A basic science to clinical practice Yuttapong Wongswadiwat MD Assistant professor Division of Pediatric Cardiology Department of Pediatrics Faculty of Medicine Khon Kean University ID: 1041650
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1. Congestive Heart FailureA basic science to clinical practiceYuttapong Wongswadiwat, M.D.Assistant professor, Division of Pediatric Cardiology, Department of PediatricsFaculty of Medicine, Khon Kean UniversityLao Paediatric CME conference 2019Vientiane Capital, Lao PDR26 April 2019
2. Congestive heart failure (CHF)Clinical state of systemic and pulmonary congestion resulting from inability of the heart to pump as much blood as required for the adequate metabolism of the bodyStrictly related to agePathophysiology related to preload, afterload contractility and heart rateManagement is an application of basic sciences to clinical practice
3. The Frank Starling mechanismClinical critical care medicine, Richard K. Albert et al. 2006
4. The Pressure volume loop of ventriclesClinical critical care medicine, Richard K. Albert et al. 2006
5. Maximizing Oxygen DeliveryStroke VolumeContractilityDiastolic FillingAfterload ( SVR )Heart ratePhysiologic ResponseNon-physiologic ResponseSinus vs. junctional vs. paced ventricular rhythmCardiac OutputStrokeVolumeHeartRate=XNormal CI = 3.5 – 5.0 L/min/m2NB CI = 1.7 – 3.5 L/min/m2
6. Pediatrics and Neonatology (2017)58, 303e312 http://dx.doi.org/10.1016/j.pedneo.2017.01.001 Pathophysiology of Heart Failure
7. Causes of CHF resulting from CHDAge of OnsetCauseAt birthHLHS Volume overloaded lesions: TR,PRLarge systemic AV fistulaFirst weekTGA, PDA, HLHS, TAPVR, Systemic AV fistulaCritical AS/PS1-4 weekCoA with associated anomalies, Critical ASLarge left to right shunt lesions(VSD,PDA)4-6 weekEndocardial cushion defect6 weeks-4 monthLarge VSD, Large PDA, ALCAPA
8. Clinical ManifestationsIn neonates and infants Tachypnea, feeding difficulties, poor weight gain, excessive perspiration, irritability weak cry and noisy, labored respirationHepatomegaly and CardiomegalyTachycardia and gallop rhythmEdemaPallor and deep coloring
9. Clinical ManifestationsIn Children Fatigue, effort intolerance, anorexia, abdominal pain and coughEngorged neck vein, hepatomegaly and edemaDyspnea, orthopnea and pulmonary ralesCardiomegalyGallop rhythm
10. CHF in Neonates and InfantsFeeding difficulties and excessive sweatingTachycardia >150/min is commonMild-moderate-severe feeding volume & time, RR, HRTachycardia, Tachypnea, Cardiomegaly HepatomegalyPathophysiology of symptoms
11. MJAFI 2003; 59 : 228-233Heart Failure scores
12. CXR in congenital complete heart block with PPM
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14. The underlying causesGeneral measuresDiet : restrict, low salt, high caloriesDigitalisDiuretics : furosemide, spironolactoneAfterload-reducing agentsAdrenergic agonistsPhosphodiesterase inhibitorsTreatment
15. Mechanism of digitalis action http://www.cvpharmacology.com/cardiostimulatory/digitalis.htm
16. DigitalisHalf life 36 hours (daily or twice daily)60 – 85% GI absorption(elixir > tablet)Peak effect (oral 2 – 6 hr, IV 1 – 4 hr)Cross the placentaAlmost eliminated by kidneyDigitalizationSerum digitalis level 1 – 2 ng/ml ( infant may 2 – 4 ng/ml )
17. Pediatric digitalis dose AgeTotal Digitalizing Dose (mcg/kg)Maintenance Dose* (mcg/kg/day)Premature infants205Newborn infants30 8<2 yr40–5010–12>2 yr30–408–10
18. Effects of catecholamines ReceptorsDrugs α β1 β2 DopaEpinephrine +++ +++ +++ 0Norepinephrine +++ ++ 0 0Dopamine ++ ++ + ++Dobutamine 0 - + +++ + 0Isoproterenol 0 +++ +++ 0
19. Common CHD with CHFVSDASD,AVSDPDACoATAPVR, Truncus arteriosus, DTGASingle ventricleALCAPA
20. Thank you for your attentionContact Address: Assistant professor. Yuttapong WongswadiwatDepartment of Pediatrics, Faculty of Medicine, KhonKaen University, THAILAND Email: wyutta@kku.ac.th