Management of newborn with cardiac problems Speaker: Prof. Brig - - PowerPoint PPT Presentation

Management of newborn with cardiac problems

Speaker:

• Prof. Brig Gen Nurun Nahar Fatema

Head Of Paediatric Cardiology CMH, Dhaka Cantt.

INTRODUCTION

Khadiza o5 days old female child got admitted with cyanosis & respiratory distress since birth. With this complaints they first With this complaints they first reported to a private clinic from there she is referred to CMH Dhaka. In CMH dhaka Hyperoxia test in done which indicated for heart disease & urgent ECHO had been done

Corrective surgery

Then the patient send to abroad for final corrective surgery with in 1 months of age. in 1 months of age. Arterial switch operation was done on 25 Aug 2017 in Jaypee Hospital, India

Neonatal ICU in every

hospitals are trying to incorporate neonatal cardiac care in respective hospitals. Baby born with cardiac problems are increasing alarmingly ………… hospitals.

Expanded availability of prenatal diagnosis and assessment, increased accuracy of genetic analyses and counseling have made it possible to alert families and caregivers to the possibility of a newborn born with cardiovascular compromise.

INTRODUCTION

newborn born with cardiovascular compromise. Unfortunately despite the increasing sophistication, precision and availability of methods of detection,

• nly 1% of all complex cardiac malformations in

viable fetus are detected before acute clinical presentation.

INTRODUCTION cont…

Evaluation of a newborn with real or suspected CHD are not performed in isolation but are integrated into the overall assessment of the patient, these are: Pulse oxymetry / arterial blood gas Chest x-ray Hyperoxia test Umbilical venous sampling Echocardiography Cardiac catheterization, angiography

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Background

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• Background

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Frequency of congenital heart disease among hospital live birth (2004-2006).

Background

Table-I: Subject Male Female Total Percentage Live birth 3117 2551 5668 100%

Neonates with congenital heart disease

92 50 142 2.5%

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Percentage of positive Echocardiographic findings in suspected newborn and newborn for screening (In CMH ECHO LAB) 2004-2006

Background

Table-II:

(In CMH ECHO LAB) 2004-2006

Subject No (Screening) Percentage (Screening) Total suspected newborn CHD 658 (207) 100% (31.45%) Newborn with CHD 142 (58) 21.58% (8.81%)

Percentage of newborn echo in Lab Aid Cardiac Hospital in Ped lab 2009

Background

Table – III

Hospital in Ped lab 2009

Parameter No Percentage Total Echo (Pediatric) 9065 100% Newborn Echo 926 11.05

Percentage of newborn echo in Lab Aid Cardiac Hospital ( Ped lab) from 2009 to 2017

Background

Statistics of Newborn Catheter Intervention since 1998

Statistics of Pharmacological Intervention since 1998

Recently there has been an increasing awareness of the importance of early referral of newborn infants with heart disease to special centers.

Awareness created

The ease and safety of transport in new ventilator incubators has encouraged this transfer.

Early referral, improvement of diagnostic methods, medical management, catheter intervention and surgical treatment have further improved outcome of congenital heart diseases.

Treatment facilities : Newborn

Incidence

Sr Types Persentage

01 Newborn 0.8% ( 2.5% in Bangladesh) 02 Still born 3 – 4 % 03 Abortus 10 – 25% 04 Premature infants 2% 05 Newborn with symptomatic CHD 2 – 3% 06 Diagnosis achieved by 1 week 40 – 50% 07 Diagnosis achieved by 1 month 50 – 60%

MANIFESTATIONS OF CHD IN NEWBORN

Observation

Cyanosis, Respiratory distress, Peripheral desaturation, Behavioral abnormality

and less activity

Thrill Poor perfusion

MANIFESTATIONS OF CHD IN NEWBORN

Palpation

Poor perfusion Hepatomegaly

Auscultation

Abnormal heart

sounds

Murmurs & bruits

• Definitive diagnosis

TRANSPORTATION OF NEWBORN

Transportation is necessary to provide:

• Definitive diagnosis
• Ongoing medical care
• Corrective intervention
• Lifesaving intervention
• Corrective surgery

Treatment of acute

deterioration

Baby should arrive at referral centre

in as good a condition as possible.

The following complications must be

avoided: Hypothermia

Cont…

Hypothermia Acidosis Metabolic disturbances Severe hypoxia

Logistics of transport should be

checked properly before transfer

Commonest in the first week of life.

Hypo plastic left heart

syndrome

Transposition of Great Arteries

CARDIAC EMERGENCIES: CYANOTIC -CHD

Transposition of Great Arteries Pulmonary atresia or severe

pulmonary stenosis

Total anomalous pulmonary

venous drainage

Tricuspid Atresia Ebstein Anomaly

a.

Hypoplasia of the left heart.

b.

Coarctation of Aorta.

c.

Severe Aortic Stenosis

CARDIAC EMERGENCIES: HEART FAILURE

c.

Severe Aortic Stenosis

d.

Persistent Truncus Arteriosus.

e.

Double Outlet Right Ventricle

f.

Complete A-V canal defect

g.

Cortriatiatum.

h.

Large A-V fistula

Cyanotic A cyanotic

• TGA
• TAPVD
• HLHS
• PA
• CoA
• Cortriatriatum
• Myocarditis
• Single ventricle

CADIAC EMERGENCIES: MURMURLESS HEART

• PA
• Single ventricle
• ALCAPA

Persistent fetal circulation (PFC):

PA Pressure high Rt to Lt shunt through ASD and PDA Infant presents with cyanosis, respiratory distress. H/O Perinatal Asphyxia present.

MURMURLESS OTHER EMERGENCIES

H/O Perinatal Asphyxia present. Difficult to diagnose by Echocardiography and often

missed by inexperienced Echo cardiographer

Mortality 25-30%if not treated.

Persistent Pulmonary Hypertension (PPHN):

PA Pressure high Lt to Rt shunt through ASD and PDA Infant presents with cyanosis, respiratory distress. H/O Perinatal Asphyxia may not present.

MURMURLESS OTHER EMERGENCIES

H/O Perinatal Asphyxia may not present. Difficult to diagnose by Echocardiography and often

missed by inexperienced Echo cardiographer

Mortality 25-30% if not treated.

H/O Perinatal Asphyxia present Myocardial glycogen reduced Present with cyanosis, respiratory

distress, hepatomegaly.

TRANSIENT MYOCARDIAL ISCHAEMIA

distress, hepatomegaly.

Shock in severe case.

Neonatal Hypocalcaemia (cause of heart

failure)

Systemic Arteriovenous fistula Arrhythmias in newborn: SVT, Complete

DO NOT FORGET

Arrhythmias in newborn: SVT, Complete

heart block.

Severe anemia, hypoxia, hypoglycemia

Hypotension Desaturation Brady / Tachycardia Hypo perfusion

PROBLEMS ASSOCIATED WITH HAEMODYNAMICS AND MITABOLIC BALANCE

Hypo perfusion Hypoxia Acidosis Hypothermia Hypoglycemia /

Hypocalcaemia

Renal failure Multi organ failure

• A. Clinical suspision
• Cyanosis
• Respiratory distress
• Lathergy
• Hypoperfusion

HOW TO DIAGNOSE

• Hypoperfusion
• Shock
• B. Investigation
• Hyperoxia test
• CXR
• ECG
• Echo
• Blood gas analysis

Ensure

Safe transport Nutrition Ventilation

REFERRAL TO CARDIAC CENTRE / PEDIATRIC CARDIOLOGIST

Ventilation

Medical treatment /

General

Catheter Intervention Surgical Intervention

TREATMENT OF NEONATAL CARDIAC EMERGENCIES

Surgical Intervention

Care of ventilation

• Room air
• O2 Inhalation
• Artificial ventilation

a.

Non invasive

Medical Treatment / General

a.

Non invasive

b.

Invasive

Maintenance of Acid base and

electrolyte status.

Care of I/V lines:

Central Peripheral

Medical Treatment cont…

Maintenance of intake out put chart Care of catheter in ventilated patient Skin care Care of eye and oral cavity Planning for Investigation

Correction of anemia or any

blood component deficiency: Whole blood FFP

Medical Treatment cont…

FFP Platelet

Nutrition:

Milk TPN Fluid

Digitalization Diuretics

Treatment of heart failure Inotropes

SPECIFIC TREATMENT

Diuretics Dopamine Dobutamine Adrenaline Noradrenaline Milrinone Isopranaline

Inotropes

Digoxin Diuretics Oxygen/ventilation

Correction of acidosis

Treatment

TREATMENT of MI

Correction of acidosis

/hypoglycemia

Electrolyte imbalance.

Pulmonary vasodilators Ionotropes Digoxin Diuretics

TREATMANT OF PFC

Diuretics High flow oxygen Therapy

ACE Inhibitor O2 Therapy Sildenafil Artificial ventilation

TREATMANT OF PPHN

Artificial ventilation Nitric oxide

INTERVENTION FOR CLOSURE OF DUCTUS ARTERIOSUS

Indomethacine (intravenous 3 doses) ,0.2-0.25

mg/kg/dose 12 hourly in infusion over one hour.

Ibuprophen (oral 3 doses)10mg/kg/day for 3 days. Indication: Isolated PDA in preterm.

INTERVENTION FOR KEEPING THE DUCTUS PATENT

Inj Prostaglandin E1/E2 .01-.1microgram/kg/min Indication :Ductus dependent cyanotic cong heart lessons.

Ionotropes Diuretics

DILATED CARDIOMYOPATHY

Diuretics Vasodilators

Digitalization Adenosine Propranolol

SVT

SUPRAVENTRICULAR TACHYCARDIA

Propranolol Esmolol DC shock

DC shock

Hydration

CYANOTIC SPELL

Hydration Sedation Esmolol Propranolol, Morphine Maintenance of acid base status, hydration Intubation Urgent B T shunt.

On spell After management

Balloon atrial septostomy for those with closed

circuit circulation TGA, TAPVD, TA, PA, MA

Balloon valvoplasty

• Critical PS

CATHETER INTERVENTION IN NEWBORN

• Critical PS
• Critical AS
• Balloon angioplasty for Coarctation of Aorta
• Stenting of PDA for ductus dependent lesion.

Laser Perforation of atretic pulmonary valve

Life Saving intervention Life Saving intervention Life Saving intervention Life Saving intervention

• A. Curative
• PDA Ligation
• COA Repair

SURGERY OF NEWBORN

• COA Repair
• Interrupted aortic arch repair
• B. Palliative
• BT shunt for cyanotic lesion
• pulmonary artery banding

for left to Rt shunt lesion.

PDA LIGATION

BT SHUNT

The clinical diagnosis of heart disease is more

difficult in the newborn period than at any other time, yet a correct diagnosis without delay is essential for effective treatment.

CONCLUSION

essential for effective treatment.

It is important to stress that the absence of heart

murmur dose not rule out heart disease. There may be no heart murmur in some of the most severe, yet operable, cyanotic lesions.

So diagnosis should be made without delay to

save the life of a newborn by doing specific interventions.

Any Question