1. CCF in Neonates Dr Rajesh Kumar
MD (PGI), DM (Neonatology) PGI, Chandigarh, India
Rani Children Hospital, Ranchi

2. 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?

3. Definition
Heart is unable to meet the metabolic demands of the tissues

4. Pul edema, hepatomegaly
Stress on heart
­HR
Contractility
­catecholamine
­autonomic input
Preload
renal preservation
venous constriction
Decompesation
­­ HR
Pul edema, hepatomegaly
¯ Cardiac output

5. Diagnosis of CCF
Clinical
Radiographic findings
Laboratory findings

6. Signs and symptoms of CCF
Tachycardia
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

7. 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)

9. Diagnosis of CCF: ECG
More useful in D/D of cyanotic newborn with ¯ pul blood flow
-90
Tricuspid
atresia
180
Pul atresia with intact vent septum
TOF, Pul stenosis
+90

10. 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

11. Diagnosis of CCF: Cardiac catheterisation
Necessary to delineate vascular anatomy before surgery in some cases

12. Causes of CCF Cardiac Non-cardiac ­ Preload (ARF) ­ Afterload (HT)
Structural
Arrythmia
Myocardial dysfunction
Extracardiac compression
Non-cardiac
­ Preload (ARF)
­ Afterload (HT)
¯ O2 carrying capacity (anemia)
­ Demand (sepsis)

14. 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

15. 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

17. 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 00

18. 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

20. Causes of CCF: Cardiac-arrythmia
Congenital heart block
Supraventricular tachycardia
Ventricular tachycardia

21. Causes of CCF: Cardiac-myocardial dysfunction
Cardiomyopathy
Perinatal asphyxia
Myocardial infarction
Sepsis
Acute LVF

22. Treatment Treatment of underlying cause
Reversing metabolic derangements
Improving cardiac performance
Altering preload / afterload burden
Improved oxygen delivery
Enhanced nutrition

23. Improving cardiac performance
Sympathomimetics
Dopamine
Dobutamine
Phenylephrine
Adrenaline, Noradrenaline
Phosphodiasterase inhibitors
Amrinone, Minrinone
Digoxin

24. Dopamine 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 (mg/kg/min) Effects
1-5 ­HR, ­UOP, ­contractility
5-10 ­HR, ­contractility, ­BP
­ ­HR, ­contractility, ­BP, ­SVR

25. Dopamine 40 mg per ml (1mg per unit by insuline syringe) Neonate:
In Pediadrip set:
2mg /kg/ 6hrs fluid (5.5 mg/kg/min) to 6mg/kg/6hours fluid
By infusion pump:
15 mg (15 units) dopamine + 50 ml NS, 1ml/kg/hour ( 5mg/kg/min) to 4 ml/kg/hour

26. Dobutamine 50 mg per ml (1.25mg per unit by insuline syringe) Neonate:
In Pediadrip set:
2mg /kg/ 6hrs fluid (6.87 mg/kg/min) to 6mg/kg/6hours fluid
By infusion pump:
15 mg (15 units) dopamine + 50 ml NS, 1ml/kg/hour ( 6.87 mg/kg/min) to 4 ml/kg/hour

27. 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

28. 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: mg/kg, folowwed by infusion of 3-5 mg/kg/min
Infant: loading: mg/kg, folowwed by infusion of 10 mg/kg/min

29. Amrinone
5 mg per ml, 20 ml ampoule, dilute only with saline, never with dextrose
Neonate:
10mg (2ml) + NS 48 ml
1ml/kg/hr (3.3 mg/kg/min) to 1.5ml/kg/hr
Infant:
30mg (6ml) + NS 44 ml
1ml/kg/hr (10 mg/kg/min)

30. Epinephrine ­myocardial contractility, ­ SVR
Useful in sepsis induced cardiac failure as second or third line drug
Dose: Starting mg/kg/min can be ­ rapidly
Preparation: 0.3ml(12 units)+ 50 ml NS, Start with ML in kg /hr (0.1 mg/kg/min ) and then increase

31. Digoxin Inotropic agent Loading dose:
Premature neonate:20-30 mg/kg
Term neonate: mg/kg
Schedule for loading: ½, ¼, ¼ 8hours apart
Maintanance dose:
Premature neonate: 5-10 mg/kg/day BD
Term neonate: 10 mg/kg/day BD

32. Digoxin Route: IV, IM, oral Injection: 1ml ampoule, 250 mg /ml
1unit = 6.25 mg ; 10 mg /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

33. 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

34. 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)

35. Prostaglandin E1 Useful in ductal dependant CHD
Best before 96 hours after birth
Dose: 0.5 –0.2 mg/kg/minute
Presentation: ALPOSTIN, 1 ml ampoule, 1ml=500mg
C/I: PFC, infradiafragmatic TAPVC
Side effects: Apnea

36. 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

37. Improved oxygen delivery
Oxygen content of blood=
Hb X %saturation X X PaO2
Start oxygen
Blood transfusion if HB <10-13 gm%
Iron supplementation

38. 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

39. Summary Treat metaboloic derangements aggresively
Get echo done whenever in doubt
Many of the structural heart disease is treatable is our setup

40. Thank You

41. Thank you