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 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 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 dose 20mg). 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 FiO₂ 100%.

·  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.