Cardiac Failure

Possible causes

Important points in the history

• Breathlessness- on feeding (infant); at rest; on exertion; on lying flat; sport
• Fatigue- on feeding (infant); exercise tolerance/ ability to do household chores / ability to get to school
• Sweating- especially on feeding (infants)
• Failure to thrive- is he/she growing?
• Unexpected increase in weight/ obvious oedema?
• Pain in the right upper abdominal quadrant (hepatic engorgement)

What is the cause?

• Recent development of marked pallor
• Recent administration of intravenous fluids
• Recent change in urine output
• Known past medical history of cardiac or renal problem, TB, HIV
• Possible past rheumatic fever? (e.g. sore throat followed by arthritis)
• Recent "viral illness" with fever/ non-specific symptoms e.g. myalgia
• Recent joint pain or swelling, recent chest pain

Important points in the examination

• Respiratory rate and effort; presence of bibasal crepitations
• Pulse rate and volume; peripheral perfusion; femoral pulses
• Heart sounds: gallop rhythm, murmurs (especially mitral regurgitation)
• Displaced apex beat (should normally be in the 5th intercostal space mid-clavicular line)
• Raised JVP (older child)
• Hepatomegaly
• Peripheral/ sacral oedema (oedema will be in dependant area)
• Sweating
• IN INFANTS: tachycardia, tachypnoea and hepatomegaly are the most common signs.

What is the likely cause?

• Pallor of conjunctivae or palms
• Look at the intravenous fluid bag - how much and how quickly has run through?
• Nutritional status
• Signs of tamponade? (Muffled heart sounds, raised JVP, shock)
• Structural heart disease: heart murmur, thrill, absent femoral pulses or radiofemoral delay
• Signs of immunosuppression (thrush, severe malnutrition etc)
• Vascular malformations in infant eg. haemangiomas; cranial or hepatic bruits

Differential diagnoses include

Breathless child	Oedematous child
Lower respiratory tract infection Acute asthma Pleural effusion Metabolic problems (DKA) Poisoning	Protein energy malnutrition Nephrotic syndrome Liver failure

Relevant investigations

• PCV and MPS - Is there anaemia? Is malaria worsening heart failure?
• Blood pressure - cuff should be 2/3 of size of upper arm measured at heart level
• Urinalysis - Is it nephrotic/nephritic syndrome?
• HIV test
• Consider (not every child requires these. Helpful to find cause of cardiac failure in some cases)
  • Chest x-ray
  • Echocardiogram
  • ECG
• Mantoux test (if available)

Management

Indications for admission

• Admit every child with acute cardiac failure
• Chronic cardiac failure may be managed as an outpatient unless acutely exacerbated

Specific treatments

• Severe anaemia
• Excessive i.v. fluids: Stop i.v. fluids; consider STAT furosemide 1-2mg/kg i.v
• Renal disease: Extreme care with use of fluids and diuretics; antihyper- tensives if required
• Acute rheumatic fever: Penicillin and aspirin ( Heart diseases cause by infections )
• HIV cardiomyopathy: Stage 4 disease – start HAART

Heart failure generic treatment

Ongoing management with diuretics to reduce preload

• Oral furosemide 1mg/kg once, twice or three times per day
• Consider spironolactone 1mg/kg at same dose frequency as furosemide.
• Patients on furosemide alone need bananas (better!) / potassium (K+) supplements
• Patients on furosemide AND spironolocatone dont need K+

Always consult senior before starting Digoxin Improves myocardial contractility but can be dangerous in acute viral myocarditis In practice: Don't "digitalize" with high-dose digoxin. Start with maintanance dose: Consider urine catheter 2-5 years: 10 mcg/kg OD 5-10 years: 6 mcg/kg OD 10-18 years: 250-750 mcg OD ACE inhibitors - e.g. Captopril, Linisopril, Enalapril Reduces mortality by reducing afterload and prevention of cardiac remodelling Pericardiocentesis May be necessary if large pericardial effusion

Supportive care

• Nursing at 60 degree reduces pulmonary oedema. Do not elevate the legs
• Oxygen if respiratory distress or hypoxia
• Rest reduces cardiac output
• Avoid intravenous fluids
• High calorie, low sodium diet ideal for chronic cardiac (or renal) failure (breast milk is fine for neonates).

Monitoring

• Daily HR, RR, BP, respiratory effort, presence of oedema, weight

Palliative care and Morphine

• Involve Umodzi early if in terminal chronic cardiac failure (CCF)
• Morphine is a venodilator reducing preload in children in cardiac failure and improves
  pulmonary oedema (Morphine dosing: 200-400 mcg/kg every 4 hours)

When to discharge

• Symptoms and signs of acute failure relieved - child able to walk a short distance without
  dyspnoea
• Underlying cause of cardiac failure identified (if possible)
• Treatment regime for long-term care established, written in health passport
• Family counselled about nature of illness and future implications - involve Umodzi team if necessary

Follow-up

• Cardiac clinic: Tuesdays 9:00 am for children with ongoing problems
• Children receiving palliative care can also be seen at the UMODZI clinic