The Child with Cardiovascular Dysfunction

Chapter 25

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Fetal Circulation Structures

Umbilical vein; umbilical arteries
Foramen ovale Ductus arteriosus Ductus venosus

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Changes at Birth
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Pediatric Indicators of Cardiac Dysfunction

Poor feeding
Tachypnea/ tachycardia Failure to thrive/poor weight gain/activity intolerance Developmental delays + Prenatal history + Family history of cardiac disease
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Innocent Murmurs

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Thrills

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Two Types of Cardiac Defects

Congenital
Anatomic>abnormal function Acquired Disease process

Infection

Autoimmune response
Environmental factors Familial tendencies
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Causes of CHD
Chromosomal/genetic = 10%-12% Maternal or environmental = 1%-2% Maternal drug use Fetal alcohol syndrome50% have CHD Maternal illness Rubella in 1st 7 wks of pregnancy50% risk of defects including PDA and pulmonary branch stenosis CMV, toxoplasmosis, other viral illnesses>> cardiac defects IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA most common) Multifactorial = 85%
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CHD
Incidence: 5-8 per 1000 live births
About 2-3 of these are symptomatic in first year of life Major cause of death in first year of life (after prematurity) Most common anomaly is VSD 28% of kids with CHD have another recognized anomaly (trisomy 21, 13, 18, +++ )
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Older Classifications of CHD

Acyanotic
May become cyanotic Cyanotic May be pink May develop CHF

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Newer Classification of CHD

Hemodynamic characteristics
Increased pulmonary blood flow Decreased pulmonary blood flow Obstruction of blood flow out of the heart Mixed blood flow

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Increased Pulmonary Blood Flow Defects

Abnormal connection between two sides of heart
Either the septum or the great vessels

Increased blood volume on right side of heart

Increased pulmonary blood flow

Decreased systemic blood flow

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Increased Pulmonary Blood Flow Defects

Atrial septal defect
Ventricular septal defect Patent ductus arteriosus

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ASD
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VSD
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PDA
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Obstructive Defects
Coarctation of the aorta
Aortic stenosis Pulmonic stenosis

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COA
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Aortic Stenosis
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Pulmonic Stenosis and Catheter Placement

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Decreased Pulmonary Blood Flow Defects

Tetralogy of Fallot
Tricuspid atresia

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Tetralogy of Fallot
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Tricuspid Atresia
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Mixed Defects
Transposition of great vessels
Total anomalous pulmonary venous connection

Hypoplastic heart syndrome

Right Left

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Transposition of Great Vessels

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Normal Heart
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Totally Anomalous Pulmonary Venous Connection

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Hypoplastic Left Heart

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CHF in Children
Impaired myocardial function Tachycardia, fatigue, weakness, restless, pale, cool extremities, decreased BP, decreased urine output Pulmonary congestion Tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis Systemic venous congestion Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein distention

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Interventional Cardiac Catheter Procedures in Children

Transposition of great vessels
Some complex single-ventricle defects ASD Pulmonary artery stenosis

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Interventional Cardiac Catheter Procedures in Children (contd)

DIAGNOSIS INTERVENTION

Valvular pulmonic stenosis Recurrent coarctation of aorta Congenital mitral stenosis

Balloon dilation

Balloon dilation

Balloon dilation

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Surgical Interventions
Open heart
Closed heart procedures Staged procedures Prepare child and family for procedures

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Postpericardiotomy Syndrome
Symptoms: fever, pericardial friction rub, pericardial and pleural effusion
Occurs in immediate postoperative period Also can occur later (postoperative day 7-21)

Etiology unknown
Theories of etiology Viral infection; auto immune response; reaction to blood in pericardium May require pericardiocentesis or pleurocentesis
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Acquired Cardiovascular Disorders

Infectious and Inflammatory Cardiac Disorders

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Endocarditis
BE, IE, or SBE
Strep Staph Fungal infections PROPHYLAXIS: 1 hr before procedures (IV) or may use PO in some cases

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Rheumatic Fever Rheumatic Heart Disease

RF
Inflammatory disease occurs after Group A -hemolytic streptococcal pharyngitis Infrequently seen in U.S.; big problem in Third World

Self-limiting

Affects joints, skin, brain, serous surfaces, and heart

Rheumatic heart disease

Most common complication of RF

Damage to valves as result of RF

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Clinical Manifestations of RF
Carditis
Polyarthritis Erythema marginatum Subcutaneous nodules

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St. Vitus Dance 5th Manifestation

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Prevention of RHD
Treatment of streptococcal tonsillitis/pharyngitis
Penicillin GIM X 1 Penicillin VOral X 10 days

SulfaOral X 10 days
Erythromycin (if allergic to above)Oral X 10 days Treatment of recurrent RF Same as above

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Kawasaki Disease

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Kawasaki Disease Treatment

IVIG
ASA 80-100 mg/kg/dayfever

Then 3-5 mg/kg/dayantiplatelet

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Systemic Hypertension
Primary: No known cause
Secondary: Identifiable cause Pediatrics: HTN generally secondary to structural abnormality or underlying pathology Renal disease CV disease Endocrine or neurologic disorders
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BP Screenings for Children

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Hyperlipidemia
Identify kids at risk and treat early
Treatment: dietary Restrict intake of cholesterol and fats If no response to dietRx colestipol (Colestid)

cholestyramine (Questran)

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Pharmacology
Iv IgG
Digoxin/lanoxin ACE inhibitors ASA, NSAIDs Lasix

Spironolactone (Aldactone)

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Heart Transplantation
Orthotopic transplant
Heterotopic transplant (piggyback) Organ donation issues Nursing considerations

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Anaphylaxis
Definition
Clinical manifestations Therapeutic management Nursing considerations

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Toxic Shock Syndrome (TSS)

Diagnostic evaluation
Therapeutic management Nursing considerations Criteria for definition of TSS

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