-chest position
( SVR)♥ MSO4
( agitation)♥ NaHCO3
(correct acidosis)♥ Oxygen
( pulmonary vasodilator)
♥Phenylephrine ( SVR)
(http://www.nlm.nih.gov/medlineplus/ency/imagepages/18134.html)
Palliative B-T (Blalock-Taussig) Shunt
♥ Right or left subclavian artery to the pulmonary artery
♥Modified= use of
artificial material for a graft/conduit
http://www.americanheart.org/images/ImagePicker/13032-inter-full.jpg
Surgical Repair: TOF(www.cincinnatichildrens.org)
5. The muscular right ventricular outflow tract obstruction
is cut away (resected). 6. The VSD has been closed with a
patch. 7. A look from the outside of the patch repair to the pulmonary artery to enlarge the outflow tract.
What about these patients?♥Bambi, 5 year old, arrives to the ED with a
complaint of constant headaches, mild facial edema. BP of the upper extremities are 30mmHg higher than the lower and femoral pulses are hard to palpate…
♥ Harry is a 12 year old who collapses suddenly when playing soccer…
Obstruction to Systemic Blood Flow
Signs and symptoms of low cardiac output:• decreased perfusion to the gut (may lead to future
complication of necrotizing enterocolitis)• shock (critical aortic stenosis)• myocardial dysfunction
Elevated LA, RA pressures; CHF, pulmonary edema
Left ventricle failure overtime due to stress of pumping against high resistance
Defect may be ductal dependent
Obstruction to blood flow: Coarctation of the Aorta
Narrowing of Aorta Pressure to head,
pressure to body Bounding upper pulses,
lower pulses Systolic difference
between UE and LE ~ 15-30mm Hg
Hypotension and acidosis May need PGE1 pre-op Post-op considerations
http://pediatriccardiology.uchicago.edu.
Obstruction to blood flow: Aortic Stenosis
♥ Narrowing: above, at, or below aortic valve
♥ May be CRITICAL:– cardiac output-LVOT
obstructed♥ LVH
– Increased LAP – Reflects increased
pulmonary vascular congestion
– coronary artery perfusion myocardial infarction
Here is another….
♥ A 3 year old child presents to the ED with a history of increased respiratory infections, increasing fatigue with play with a tendency to sweat “buckets”, difficulty gaining weight despite frequent meals.
♥ The child is tachycardic and has a respiratory rate of 50. A CXR shows increased vascular markings and a large cardiac silhouette.
Increased Pulmonary Blood Flow
Left to right blood flow pattern (shunting)What color will the child be?
May lead to congestive heart failure: alteration in oxygenation tachypnea, tachycardia diaphoretic, periorbital edema
Clinical picture: small thin infant/child with history of feeding issues and pneumonias
Increased Pulmonary Blood Flow
♥ Remember that oxygen INCREASES pulmonary vasodilation and blood flow through the lungs.
♥ What will giving oxygen to your patient do? Think with a NURSING Focus!!
♥ Risk for developing pulmonary hypertension.
Increased PBF: PDA♥ Ductus does not close♥ Preterm infant, acidemia,
hypoxia♥ Blood flows from Ao PA
(left to right)♥ PVR, SVR determine
hemodynamics♥ Increased pulmonary blood
flow and RVH♥ Female:male 2:1
http://www.childrenshospital.org/az/Site507/Images/ei_0350.gif
Increased PBF: ASD♥ L>R shunt♥ blood to RA /RV♥May/may not be
symptomatic♥ Risk:
♥atrial dysrhythmias
♥ stroke/emboli♥pulmonary
HTN, Eisenmenger’s
http://www.childrenshospital.org/az/Site477/Images/normal_large.gif
Increased PBF: VSD
♥ L>R shunting (acyanotic)♥ blood to RV ♥ Over time: can lead to
PHTN and RVH♥ CHF is common, occurs
typically at 2-4 weeks 2o
decreasing PVR♥ Spontaneous closure can
occur if small (muscular type)
http://www.childrenshospital.org/az/Site500/Images/ei_0435.gif
Increased PBF: CAVC/AVC♥ Endocardial cushion defect
• Low ASD• High VSD • Clefts of mitral and
tricuspid valves
♥ Flow determined by:• PVR and SVR,
chamber compliance, ventricular pressures, symmetry of the ventricles
♥ Highly associated w/Down Syndrome-40-60%
What do you think of this child?
♥ Within 24 hours after birth, the baby looked “shocky” and deeply cyanotic.
♥ Heidi is a 20 day old infant brought to the ED in respiratory distress, grunting, flaring, hypotensive, bradycardic.
Variable PBF: TGA
www.driscollchildrens.org
Transposition of the Great Arteries (TGA)
♥Blood flows in parallel circulation
♥The Aorta arises from the Right Ventricle
♥The Pulmonary Artery arises from the Left Ventricle
♥Child presents with profound cyanosis
TGA
♥Without one/both of the fetal structures (PDA and PFO), the child will die within minutes of birth
♥Emergency procedure in the cath lab or even at the bedside to restore mixing of blood
Jantene ProcedureArterial Switch Procedure
♥The vessels are surgically moved and re-anastomosed to the correct ventricle as early as possible.♥ If not done early, ventricles
will fail to pump correctly
♥Linked to mothers w/ IDDM
Variable PBF: HLHS
♥ Descending Ao PDA dependent
♥ Flow to systemic and pulmonary circulation are dependent on PVR and SVR
http://www.childrenshospital.org/az/Site502/Images/ei_0248.jpg
Variable PBF: HLHS
♥ Norwood Procedure (Stage I):• anastomosis of
the main pulmonary artery to the aorta to create a “neo-aorta”
• BT shunt• ASD
http://www.cincinnatichildrens.org/health/heart-encyclopedia/anomalies/hlhs.htm
Stage 2: Hemi-Fontan
Bi-directional Glen or Hemi-Fontan
Goal is to maintain the flow of deoxygenated blood to the lungs by attaching the superior vena cava directly onto the pulmonary artery
http://www.chc-pa.org/PrinterFriendly.cfm?PID=1078
Fontan Procedure
♥ Attach the IVC to the RA and PA.
♥ All returning deoxygenated blood directed straight to the lungs.
♥ Will cause an increase in pressure in the lung vessels
♥ Small fenestration or hole will be created in the baffle in the atrium
♥ Fenestration acts as “pop off” valve
http://www.chc-pa.org/Patient_Info.cfm?ID=1079
A word about single ventricle physiology after the Fontan...
♥ Remember that one functional ventricle pumps to the systemic circulation.
♥ The ventricle may become overloaded.♥ Pulmonary blood flow is passive, non-pulsatile
directly from the SVC and IVC to the lungs.♥ If the PA pressure is normal, the systemic venous
pressure should allow for forward flow by exceeding pulmonary artery resistance.
Goal is to find the balance between adequate oxygenation & systemic perfusion
Post-operative Care/Management
Post-operative Care/Management
♥ Bleeding♥ Arrhythmia/Pacing♥ Heart failure/poor
function♥ Hypoxemia♥ Pleural Effusions♥ Pneumonia♥ Temperature instability
♥ Acid-base balance♥ Fluid/electrolyte
management♥ Renal Complications♥ Neurologic
Complications♥ Infection♥ Pharmacologic Support
Post-operative Care/Management♥ Bleeding♥ Arrhythmia♥ Heart failure/poor
function♥ Hypoxemia♥ Fluid management♥ Neurologic
Complications♥ Pharmacologic Support
♥ Diuretics, heparin♥ WHY??
♥ Why are these considerations so important??
Why are these considerations so important??
♥ Cyanotic CHD♥ Increased Hgb/Hct (Polycythemia) due to chronic
hypoxemia♥ Increased blood viscosity♥ Diuretics—>decrease amount of extra
fluidfurther increase viscosity.♥ High risk of CVA/Stoke♥ Must monitor hydration status carefully!!
♥ Cannot be allowed to become too dehydrated
♥ Similar considerations for CHF patients
Genetics, Syndromes, and CHD
♥ Down Syndrome♥ Trisomy 18♥ Trisomy 13♥ Marfan’s Syndrome♥ Turner’s Syndrome♥ Noonan’s Syndrome
♥ CHARGE Syndrome♥ 22q Deletion Syndrome♥ Duchenne muscular
dystrophy♥ Velo-Cardio-Facial
Syndrome (VCFS)
Acquired Heart Disease
♥ Kawasaki Disease♥ Rheumatic Heart Disease♥ Myocarditis♥ Cardiomyopathy
Kawasaki Disease
♥ A leading causes of acquired heart disease in children in the US
♥ Etiology unknown ♥ Incidence: 80% are children ages 1-5yrs♥ Pathophysiology involves acute, diffuse, vasculitis of
the medium size arteries and small vessels of the body → particularly the coronary arteries; potential for coronary artery aneurysm
Diagnosis
♥ No definitive laboratory or diagnostic test♥ Diagnosis is based on CDC criteria
♥ Fever >5 days, unresponsive to antibiotics♥ Bilateral conjunctivitis♥ Oral mucosal changes (strawberry tongue♥ Peripheral extremity changes (erythema)♥ Rash♥ Cervical lymphadenopathy
Kawasaki Disease
http://circ.ahajournals.org
Clinical Manifestations and Complications
♥ Aseptic meningitis♥ Increased ESR♥ Leukocytosis♥ Elevated liver enzymes♥ Thrombocytosis
♥ Anemia♥ ECG and
Echocardiography changes
♥ Aneurysm♥ Infarction
Kawasaki Disease
http://circ.ahajournals.org
Management and Treatment
♥ IVIG-IV Gamma Globulin♥Anti-inflammatory agent: reduce inflammation
& decrease incidence of coronary abnormalities♥ Within the first 10 days of symptoms♥ High dose: 2 gm/kg, q 8-12 hours♥ Decreases the acute phase of the illness♥ Hemodynamic monitoring for CHF ♥ Pre-med with Benadryl
Management and Treatment
♥ Aspirin therapy♥ High dose (80-100mg/kg/day) for 2-4 days for
inflammation, fever reduction♥ Anti-platelet doses after fever has been reduced♥ Low dose aspirin during the convalescent phase
♥ Antithrombotic therapy♥ Surgical intervention → if aneurysm is
present
Rheumatic Fever
♥ Rheumatic fever is an inflammatory disease that may develop after an infection with Streptococcus bacteria (such as strep throat or scarlet fever).
♥ The disease can affect the heart, joints, skin, and brain.
Rheumatic Fever
♥ Rheumatic fever primarily affects children ages 6 -15, and occurs approximately 20 days after strep throat or scarlet fever.
♥ Can affect valves within the heart, most often mitral and or aortic valve.
♥ Valves often become stenotic, requiring replacement.
Rheumatic Fever
♥ Dysfunctional valves and often lead to left ventricular dilation and congestive heart failure, sometimes decades later.
♥ Vegetation may develop on damaged valves and become infected leading to endocarditis.
♥ Myocarditis is present but is not the direct cause of heart failure.
Rheumatic Fever
♥ Rheumatic fever is likely to come back in people who don't take low-dose antibiotics continually, especially during the first 3 -5 years after the first episode of the disease.
♥ Cardiac complications may be severe, particularly if the heart valves are involved.
Rheumatic FeverDiagnosis
♥ Polyarthritis♥ Myocarditis♥ Subcutaneous skin
nodules♥ Rapid, jerky
movements (Sydenham chorea)
♥ Skin rash♥ Fever♥ Increased
sedimentation rate♥ Abnormal CBC
Myocarditis
♥ Myocarditis♥ Inflammation of the myocardium♥ Can be viral or bacterial
♥ Attempt to shorten the inflammatory/acute phase in order to prevent permanent damage to muscle
Myocarditis
♥ Variable presentation♥ Fatigue♥ Arrhythmias♥ Fever♥ Dyspnea♥ Exercise Intolerance♥ Decreased urine output♥ Edema
♥Legs, face
Cardiomyopathy
♥ Failure of the heart muscle♥ Several types
♥ Dilated, hypertrophic, restrictive♥ Dilated is most common
♥ dilation and impaired contraction of one or both ventricles
♥ Myocarditis often progresses into Dilated Cardiomyopathy (DCM)
Cardiomyopathy
♥ Variable presentation♥ Fatigue♥ Arrhythmias/Cardiac Arrest/Sudden death♥ Fever♥ Dyspnea♥ Exercise Intolerance♥ Decreased urine output♥ Edema
♥Legs & face
Myocarditis/Cardiomyopathy
♥ Nursing Considerations♥ Promote rest♥ Careful I/O monitoring♥ Monitor of arrhythmias♥ Medication administration/teaching ♥ Assist devices and Transplantation are often the
result of these processes.♥ This requires a tremendous amount of care, education
and support for both the child and the family.
http://www.chop.edu
What is theclinical significancepre or post-op?
A few words about arrhythmias….♥ Assess the patient FIRST
♥ Is the child’s clinical condition compromised by the arrhythmia?
♥ Too Fast/Too Slow♥ Treat the underlying cause, if possible
♥ Hypothermia, hypovolemia, electrolyte imbalances
♥ Cardioversion vs. Defibrillation♥ What’s the difference?♥ When to use and with what rhythm?
♥ Pacemakers♥ Temporary and permanent
Cardiac Catheterization
♥ Diagnostic♥ Provide pressures/data♥ Drug Studies-Pulmonary HTN
♥ Interventional♥ Closure of ASD/VSD♥ Coil embolization of collateral vessels♥ Ablation of aberrant conduction pathways
Cardiac Catheterization
♥ Pre-cath Care-Nursing Considerations♥Allergies-shellfish, dyes, food, medications?♥Teaching
♥Patient and family♥ What to expect (warm, flushed feeling w/dye, flat
time)
♥NPO time?♥Assessments/Documentation
♥ Diaper rash??
♥ Pre-medication/Sedation/Anesthesia♥Conscious sedation vs. intubation
Cardiac Catheterization♥ Post-cath Care
♥ Site check♥ Groin, neck, brachial♥ Bleeding, hematoma♥ Distal circulation
♥ Flat time-4-6 hours♥ How to do this in a child?? ♥ Nursing Considerations
♥ Parental assistance, distraction, medical play, environmental modifications, medications.
Nursing considerations
♥ Patient education/support issues♥ Age appropriate answers to questions♥ Medical play ♥ Prepare child for what they will experience♥ Do not lie or “sugar coat”♥ Offer reasonable choices
♥ “whens” and “wheres” ♥ helps the child to feel in control
Nursing considerations
♥ Parental Support♥ Stressful-may not have comparable coping
strategies♥ Can “make” or “break” relationships
♥ Marriage/relationship issues♥ High divorce rates
♥ Bonding issues♥ include parents in child’s care-ADLs, diapering♥ Family-centered care, family rounds
♥ Social work, chaplain services
Psychosocial/Family Considerations
♥ Stress♥ Chronically ill child♥ “Will my child live?”♥ “Will my child ever be normal?”
♥ High prevalence of learning disabilities, behavior issues
♥ Siblings♥ Long periods of separation from parents/sibling♥ Death and dying questions
♥ Work/financial considerations
Psychosocial/Family Considerations
♥ Nurses play a pivotal role in supporting families.
♥ Social work, child life therapists, PT/OT, educators, physicians, external support groups play a tremendous role in helping these families not only cope but thrive and live full, happy, healthy lives.
A mother’s point of view….
• http://www.youtube.com/watch?v=zB8ySBjX2-U
THANK YOU & GOOD LUCK!