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

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Presentation on theme: "CCF in Neonates Dr Rajesh Kumar MD (PGI), DM (Neonatology) PGI, Chandigarh, India Rani Children Hospital, Ranchi."— Presentation transcript:

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 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 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

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 Tricuspid atresia Pul atresia with intact vent septum TOF, Pul stenosis

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 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

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

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

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 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, contractility 5-10 HR, contractility, BP HR, contractility, BP, SVR Dopamine

25 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, 1ml/kg/hour ( 5 g/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 g/kg/min) to 6mg/kg/6hours fluid By infusion pump: 15 mg (15 units) dopamine + 50 ml NS, 1ml/kg/hour ( 6.87 g/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 g/kg/min Infant: loading: mg/kg, folowwed by infusion of 10 g/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 g/kg/min) to 1.5ml/kg/hr Infant: 30mg (6ml) + NS 44 ml 1ml/kg/hr (10 g/kg/min)

30 Epinephrine myocardial contractility, SVR Useful in sepsis induced cardiac failure as second or third line drug Dose: Starting 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

31 Digoxin Inotropic agent Loading dose: Premature neonate:20-30 g/kg Term neonate: 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

32 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

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 E 1 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

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


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