Acute heart failure in children

Acute congestive heart failure in children is a clinical syndrome characterized by a sudden impairment of systemic blood flow as a result of decreased myocardial contractility.

Acute heart failure in children can occur as a complication of infectious-toxic and allergic diseases, acute exogenous poisoning, myocarditis, cardiac rhythm disturbances, as well as rapid decompensation of chronic heart failure, usually in children with congenital and acquired heart defects, cardiomyopathies, arterial hypertension. Consequently, acute heart failure can occur in children without chronic heart failure and in children with such (acute decompensation of chronic heart failure).

In acute heart failure, the child's heart does not provide the body's blood supply. It develops as a result of a decrease in the contractility of the myocardium or rhythm disorders that interfere with the pumping function of the heart.

[1], [2], [3], [4], [5], [6]

What causes acute heart failure in children?

• damage to the myocardium;
• overload by volume and / or pressure;
• disturbances of a warm rhythm.

The sympathoadrenal system, the Frank-Starling mechanism, the renin-angiotensin-aldosterone system play a leading role in providing the adaptive-compensatory reactions of the heart.

How does acute heart failure develop in children?

In children of the first 3 years of life, the causes of acute heart failure may be: congenital heart disease, acute infectious diseases, manifested by toxic or viral myocardial damage, electrolyte disorders. In older children, OCH is usually observed against the background of infectious-allergic carditis, acquired heart defects, poisoning. The classic picture of OOS is formed with pneumonia. There are 3 stages of acute heart failure:

1. the stage is characterized by a decrease in the minute volume of blood, moderate hypervolemia, dyspnea, tachycardia, signs of blood stagnation in a small or large circle of blood circulation. The ratio of BH and HR increases to 1: 3-1: 4. The liver is enlarged, small damp and dry rattles are heard in the lungs, the heart sounds are muffled, its borders increase.
2. the stage, in addition to the features listed above, is accompanied by a distinct oliguria, apparent peripheral edema, signs of pulmonary edema. BH / HR = 1: 4-1: 5. Increases CVP, pulsate the jugular veins, appear puffiness of the face, acrocyanosis, the liver increases, wet wheezing in the lungs.
3. stage - hyposystolic phase of OCH with the development of arterial hypotension against the background of pulmonary edema and (or) peripheral edema in combination with severe intravascular hypovolemia (decreased BCC). Characteristic decrease in blood pressure and increased CVP. Clear oliguria.

According to the pathogenetic mechanism, the energy-dynamic and hemodynamic forms of OCH are distinguished. In the first case, depression of metabolism in the myocardium is at the heart of acute heart failure, in the second - heart depression due to its long work on overcoming high vascular resistance (for example, with stenosis of the aorta or right ventricular aperture).

Pathogenetic forms of acute heart failure

• The energy-dynamic form arises as a result of primary disturbances of metabolic and energy processes in the myocardium (myocardial insufficiency, or asthenic form, according to AL Myasnikov).
• The hemodynamic form. Acute heart failure in children is due to overload and secondary metabolic disorders on the background of hypertrophy (myocardial insufficiency, or hypertension, according to AL Myasnikov).

In assessing acute heart failure, it is advisable to isolate its clinical variants.

Clinical options for acute heart failure:

• left ventricular;
• right ventricular;
• total.

Hemodynamic variants of acute heart failure:

• systolic:
• diastolic;
• mixed.

Degrees of insufficiency: I, II. III and IV.

Symptoms of acute heart failure in children

The main clinical signs of acute heart failure are: shortness of breath, tachycardia, enlargement of the heart boundaries due to enlargement of the heart cavities or myocardial hypertrophy, enlargement of the liver, especially the left lobe, peripheral edema, an increase in central venous pressure. According to the EchoCG data, a decrease in the ejection fraction is detected, according to the data of chest radiographs - stagnant phenomena in the lungs.

Acute left ventricular failure

Clinically manifested symptoms of cardiac asthma (interstitial stage OLZHN) and pulmonary edema (alveolar stage OLZHN). The onset of cardiac asthma begins suddenly, more often in the early morning hours. During an attack, the child is restless, complains of lack of air, chest tightness, fear of death. There is a frequent, painful cough with the allocation of sparse light sputum, shortness of breath for a mixed type. Typically the position of orthopnea. At auscultation, they listen to hard breathing with an extended exhalation. Wet wheezing in the beginning can not be listened to or a scant amount of small bubbling rales over the lower parts of the lungs is detected.

Edema of the lungs is manifested by severe shortness of breath, inspiratory or mixed. Breath noisy, bubbling: cough moist, with the allocation of foamy sputum, usually colored in pink. There are symptoms of acute hypoxia (pallor, acrocyanosis), agitation, fear of death, often the consciousness is broken.

[7], [8], [9], [10], [11]

Acute right ventricular failure

Acute right ventricular failure is the result of a sharp overload of the right heart. It occurs with thromboembolism of the pulmonary artery trunk and its branches, congenital heart defects (pulmonary artery stenosis, Ebstein abnormality, etc.), severe asthma attack, etc.

It develops suddenly: immediately there is a feeling of suffocation, tightness behind the sternum, pain in the region of the heart, a sharp weakness. Cyanosis rapidly builds up, the skin becomes covered with cold sweat, signs of increased central venous pressure and stagnation in the large circle of blood circulation arise: the cervical veins swell, the liver rapidly grows, which becomes painful. The pulse of weak filling is much faster. Blood pressure is reduced. Possible edema in the lower parts of the body (with a long horizontal position - on the back or side). Clinically, from chronic right ventricular failure, it is characterized by intense pain in the liver, which is enhanced by palpation. The signs of dilatation and congestion of the right heart are determined (expansion of the heart's borders to the right, systolic murmur over the xiphoid process and proto-diastolic rhythm of the gallop, accent of the 2nd tone on the pulmonary artery and corresponding changes in the ECG). Reducing the filling pressure of the left ventricle due to right ventricular failure can lead to a drop in the minute volume of the left ventricle and the development of arterial hypotension. Up to a picture of a cardiogenic shock.

[12], [13], [14]

Total acute heart failure in children

It occurs mainly in young children. It is characterized by signs of stagnation in the large and small circle of blood circulation (shortness of breath, tachycardia, enlargement of the liver, cervical veins swelling, small bubble and crepitating wheezing in the lungs, peripheral edema), muffled heart tones, decreased systemic blood pressure.

Cardiogenic shock

In children, it occurs with a rapid increase in left ventricular failure. Against a background of life-threatening arrhythmias, destruction of heart valves, cardiac tamponade, pulmonary embolism, acute myocarditis, acute dystrophy or myocardial infarction. At the same time, cardiac output and BCC decrease sharply with a decrease in arterial and pulse pressure. Brushes and feet are cold, the pattern of skin "marble", "white spot" when pressing on the nail bed or the center of the palm disappears slowly. In addition, as a rule, there is an oliguria, consciousness is broken, CVP is reduced.

[15], [16], [17], [18], [19],

Treatment of acute heart failure in children

Treatment of acute heart failure in children is carried out taking into account clinical and laboratory data, the results of additional research methods. At the same time, it is very important to determine the form, the variant and the degree of its severity, which will allow the best way to carry out therapeutic measures.

In severe acute heart failure, it is very important to give an elevated position to the child, to ensure peace. Meals should not be plentiful. It is necessary to limit the intake of table salt, liquid, sharp and fried foods, foods that promote flatulence, as well as stimulating drinks (strong tea, coffee). Infants are best served with expressed breast milk. In some cases, with severe heart failure, it is advisable to perform parenteral nutrition or probing.

The main principles of treatment of acute heart failure in children are the use of cardiac glycosides (more often digoxin for parenteral administration), diuretics (usually a lasix in a dose of 0.5-1.0 mg / kg) for discharging a small circle of blood circulation, cardiotrophic drugs (potassium preparations) and funds that improve coronary and peripheral blood flow (komplamin, trental, agapurin, etc.). The order of their use depends on the stage of the DOS. So, at the first stage, the focus is on improving microcirculation, cardiotrophic therapy, including aerotherapy. At the second stage, treatment begins with oxygen therapy, diuretics, drugs that improve myocardial trophism; then apply glycosides at a moderately fast rate of saturation (24 to 36 hours). At the III stage of OCH, therapy is often started with the introduction of cardiotonics (for example, dobrex in a dose of 3-5 μg / kg per minute), the appointment of cardiac glycosides, diuretics, cardiotrophic drugs and only after stabilization of hemodynamics, microcirculants are connected.

In the case of cardiac asthma dominance (overload of the left heart), the following measures should be provided:

• head and upper shoulder girdle of the child give an elevated position in the bed;
• inhalation of oxygen in a concentration of 30-40%, fed through a face mask or nasal catheter;
• introduction of diuretics: lasix in a dose of 2-3 mg / kg orally, intramuscularly or intravenously and (or) veroshpiron (aldactone) at a dose of 2.5-5.0 mg / kg orally in 2-3 doses under the control of diuresis;
• when tachycardia is indicated, the appointment of cardiac glycosides - strophanthin (at a dose of 0.007-0.01 mg / kg) or korglikon (0.01 mg / kg), repeated administration of them every 6-8 h until the effect is obtained, then in the same dose through 12 hours digoxin in a dose of saturation (0.03-0.05 mg / kg) in 4-6 receptions intravenously after 6-8 hours, then in a maintenance dose (75 doses of saturation) divided into 2 parts and administered after 12 hours. A variant of accelerated dosing of digoxin is also proposed: 1/2 dose intravenously at once, then 1/2 dose after 6 hours; after 8-12 hours the patient is transferred to maintenance doses: 1/2 dose of saturation in 2 doses after 12 hours.
• cardiotrophic therapy: panangin, asparkam or other drugs of potassium and magnesium in age doses.

When manifesting the alveolar edema of the lung, the following treatment is added:

• Inhalation of 30% alcohol solution for 20 min to reduce the sputum formation; 2-З ml of a 10% solution of antifensilane in children older than 3 years;
• oxygen therapy up to 40-60% 02 and, if necessary, ventilation with airway cleaning by suction (very carefully because of possible reflex heart failure), the PEEP mode may worsen hemodynamics;
• it is possible to prescribe soft edema of ganglion blockers (pentamine) in a complex therapy, with known hypertension of pulmonary vessels and elevated CVP, AD;
• prednisolone in a dose of 1-2 mg / kg or 3-5 mg / kg intravenously, especially with the development of OCH against an infectious-allergic carditis; course of treatment - 10-14 days with a gradual cancellation;
• the introduction of analgesics (promedol) and sedatives.

Emergency care for acute left ventricular failure

In the presence of signs of cardiac asthma and pulmonary edema, the child is given an elevated position with lowered legs, provides airway patency, oxygen inhalation, passed through 30% ethanol, for 15-20 minutes, alternating with 15-minute inhalation of moistened oxygen.

Children of all ages should be prescribed furosemide at a dose of 1-3 mg / kg intravenously bolus, a maximum dose of 6 mg / kg. To reduce pre- and postnagruzki intravenously, drip veno-and vasodilators (nitroglycerin from the calculation of 0.1-0.7 μg / kg hmin), sodium nitroprusside in a dose of 0.5-1 μg / kghmin).

The remaining signs of pulmonary edema with stabilization of hemodynamics may indicate an increase in the permeability of membranes, which dictates the need for adding glucocorticosteroids (hydrocortisone 2.5-5 mg / kg x 10), prednisolone 2-3 mg / kg xut) intravenously or intramuscularly into the complex therapy). To reduce the heightened excitability of the respiratory center, children older than 2 years are shown to be administered 1% morphine solution (0.05-0.1 mg / kg) or 1% solution, and to increase tolerance to hypoxia, 20% sodium oxybate solution is injected intravenously on a 50- 70 mg / kg. In the presence of bronchospasm and bradycardia, it is advisable to inject intravenously a 2.4% aminophylline solution at a dose of 3-7 mg / kg in 10-15 ml of a 20% dextrose solution. Aminophylline is contraindicated in coronary insufficiency and electrical instability of the myocardium.

Modern methods of drug treatment have minimized the importance of superimposing venous tourniquets on the limbs, however, if adequate drug therapy is not possible, this method of hemodynamic relief can not only, but should be used, especially with rapidly progressive pulmonary edema. The tourniquets are superimposed on 2-3 limbs (the upper third of the shoulder or thighs) for 15-20 minutes, with repetition of the procedure after 20-30 minutes. An indispensable condition in this case is the preservation of the pulse on the artery distal to the tourniquet.

[20], [21], [22], [23], [24]

Hypokinetic variant of acute left ventricular failure

To increase the contractility of the myocardium, fast-acting drugs with a short half-life (sympathomimetics) are used. Of these, dobutamine [2-5 μg / kghmin]] and dopamine [3-10 μg / kghmin] are most often used]. With decompensated heart failure, cardiac glycosides are prescribed (strophanthin at a dose of 0.01 mg / kg or digoxin at a dose of 0.025 mg / kg intravenously slowly or drip). The use of cardiac glycosides is most justified in children with a tahisystolic form of flicker or atrial flutter.

Hyperkinetic variant of acute left ventricular failure

Against a background of normal or high blood pressure, ganglion blockers (azamethonium bromide at a dose of 2-3 mg / kg, hexamethonium benzenesulfonate 1-2 mg / kg, arfonad 2-3 mg / kg) should be administered. They contribute to the redistribution of blood from the small circle into a large ("bloodless bloodletting"). They are administered intravenously drip under the control of blood pressure, which should not decrease by more than 20-25%. In addition, this version shows the appointment of 0.25% solution of droperidol (0.1-0.25 mg / kg) intravenously, as well as nitroglycerin, sodium nitroprusside.

Emergency care for acute right ventricular and total heart failure

First of all, it is necessary to eliminate the causes that cause heart failure, to start oxygen therapy.

To increase the contractile ability of the myocardium, appoint sympathomimetics (dopamine, dobutamine). To date, use of cardiac glycosides [digoxin is prescribed in the hemodynamic form of heart failure at a saturation dose of 0.03-0.05 mgDkgsut)]. The maintenance dose is 20% of the saturation dose. In conditions of hypoxia, acidosis and hypercapnia, cardiac glycosides should not be prescribed. They should also not be used with volume overload and diastolic heart failure.

The appointment of vasodilators depends on the pathogenetic mechanisms of hemodynamic disorders. To reduce preload, the appointment of venous dilators (nitroglycerin) is indicated, to reduce afterload - arterial (hydralazine, sodium nitroprusside).

In the complex therapy of these options for heart failure, cardiotrophic drugs must be included, with diuretics (furosemide) prescribed in the presence of an edematous syndrome.

[25], [26], [27], [28], [29]

Emergency care for cardiogenic shock

A child with a cardiogenic shock should be in a horizontal position with an elevated angle of 15-20 ° feet. In order to increase bcc and increase blood pressure should be an infusion therapy. Usually, rheopolyglucin is used in this dose at a dose of 5-8 ml / kg + 10% glucose solution and 0.9% sodium chloride solution at a dose of 50 ml / kg in a ratio of 2 to 1 with the addition of cocarboxylase and 7.5% potassium chloride solution in a dose 2 mmol / kg body weight, 10% dextrose solution.

With the preservation of low blood pressure, glucocorticosteroids and sympathomimetics (dopamine, dobutamine) are prescribed. In cardiogenic shock with moderate arterial hypotension, it is more preferable to use dobutamine, with pronounced arterial hypotension - dopamine. With their simultaneous use, a more pronounced increase in blood pressure is achieved. With increasing arterial hypotension, dopamine is best used in combination with norepinephrine, which, with predominantly alpha-adrenostimulating action, causes narrowing of the peripheral arteries and veins (with the coronary and cerebral arteries widening). Norepinephrine, contributing to the centralization of blood circulation, increases the load on the myocardium, worsens the blood supply of the kidneys, promotes the development of metabolic acidosis. In this regard, when it is used, blood pressure should be raised only to the lower limit of the norm.

In children with the syndrome of "diastole defect", which develops against a background of pronounced tachycardia, it is necessary to administer magnesium preparations (potassium and magnesium asparaginate in a dose of 0.2-0.4 ml / kg intravenously).

To reduce the need for oxygen and provide a sedative effect, it is recommended to use GABA (in the form of a 20% solution of 70-100 mg / kg), droperidol (0.25 mg / kg) intravenously.

[30], [31], [32], [33], [34], [35]