Cardiovascular Pedeatric Nursing

The Child with a Cardiovascular Disorder

Nursing 352 Khulood Shattnawi

History Taking • Must be careful. Some of the symptoms are very subtle. • Some symptoms do not show up right after birth • Typical presentations of infants are tachycardia, tachypnea, and poor feeding • Older children may present with fatigue and frequent lower respiratory infections. Some children may perspire excessively • Edema is a late sign and usually presents first as periorbital edema. • Cyanosis • May complain of decreased UOP • May have headaches, nose bleeds, high blood pressure in upper extremities 3/31/2008

K.Shattnawi

٢

History Continued • Obtain a detailed prenatal history including exposure to infections (cytomegalovirus, toxoplamosis, rubella or varicella), medication usage, drug and alcohol use, nutrition, exposure to radiation • Determine if there is any family history of congenital heart defects or heart disease.

3/31/2008

K.Shattnawi

٣

Physical Assessment • Compare height and weight to standard growth chart • Assess: capillary refill presence of clubbing ruddy complexion vital signs Lethargy rapid respirations tachycardia abnormal body posture cyanosis presence of a murmur

3/31/2008

K.Shattnawi

٤

Innocent murmur • An innocent or functional heart murmur is a murmur not resulting from heart disease. This is the most common type of heart murmur. It is heard because the child may have fever, anemia, or a thin chest. It disappears when the fever subsides or when the anemia is treated. 3/31/2008

K.Shattnawi

٥

Organic murmur • A murmur, which indicates there is something abnormal in the heart or a major artery is, called a not-innocent, notfunctional, or organic murmur. A narrow valve, a leaking valve, or a hole in the heart, usually causes it.

3/31/2008

K.Shattnawi

٦

– With all murmurs, document position in cardiac cycle, duration, quality, pitch, intensity, location, whether there is a thrill and whether the murmur changes with position change – Organic murmurs are either systolic or diastolic, long, harsh or blowing, loud, constant and heard not matter what position the child is in 3/31/2008

K.Shattnawi

٧

• Common nursing diagnoses: – Decreased cardiac output related to congenital structural defect – Altered tissue perfusion related to inadequate cardiac output – Knowledge deficit related to care of the child preand postoperatively – Fear related to lack of knowledge about child’s disease – Altered family processes related to stresses of the diagnosis and care responsibilities – Ineffective individual or family coping related to lack of adequate support – Altered parenting related to inability to bond with critically ill newborn 3/31/2008

K.Shattnawi

٨

Diagnostic Tests • ECG - indicates HR, rhythm, presence or absence of hypertrophy, ischemia or necrosis, abnormalities in the conduction system, presence of electrolyte imbalances • Chest x-ray - shows heart size and shape, presence of CHF, prominence of pulmonary blood flow • Fluoroscopy can be used to visualize the chambers of the heart, the great vessels, lungs, thoracic cage and diaphragm. Sometimes radioactive dye in injected. Sometimes contrast dye in used in conjunction with a cardiac cath

3/31/2008

K.Shattnawi

٩

Diagnostic Tests Cont’d • Echocardiogram - primary diagnostic test. Looks at the movement and dimensions of the cardiac structures using high-frequency sound waves • Phonocardiogram - heart sounds are recorded and displayed as a diagram • MRI - used to evaluate heart structure, size or blood flow • Treadmill - studies response to exercise • Lab tests - Hgb and Hct (polycythemia), ESR (rheumatic fever, myocarditis), ABG (presence of a right to left shunt), O2 Sat, clotting times (PT, PTT) and platelet count, Na, K, dig level 3/31/2008

K.Shattnawi

١٠

Cardiac Catheterization • Can be either diagnostic or interventional – – – – –

Pressures in the heart can be measured CO can be evaluated Blood samples can be obtained and tested (O2 sat) Electrical activity can be studied Contrast can be injected to study blood flow, vessels and chambers – Balloon angioplasty can be performed to stretch stenosed areas or blockages in vessels

3/31/2008

K.Shattnawi

١١

• Pre-procedure - Patient teaching – How the test will be done – what to expect during the test, – that afterward the child will have to lie flat and will have a bulky dressing over the catheter insertion site

3/31/2008

K.Shattnawi

١٢

Cardiac Catheterization Cont’d • Post-Procedure – Will have to lie flat 3-4 hours – VS every 15 minutes for the first several hours – Check site every 15 minutes for integrity of dressing, hematoma, redness, swelling – Check pulses distal to site. Also check extremity for capillary refill and warmth – Avoid dehydration – Avoid hypothermia – Check site daily for signs of infection – Avoid tub baths and strenuous exercise for 2-3 days

3/31/2008

K.Shattnawi

١٣

Congenital Heart Disease • Occurs in about 8% of term newborns. Higher in preterm infants. Can be as high as 10-15% in infants who have a parent with aortic stenosis, ASD, VSD, or pulmonic stenosis • Females - more prone to have PDA and ASD • Males - more prone to have valvular aortic stenosis, coarctation of the aorta, TOF and transposition of the great vessels • The usual cause is failure of the heart to develop beyond an early stage of embryonic development • Maternal rubella is associated with PDA, stenosis, ASD, VSD 3/31/2008

K.Shattnawi

١٤

Congenital Heart Disease • Classification – Acyanotic vs. Cyanotic • Left-to-right shunt - oxygenated to unoxygenated blood • Right-to-left shunt - deoxygenated blood to oxygenated blood

– Hemodynamic and Blood Flow Patterns - allows more predictable signs and symptoms • • • • 3/31/2008

Increased pulmonary flow Obstruction to blood flow (out of the heart) Decreased pulmonary flow Mixed blood flow (oxygenated and deoxygenated blood mixing in the heart or great vessels) K.Shattnawi

١٥

Acyanotic

Cyanotic

(left-to-right shunt)

(right-to-left shunt)

(2) Obstruction to blood flow from ventricles

(3) Decreased pulmonary blood flow

Atrial septal defect.

Coarctation of aorta.

Tetralogy of fallot.

Transposition of great arteries.

Ventricular septal defect.

Aortic stenosis.

Tricuspid atresia.

Total anomalous pulmonary venus return.

Patent ductus arteriosus.

Pulmonic stenosis.

(1) Increased pulmonary blood flow

Truncus arteriosus.

Atrioventricular canal. 3/31/2008

(4) Mixed blood flow

Hypoplastic left heart syndrome. K.Shattnawi

١٦

3/31/2008

K.Shattnawi

١٧

3/31/2008

K.Shattnawi

١٨

3/31/2008

K.Shattnawi

١٩

Defects with Increased Pulmonary Blood Flow • Blood flows from the left side of the heart to the right side of the heart through an abnormal opening or connection between the system or great arteries – Ventricular Septal Defect (VSD) – Atrial Septal Defect (ASD) – Atrioventricular canal defect (AVC) – Patent Ductus Arteriosis (PDA)

3/31/2008

K.Shattnawi

٢٠

Ventricular Septal Defect • VSD - most common, 25% of all defects, 2 in every 1000 live births – opening in the septum between the two ventricles – results in right ventricular hypertrophy and increased pressure on the pulmonary artery

3/31/2008

K.Shattnawi

٢١

3/31/2008

K.Shattnawi

٢٢

VSD Cont’d – VSD May be classified according to location: • membranous VSD - an opening in the upper section of the ventricular septum, near the valves, occurs in 75- 80 % of all VSD cases. • muscular VSD - an opening in the lower section of the ventricular septum occurs in up to 20 percent of all VSD cases.

– May not be evident at birth because high pulmonary resistance from incomplete opening of alveoli keeps the blood from coming across to the right ventricle 3/31/2008

K.Shattnawi

٢٣

3/31/2008

K.Shattnawi

٢٤

– S&S (by age 4 to 8 weeks) - develops a loud, harsh, systolic murmur along the left sternal border 3rd or 4th ICS, widely transmitted, usually with a thrill – Respiratory manifestations – RV hypertrophy may also be seen on ECG

3/31/2008

K.Shattnawi

٢٥

Symptoms • • • • • • • • •

Shortness of breath Fast breathing Hard breathing Paleness Failure to gain weight Fast heart rate Pounding heart Sweating while feeding Frequent respiratory infections

3/31/2008

K.Shattnawi

٢٦

Treatment – 60% close spontaneously - otherwise at risk of infectious endocarditis and cardiac failure – May require a Silastic or Dacron patch to close opening if edges can’t be approximated and sutured

3/31/2008

K.Shattnawi

٢٧

Atrial Septal Defect (ASD) •

•

Abnormal opening between the two atria – ASD1 (ostium primum) – 5% defect is at the lower end of the septum – ASD2 (ostium secondum) – 90% defect is near the center of the septum and may be asymptomatic – Sinus venosus defect: 5 % of ASDs, opening high in the atrial septum, near junction of superior vena cava and right atrium. Harsh systolic murmur over 2nd or 3rd ICS, fixed splitting of S2

3/31/2008

K.Shattnawi

٢٨

3/31/2008

K.Shattnawi

٢٩

3/31/2008

K.Shattnawi

٣٠

Symptoms • Echo will show enlarged right side and increased pulmonary circulation • At risk for infectious endocarditis and heart failure • Frequent respiratory infections in children • Difficulty breathing (dyspnea) • Shortness of breath with activity • palpitations in adults 3/31/2008

K.Shattnawi

٣١

Treatment • May require a patch if defect not able to be closed • May have arrhythmias post-op

3/31/2008

K.Shattnawi

٣٢

Atrioventricular Canal (AVC) Defect • An incomplete fusion of the endocardial cushion. May be seen as a low ASD continuous with a high VSD. Mitral and tricuspid valves are usually distorted. Seen in 1 out of 9 children with Down syndrome • Blood flow is usually left to right, but may flow between all four chambers • Requires surgical repair and possible double valve replacement 3/31/2008

K.Shattnawi

٣٣

3/31/2008

K.Shattnawi

٣٤

3/31/2008

K.Shattnawi

٣٥

Symptoms • Symptoms: heart failure, characteristic murmur, mild cyanosis that increase with crying • fatigue • sweating • pale skin • cool skin • rapid breathing • heavy breathing • rapid heart rate • congested breathing • disinterest in feeding, or tiring while feeding • poor weight gain 3/31/2008

K.Shattnawi

٣٦

Patent Ductus Arteriosus (PDA) • The ductus arteriosus between the pulmonary artery and the aorta fails to close at birth • May not close until 3 months causing blood to be shunted from the aorta to the pulmonary artery • Usually hear a continuous (systolic and diastolic) murmur at the upper left sternal border or under the clavicle of older children • ECG is usually normal, may show ventricular enlargement if the shunt is large 3/31/2008

K.Shattnawi

٣٧

3/31/2008

K.Shattnawi

٣٨

While some cases of PDA are symptomatic, common symptoms include: • tachycardia or other arrhythmia • respiratory problems • shortness of breath • continuous machine-like murmur • enlarged heart 3/31/2008

K.Shattnawi

٣٩

PDA Cont’d • May be given indomethacin or a prostaglandin inhibitor to lower plasma prostaglandin E1 (PGE1) levels and stimulate closure. Drug may be repeated as many as three times 12 to 24 hours apart • If medical management fails – ligation of defect – visual assisted thoracoscopy (VAT) - a clip is placed on the ductus • If not surgery, child is a risk for heart failure related to the increased shunting, infectious endocarditis from recirculating blood and potential stasis in the PA 3/31/2008

K.Shattnawi

٤٠

Obstructive Defects • Narrowing of a vessel or valve. Results in high pressure before the obstruction and lower after the obstruction. Prevents sufficient blood supply from reaching its intended site – Coarctation of the aorta – Aortic stenosis – Pulmonic stenosis

3/31/2008

K.Shattnawi

٤١

Coarctation of the Aorta • A constrictive band causes narrowing of the aorta either between the subclavian vein and the ductus arteriosus (infantile or preductal) or distal to the ductus arteriosus (postductal) • Since BP is greatest in the subclavian vein, you will see higher pressures in the upper extremities (at least 20 mmHg) than in the lower extremities. The increased BP can cause headaches or nosebleeds. Can even cause a CVA (arteries in the head and arms may become weakened by high pressure. Spontaneous tears in any of these arteries can occur) 3/31/2008

K.Shattnawi

٤٢

3/31/2008

K.Shattnawi

٤٣

Coarctation of the Aorta Cont’d • May only have a decreased femoral pulse. As child grows older. Veins may become visible on the chest. Child may complain of leg pain on exertion. • The left ventricle has to work harder to try to move blood through the narrowing in the aorta.

3/31/2008

K.Shattnawi

٤٤

Symptoms • • • • • • • • • • •

Dizziness or fainting Shortness of breath Pounding headache Chest pain Cold feet or legs Nosebleed Leg cramps with exercise Hypertension (high blood pressure) with exercise Decreased ability to exercise Failure to thrive Poor growth

3/31/2008

K.Shattnawi

٤٥

Coarctation of the Aorta Cont’d

• Repaired either with balloon angioplasty or surgical removal of the narrowed portion. Usually scheduled around age 2. • May have abdominal discomfort for a while post-op related to increased blood flow to lower part of the body. • Will usually still have an elevated BP for a while. 3/31/2008

K.Shattnawi

٤٦

Aortic Stenosis (AS) • Prevents blood from flowing freely from the LV to the aorta • Can lead to hypertrophy of the left ventricle and heart failure and pulmonary edema • Accounts for 5% of congenital abnormalities • Types of AS: – Valvular stenosis, the most common type, is usually caused by malformed cusps resulting in a bicuspid rather than tricuspid valve or fusion of the cusps. – Subvalvular stenosis, is a stricture caused by a fibrous ring below a normal valve. – Supravalvular stenosis, occurs infrequently.

3/31/2008

K.Shattnawi

٤٧

3/31/2008

K.Shattnawi

٤٨

• The child is usually asymptomatic. – Will usually hear a rough systolic murmur at 2nd ICS right sternal border. – May see signs of decreased CO • faint pulses, hypotension, tachycardia, poor feeding.

– Child may develop chest pain with activity. – Sudden death can occur when O2 demand far exceeds supply – Children born with aortic stenosis may show symptoms of shock, poor feeding, failure to thrive, and shortness of breath

• ECG may show left ventricular hypertrophy. Cath can show degree of stenosis • Treated with balloon angioplasty or surgical repair to divide the stenotic valve or dilate a constrictive aortic ring 3/31/2008

K.Shattnawi

٤٩

Pulmonic Stenosis • Pulmonic Stenosis - 25% to 35% of anomalies – May be asymptomatic or have mild heart failure – Usually systolic murmur with a thrill. Heard loudest at the upper left sternal border. May have a split S2 – ECG may show right ventricular hypertrophy. Cath can demonstrate degree of stenosis. 3/31/2008

K.Shattnawi

٥٠

3/31/2008

K.Shattnawi

٥١

Symptoms • • • • • • •

Shortness of breath Fatigue Cyanosis Chest pain Fainting Poor weight gain or failure to thrive in infants Sudden death

3/31/2008

K.Shattnawi

٥٢

Pulmonary Stenosis Cont’d – Treatment depends on severity of stenosis and the child’s age • If severe, the pressure may reopen the foramen ovale allowing flow from right to left causing cyanosis • If severe, then given PGE1 to keep ductus arteriosus from closing so that the infant can get more oxygenated blood • Balloon angioplasty may be tried to break valve adhesions and relieve the stenosis • If there is a lesser degree of stenosis, the child can be allowed to wait until they are 4 or 5 years old so that there is less surgical risk

3/31/2008

K.Shattnawi

٥٣

FIGURE 26–6

Interventional catheterization, balloon valvuloplasty to open the pulmonary valve.

3/31/2008

K.Shattnawi

٥٤

Defects with Decreased Pulmonary Blood Flow • Involve an obstruction of pulmonary blood flow which increases pressure in the right side of the heart. – If an ASD and or VSD also exists, then deoxygentated blood shunts from the right side to the left side 3/31/2008

K.Shattnawi

٥٥

Tricuspid Atresia • Tricuspid valve is completely closed. – Blood can’t flow from RA to RV so goes through the patent foramen ovale to the LA. – Oxygenation occurs by blood being shunted through a patent ductus to the lungs – If the foramen ovale and ductus arteriosus close, the patient becomes profoundly cyanotic, tachycardic and dyspneic. – It is often associated with pulmonic stenosis and transposition of great arteries. 3/31/2008

K.Shattnawi

٥٦

3/31/2008

K.Shattnawi

٥٧

– Kept on PGE1 until surgery – Surgery consists of creating a subclavianpulmonary artery shunt or restructuring the right side of the heart with a baffle (Fantan procedure: connections between the right atrium and pulmonary artery )

3/31/2008

K.Shattnawi

٥٨

Tetralogy of Fallot (TOF) • 10% of congenital defects. – Consists of 4 anomalies • Pulmonary stenosis • VSD (usually large) • Overriding of the aorta • Hypertrophy of the RV (acquired from the increased pressure in the RV from trying to push blood through the stenosed pulmonary artery) 3/31/2008

K.Shattnawi

٥٩

3/31/2008

K.Shattnawi

٦٠

– “Blue baby” although may not be dramatically cyanotic immediately after birth – Exhibit poor physical growth, clubbing, systolic murmur, hypoxic spells (TET spells), polycythemia, activity intolerance and squatting (a knee-chest position )

3/31/2008

K.Shattnawi

٦١

FIGURE 26–10

A child with a cyanotic heart defect squats (assumes a knee–chest position) to relieve cyanotic spells.

3/31/2008

K.Shattnawi

٦٢

TOF cont’d • X-ray shows cardiomegaly. Echo and ECG show the enlarged RV. Echo also shows decreased size of the PA and reduced flow through the lungs. Extent of the defect is determined through cardiac cath. Lab values show increased RBC’s and reduced O2 sat • Usually wait until child is 1 or 2 years old. Some institutions perform surgery earlier to prevent hypoxic episodes • If having hypoxic episode, place infant in knee-tochest position.

3/31/2008

K.Shattnawi

٦٣

FIGURE 26–12 Place the infant who has a hypercyanotic spell in the knee–chest position. This position increases systemic vascular resistance in the lower extremities.

3/31/2008

K.Shattnawi

٦٤

3/31/2008

K.Shattnawi

٦٥

TOF cont’d • Can have a palliative repair in which the subclavian artery is used to create an artificial ductus arteriosus (BlalockTaussing procedure) to allow blood to flow from the aorta to the lungs • Full repair includes relief of pulmonary stenosis, VSD repair and correction of the overriding aorta 3/31/2008

K.Shattnawi

٦٦

MIXED DEFECTS

3/31/2008

K.Shattnawi

٦٧

Transposition of the Great Arteries • - The aorta comes off of the RV and the pulmonary artery comes off of the LV. (5% of anomalies) – Unless the infant also has an ASD and/or VSD this is incompatible with life because you have two closed systems • RA - RV - Aorta - body - vena cava to RA • LA - LV - Pulmonary artery - lungs - pulmonary veins to LA

– Usually cyanotic at birth, may have no murmur or various murmurs – Will be given PGE1 to try to keep the ductus open. Can also have balloon passed through foramen ovale in order to enlarge the opening – Surgical intervention involves switching the aorta and the pulmonary artery 3/31/2008

K.Shattnawi

٦٨

3/31/2008

K.Shattnawi

٦٩

Truncus Arteriosus • Truncus Arteriosus - the infant has a single vessel coming off the RV and LV instead of a separate pulmonary artery and aorta. – There is usually also a VSD – Child is cyanotic – deoxygenated and oxygenated blood mix back and forth through the ventricular septal defect.

3/31/2008

K.Shattnawi

٧٠

3/31/2008

K.Shattnawi

٧١

Symptoms • cyanosis • fatigue • sweating • pale skin • cool skin • rapid breathing • heavy breathing • rapid heart rate • congested breathing • disinterest in feeding, or tiring while feeding • poor weight gain 3/31/2008

K.Shattnawi

٧٢

• Modified Rastelli procedure is usually performed after the infant is 2 weeks old, but before the blood vessels in the lungs are overwhelmed by extra blood flow and become diseased. • The pulmonary arteries are detached from the common artery (truncus arteriosus) and connected to the right ventricle using a homograft • The ventricular septal defect is closed with a patch. 3/31/2008

K.Shattnawi

٧٣

3/31/2008

K.Shattnawi

٧٤

Hypoplastic Left Heart Syndrome • Most of the structures on the left side of the heart are small and underdeveloped. • The degree of underdevelopment differs from child to child. • The structures affected usually include Mitral valve, Left ventricle, Aortic valve and the Aorta. 3/31/2008

K.Shattnawi

٧٥

3/31/2008

K.Shattnawi

٧٦

Hypoplastic Left Heart Syndrome – The RV hypertrophies as it tries to do all of the work – Patient becomes increasingly cyanotic as more unoxygenated blood is shunted to the left side – Treatment is aimed to keep the ductus arteriosis open and increase flow of blood to the aorta 3/31/2008

K.Shattnawi

٧٧

Symptoms • cyanosis (blue color of the skin, lips, and nailbeds) • pale skin • sweaty or clammy skin • cool skin • heavy and/or rapid breathing • fast heart rate 3/31/2008

K.Shattnawi

٧٨

• A series of three operations that are done in stages: – one shortly after birth, the second at about 6 months of age, and the final at about 18 months of age (these stages may vary). – In this series of operations, the right ventricle is used as the main pumping chamber to the body, and blood flow is redirected to the lungs and the body with various surgical connections – Best hope is heart transplant 3/31/2008

K.Shattnawi

٧٩

Acquired Heart Disease Rheumatic Fever • An autoimmune disease that is a reaction to a group-A beta-hemolytic streptococcus infection • Often follows an attack of pharyngitis, tonsillitis, scarlet fever, “strep” throat, or impetigo • It is a diffuse inflammatory disease of connective tissue, primarily involving heart, blood vessels, joints, subcut. tissue and CNS 3/31/2008

K.Shattnawi

٨٠

Epidemiology • • • •

Ages 5-15 yrs are most susceptible Rare <3 yrs Girls>boys Common in 3rd world countries

• Environmental factors--

over crowding,

poor sanitation, poverty, • Incidence more during fall ,winter & early spring 3/31/2008

K.Shattnawi

٨١

Pathologic Lesions • Fibrinoid degeneration of connective tissue,inflammatory edema, inflammatory cell infiltration & proliferation of specific cells resulting in formation of Ashcoff bodies, resulting in– – – – –

Pancarditis in the heart Arthritis in the joints SC nodules in the subcutaneous tissue Basal gangliar lesions resulting in chorea Erythema marginatum: erythematous macule

3/31/2008

K.Shattnawi

٨٢

Carditis • Manifest as pancarditis (endocarditis, myocarditis and pericarditis),occur in 4050% of cases • Carditis is the only manifestation of rheumatic fever that leaves a sequelae & permanent damage to the organ • Valvulitis occur in acute phase • Chronic phase- fibrosis & stenosis of heart valves (fishmouth valves) 3/31/2008

K.Shattnawi

٨٣

Arthritis • Migratory polyarthritis, involving major joints • Commonly involved: knee, ankle, elbow & wrist • Occur in 80%,involved joints are tender • In children below 5 yrs arthritis usually mild but carditis more prominent • Arthritis do not progress to chronic disease 3/31/2008

K.Shattnawi

٨٤

Subcutaneous nodules • Occur in 10% • Painless,pea-sized,palpable nodules • Mainly over surfaces of joints, spine, scapulae & scalp • Always associated with severe carditis

3/31/2008

K.Shattnawi

٨٥

Sydenham Chorea • Occur in 5-10% of cases • Mainly in girls of 1-15 yrs age • May appear even 6/12 after the attack of rheumatic fever • Clinically manifest as- deterioration of handwriting, speech, emotional lability or grimacing of face • Sudden aimless, irregular movements of extremities 3/31/2008

K.Shattnawi

٨٦

Erythema Marginatum • Occur in <5%. • Transient, well-demarcated border lesions of 1-2 inches in size • Pale center with red irregular margin • More on trunks & limbs & nonitchy • Worsens with application of heat • Often associated with chronic carditis 3/31/2008

K.Shattnawi

٨٧

Rheumatic Fever Cont’d

• Other features (minor symptoms): – – – –

fever Anorexia, Loss of weight fatigue Arthralgia (joint tenderness)

• Diagnosis - If have two major symptoms or one major and two minor symptoms 3/31/2008

K.Shattnawi

٨٨

Laboratory Findings • • • •

High ESR Anemia, leukocytosis Elevated C-reactive protien ASO titre >200 Todd units. (Peak value attained at 3 weeks,then comes down to normal by 6 weeks) • Throat culture-GABHstreptococci 3/31/2008

K.Shattnawi

٨٩

• Treatment – Bedrest until ESR decreases (degree of bedrest is based on degree of carditis) – Antibiotics (penicillin, erythromycin) x 10 days – Reduce inflammation (Salicylates: aspirin) – Corticosteroids (if not responding to aspirin alone) – Phenobarbital for chorea – Treatment of heart failure – Prognosis depends on the amount of cardiac involvement – Kept on prophylactic antibiotics (benzathine penicillin G) for 5 years or until 18 to prevent recurrence 3/31/2008

K.Shattnawi

٩٠

Acquired Heart Disease

Heart failure • Heart failure: – The heart can’t pump enough blood to supply oxygen and nutrients to the body – The body compensates for a while. For children less than 5 y.o., increase in CO is mostly accomplished through increased HR – As renal blood flow decreases, GFR slows allowing retention of sodium and fluid. When the body senses decreased supply of oxygen, aldosterone is secreted which further promotes retention of sodium in an attempt to increase blood flow to the kidneys. ADH secretion is also increased to help retain fluid 3/31/2008

K.Shattnawi

٩١

Causes of CHF can be classified according to the following changes: • Volume overload. • Pressure overload. • Decreased contractility: cardiomyopathy or myocardial ischemia from severe anemia or asphyxia, heart block, acidemia and low level of potassium, glucose, calcium or magnesium. • High cardiac output demands (such as in sepsis, hyperthyroidism and severe anemia). 3/31/2008

K.Shattnawi

٩٢

Other Causes • • • •

heart valve disease caused by past rheumatic fever or other infections chronic lung disease hypertension hemorrhage

3/31/2008

K.Shattnawi

٩٣

Heart Failure Cont’d • Symptoms depend on whether there is right- or left sided heart failure – Right sided HF – unable to pump much blood forward into the vessels of the lungs. Because of the congestion in the right side of the heart, blood flow begins to back up into the veins. Eventually, swelling is noticed in the feet, ankles, eyelids, and abdomen due to fluid retention. 3/31/2008

K.Shattnawi

٩٤

• Left sided HF -unable to pump blood forward to the body efficiently. Blood begins to back up into the vessels in the lungs, and the lungs become stressed. Breathing becomes faster and more difficult (dyspnea, bloody sputum on coughing, cyanosis). Also, the body does not receive enough blood to meet its needs, resulting in fatigue and poor growth. growth • Edema is a late sign for children. If present, it shows up as periorbital edema 3/31/2008

K.Shattnawi

٩٥

• In infants, signs can be breathlessness from rapid respirations, tiring easily and poor feeding related to exhaustion and dyspnea, may become diaphoretic when feeding, abrupt weight gain is the most obvious indication • Apical heart beat may be displaced laterally and downward. May have a third heart sound.

3/31/2008

K.Shattnawi

٩٦

•

Impaired myocardial function: – – – – – – – – – – –

Tachycardia. sweating decreased urinary output. fatigue weakness. Restlessness. Anorexia. Pale, cool extremities. Weak peripheral pulses. Decreased blood pressure. Cardiomegaly.

3/31/2008

K.Shattnawi

٩٧

•

Pulmonary congestion: – – – – – – – – –

Tachypnea. Retractions (infants). Flaring nares. Exercise intolerance. Orthopnea. Cough, hoarseness. Cyanosis. Wheezing. Grunting.

3/31/2008

K.Shattnawi

٩٨

•

Systemic venous congestion: – – – – – –

weight gain, even when the appetite is poor hepatomegaly. visible swelling of the legs, ankles, eyelids, face, and (occasionally) abdomen Ascites. Neck vein distention. The severity of the condition and symptoms depends on how much of the heart's pumping capacity has been affected.

3/31/2008

K.Shattnawi

٩٩

Treatment is aimed at 1. improving cardiac function, 2. removing accumulated fluid and sodium 3. decrease cardiac demands 4. improve tissue O2

3/31/2008

K.Shattnawi

١٠٠

1 & 2 Enhance myocardial performance & removal of accumulated fluids: • Digitalis glycosides - Digoxin (given a loading dose and then a maintenance dose, dig level should be 0.8 to 2.0 u/L, toxicity includes, nausea, vomiting, anorexia, slow heart rate, family teaching required, hold dose if HR < 90-110 for infants and toddlers, <70-85 for older children or <60 for adolescents) • hydralazine (vasodilator), enalapril, or captopril (capoten) (Angiotensin-converting enzyme (ACE) inhibitor) reduce afterload on the heart • Diuretics - Lasix, spironalactone(Aldactone), , thiazides (Diuril), (may need K replacement 3/31/2008

K.Shattnawi

١٠١

• ****Important alert: A fall in the serum potassium level enhances the effects of digoxin, increasing the risk of digoxin toxicity. Increased serum potassium diminishes digoxin's effect. Therefore serum potassium levels (N= 3.5-5.5 mmol/L) must be monitored**** 3/31/2008

K.Shattnawi

١٠٢

3 & 4 Decrease oxygen demands & improve oxygenation • Provide rest periods and uninterrupted sleep, place in Semi-Fowler’s position, space out activities/procedures, preserve body temperature, treat any infections • Administer O2 as needed by hood, mask or nasal prongs. If prongs are used, check nostrils q 4hrs • Adequate nutrition is also important - may need six to eight small meals daily rather than 3 large meals, may need tube feedings 3/31/2008

K.Shattnawi

١٠٣