Paediatrics: Cardiovascular system difficulty - therapy- 2

Cardiovascular system difficulty: therapy- 2

Congestive heart failure

Use fluid restriction and inotropic support after cardiological advice. Digoxin may be used for the primary cardiac problem (total digitalizing dose, TDD). By age, TDDs are as follows.

• Neonate: 30micrograms/kg PO or 20micrograms/kg IV.
• <2yrs: 40–50micrograms/kg PO or 30–40micrograms/kg IV.
• 2–10yrs: 25–35micrograms/kg PO or 20–30micrograms/kg IV.
• 10yrs: 0.75–1.25mg PO or 0.5–1mg IV.

Digoxin administration

Split the TDD at the following times:

• Initial: give 50% of TDD.
• 8hr: give 25% of TDD.
• 16hr: give 25% of TDD.

Hypertension

For severe, symptomatic hypertension, the BP should be lowered by 20–25%. Do not aim for normal levels. Patients should be monitored in a high-dependency area. Discuss with the nephrologist. Hypertensive encephalopathy is an emergency and too rapid lowering of BP may lead to stroke. Short-acting antihypertensives are the treatment of choice. Consider:

• Diazoxide: 1–3mg/kg IV by rapid infusion; repeat after 5–15min.
• Hydralazine: 100–500micrograms/kg IV over several minutes (max dose20mg). May repeat dose in 20–30min.
• Sodium nitroprusside.

Congenital heart disease: alprostadil

In neonates, consider alprostadil (prostaglandin E1 (PGE1) infusion if:

• PaO₂<4–5.3kPa (30–40mm/kg).
• Oxygen saturation <70% in FiO₂100%.
• Femoral pulses are diminished or absent with poor perfusion.
• Metabolic acidosis persisting after volume and inotropes.

PGE1 dose

0.01–0.20micrograms/kg/min (start at 0.05micrograms/kg/min, increase in

0.05micrograms/kg/min increments if response is not adequate). Be aware that apnoea may develop.