Chapter 25

The Child with Cardiovascular Dysfunction

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A & P Review
Anatomy Chambers Valves Vessels Normal flow Physiology Cardiac output
Chambers of the Heart
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Valves of the Heart

Vessels of the Heart

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/def ect/normal.swf

Assessment of Cardiac Function

History Physical Examination
Inspection Palpation and Percussion Auscultation
Heart rate and rhythm Character of heart sounds

Pediatric Indicators of Cardiac Dysfunction

Poor feeding Tachypnea, tachycardia Failure to thrive, poor weight gain, activity intolerance Developmental delays Positive prenatal history Positive family history of cardiac disease
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Congenital Heart Disease

Consequences
CHF, hypoxemia

Incidence: 5-8 per 1000 live births

Major cause of death 1st yr of life

Causes
Chromosomal-genetic: 10%-12% Maternal or environmental: 1%-2%
Fetal alcohol syndrome: 50% Maternal illness
Rubella, cytomegalovirus, toxoplasmosis, other viral illnesses, IDMs

Multifactorial: 85%
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Fetal Circulation Structures

Umbilical vein, umbilical arteries Foramen ovale Ductus arteriosus Ductus venosus

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Fetal Circulation

http://www.wellesley.edu/Biology/Courses/111/ForOval.gif

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Changes at Birth

FIG. 25-1 Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left items ventricle. Mosby and derived items 2009,
2005 by Mosby, Inc., an affiliate of Elsevier Inc.
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CHDAltered hemodynamics
Cyanotic vs Acyanotic Defects
Shunting Pattern
Left to right shunting
Acyanotic

Right to left shunting

Cyanotic

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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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ACYANOTIC,
Increased Pulmonary Blood Flow Defects Atrial septal defect (ASD) Ventricular septal defect (VSD) Atrioventricular canal defect (AVC) Patent ductus arteriosus (PDA)
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Atrial Septal Defect (ASD)

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Atrial Septal Defect (ASD)

Signs & Symptoms:
May be asymptomatic May have a murmur Right atrial enlargement
At risk for dysrhythmias, CHF

Management:
Surgical patch closure (pericardial, Dacron)
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http://www.amplatzer.com/products/asd_devices/the_amplatzer_septal_occluder/tabid/188/default.aspx

Ventricular Septal Defect (VSD)

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/card 16 iology/defect/vsd.swf

Ventricular Septal Defect (VSD)

Signs & Symptoms:
Many asymptomatic Holosystolic murmur at left sternal border CHF common

Management:
May close spontaneously (20-60%) Surgical procedure (sutures or patch)
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Atrioventricular canal (AVC) or Endocardial cushion defect (ECD)

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Hockenberry (2005)

Atrioventricular Canal Defect ECD Signs and Symptoms:

Loud systolic murmur Moderate to severe CHF Possible cyanosis with crying

(AVC) or

Management:
Optimize cardiac output & weight gain Patch closure Valve reconstruction or valve replacement
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Patent Ductus Arteriosus (PDA)

http://www.nemours.org/content/dam/nemours/www/filebox/service/medic 20 al/cardiology/defect/pda.swf

Patent Ductus Arteriosus (PDA)

Signs & Symptoms:
May be asymptomatic Machinery-like murmur Possible s/s of CHF

Management:
Spontaneous closure Surgical (ligation) Transcatheter (coils) Indomethacin (Indocin)
Prostaglandin inhibitor
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Summary
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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ACYANOTIC, Obstructive Defects

Coarctation of the aorta Aortic stenosis Pulmonic stenosis
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Coarctation of the Aorta (COA)

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Coarctation of the Aorta (CoA)

Signs & Symptoms:
B/P differences between arms/legs, >10 mm Hg Bounding pulses in arms; weak or absent femoral pulses Signs of CHF in infants Cool lower extremities Risk for HTN, ruptured aorta, aortic aneurysm, stroke

Management:
Surgery-resection, anastomosis May recur Balloon angioplasty & stent placement

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Aortic Stenosis
Narrowing or stricture of aortic valve Causes increased workload on LV and hypertrophy

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Aortic Stenosis (AS)

Signs & Symptoms:
Decreased cardiac output with faint pulses Hypotension, tachycardia, poor feedings Murmur, systolic Chest pain, fatigue and syncope

Management:
Balloon angioplasty Repair or replace valve

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Pulmonic Stenosis

http://www.nemours.org/content/dam/nemours/www/filebox/service/med ical/cardiology/defect/pulmonarystenosis.swf
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http://familydoctor.co.uk/media/upload/Balloon%20valvuloplasty.jpg

Pulmonic Stenosis
Signs & Symptoms:
May be asymptomatic Loud systolic murmur Cyanosis May lead to CHF Balloon angioplasty Valvotomy Monitor for restenosis Reduce stressful situations

Nursing Care:

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CYANOTIC,
Decreased Pulmonary Blood Flow Defects

Tetralogy of Fallot Tricuspid atresia

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Tetralogy of Fallot (TOF)

http://en.wikipedia.org/wiki/Overriding_aorta

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Tetrology of Fallot (TOF)

Signs & Symptoms:
Cyanosis with crying or feeding Blue spells or TET" spells
At risk for emboli, seizures, loss of consciousness, sudden death

Management:
TET spells
Squatting, knee chest position Oxygen
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Tricuspid Atresia
Error in formation of TV Incompatible with life as single defect Most have ASD or VSD, as well as PDA
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Tricuspid Atresia (TA)

Signs & Symptoms:
Severe cyanosis Tachycardia Dyspnea

Management:

Prostaglandin (PGE1) Emergent Balloon atrial septostomy Numerous surgical repairs

http://www.ctsnet.org/doc/4960
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CYANOTIC, Mixed Defects

Transposition of great vessels Total anomalous pulmonary venous connection Truncus arteriosus Hypoplastic heart syndrome
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Transposition of the Great Vessels Arteries)

(or

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Transposition of the or Vessels (TGA or TGV)

Great Arteries

Signs & Symptoms:

Depends on type/size of associated defects Appear at birth, depressed function Severe cyanosis, CHF

Nursing Care:
Prostaglandin PGE1 (Keep PDA open) Balloon atrial septostomy Surgical repair
arterial switch operation
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Totally Anomalous Pulmonary Venous Connection

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/tapvrs upra.swf http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/tapvrin 38 fra.swf

Total Anomalous Pulmonary Venous Return (TAPVR)

Signs & Symptoms:
Cyanosis Heart failure

Management:
Surgical repair
Anastomosis ASD closed Anomalous connection ligated
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Truncus Arteriosus

http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/card iology/defect/truncusarteriosus.swf
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Truncus Arteriosus
Signs & Symptoms:
Cyanosis, poor growth Moderate to severe CHF Activity intolerance Holosystolic murmur

Management:
Close VSD Excise pulmonary arteries and attach to RV Mortality >10%

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Hypoplastic Left Heart

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Hypoplastic Left Heart Syndrome (HLHS)

Signs & Symptoms:
Mild cyanosis and s/s of CHF until PDA closes
Then progressive deterioration w/cyanosis Decreased cardiac output Leads to CV collapse

Management:
Mechanical ventilation Prostaglandin (PGE1) given Numerous surgical repairs Palliative care

http://home.cc.umanitoba.ca/~soninr/HLHSRep.html

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Hypoplastic Left Heart Syndrome

Stage I

Glenn Procedure-Stage II

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Invasive Tests
Cardiac Catheterization:
Determines pressures in heart & heart anatomy Diagnostic and/or interventional Risks

mimg.com

Bleeding, infection, thrombus, arrhythmia, perforation, stroke, death

Preprocedure

Allergy to ? NPO, assess pedal pulses Sedation

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Cardiac Catheterization
Post procedure
Monitor Assess pulses below cath site Temp/color of affected extremity Assess site Pressure dressing in the groin VS q 15 mins initially Lay flat 4-8 hours post Pain assessment
http://www.yalemedicalgroup.org/stw/images/125490.jpg

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Congestive Heart Failure

Inability to pump adequate amount of blood
Right sided failure
RV unable to pump into PA Increased pressure in RA, systemic venous circulation

Left sided failure

LV unable to pump into systemic circulation Increased pressure in LA, pulmonary veins Causes elevated pulmonary pressures, pulmonary edema

47 http://www.medmarketplace.com/images/i19Enlargev2.jpg

Congestive Heart FailureManagement

Digoxin (Lanoxin) Increased cardiac output, decreased heart size, decreased venous pressure, relief of edema Elixir (0.05 mg/ml) or IV Signs of Digoxin toxicity
Nausea, Vomiting, Anorexia Bradycardia, Dysrhythmias

Administration
Apical pulse, do not give if:
< 90-110 in infant <70 in children Parent teaching
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CHF-Management
Angiotensin-converting enzyme (ACE) inhibitors
Block conversion of angiotensin I to II
Vasodilation occurs, reduce afterload

Common meds: captopril, enalapril, lisinopril Side effects

Hypotension, cough, renal dysfunction

Beta Blockers (lol)

Causes decreased HR and BP, vasodilation Mosby items and derived items 2009, Carvedilol 2005 by Mosby, Inc., an affiliate of Elsevier
Inc.

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Congestive Heart FailureManagement

Diuretics (decrease preload)
Furosemide (Lasix)
Side effects: N/V, diarrhea, ototoxicity, hypokalemia, hypotension Foods high in potassium Observe for dig toxicity

Chlorothiazide (Diuril)
Side effects: Nausea, weakness, dizzy, muscle cramps, hypokalemia

Spironolactone (Aldactone)
Potassium sparing effects Side effects: skin rash, drowsy, ataxia, hyperkalemia
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Nursing Care Management for CHF

Nutrition/Feedings
Increased calorie formula Smaller, Q 3 hr feeds Gavage feedings or GT Nipple with larger opening Frequent rest, give 1/2 hour Breastfeeding

Fluid loss
Assess I&O, daily weights

51 http://www.mountnittany.org/wellness-library/healthsheets/documents?ID=5207

Nursing Care Management of CHF

Hypoxemia/Cyanosis
Manifestations
Apparent when O2 sats 80-85% Clubbing, polycythemia TET spells
At risk for neurological complications Developmental delays, CVA

Management
Hydration (to reduce CVA risk) Treat resp infections

Nursing care
Infection control
http://babyheartblog.org/

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Nursing care of child/family with CHD

Support Reduce anxiety Help family adjust Family education Home care teaching
Do not restrict physical activity Immunizations

Prepare for invasive procedures

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Nursing care of child/family with CHD Postoperative care

Monitor for complications, VS (pg 889, review) PIV, CVP, Intracardiac lines
Sterile technique

Maintain respiratory status

Suctioning Chest tubes
Drainage >3 ml/kg/hr for more than 3 hrs indicates hemorrhage or >5-10 ml/kg in any 1 hour Removal

Monitor fluids Rest and progressive activity

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Heart Transplantation
Indications
Worsening heart failure and end-stage CHD

Organ donation issues

Risks vs benefits Limited donors Overall survival 40% up to 20 yrs post Rejection and immunosuppressants

Nursing considerations
Compliance Close monitoring Education

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Acquired Cardiovascular Disorders

Infectious and Inflammatory Cardiac Disorders

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Bacterial (Infective) Endocarditis

Infection of valves and inner lining Caused by bacteremia in child with acquired or CHD
Streptococcal Staphylococcal Fungal

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Bacterial (Infective) Endocarditis

Manifestations
Fever, malaise, anorexia, wt loss Splinter hemorrhages (fig. A) Osler nodes (fig. C) Janeway lesions (fig. D) Petechiae on mm (fig. B) CHF, dysrhythmias, murmur

Treatment
IV antibiotics

http://www.rjmatthewsmd.com/Definitions/pop/201afig.htm

Prophylaxis: 1 hour before procedure, IV or PO

Amoxicillin

D
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Rheumatic Fever (RF) and Rheumatic Heart Disease (RHD)

RF
Inflammatory disease occurs after group A hemolytic streptococcal pharyngitis Infrequently seen in US Self-limiting
Affects joints, skin, brain, serous surfaces, and heart

Rheumatic Heart Disease

Most common complication of RF Causes damage to valves
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Rheumatic Fever
Manifestations
Usually 2-6 weeks post infection Carditis Polyarthritis Erythema marginatum Subcutaneous nodules Chorea

http://www.aafp.org/afp/2005/0515/p1949.html

Treatment
Antibiotics

Prevention

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http://www.peds.ufl.edu/peds2/research/debusk/pages/page4_53.html

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Hyperlipidemia
Identify kids at risk and treat early R/O secondary causes Normal TC <170, LDL <110 Treatment
Dietary Medications
Colestipol (Colestid) & Cholestyramine (Questran)
Powder mixed with water or juice GI side effects

Statins

LFTs, Creatinine kinase

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Systemic Hypertension
Primary vs Secondary Pediatrics: usually secondary
Renal, CV, Endocrine, Neurological disorders

Management
Dietary and lifestyle changes Beta blockers Other meds: ACE inhibitors, CCBs, ARBs, Diuretics Education
Monitoring Side effects
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Kawasaki Disease (KD; Mucocutaneous Lymph Node Syndrome)

Acute systemic vasculitis Unknown cause Children <5 years old (75%) 15-25% develop coronary aneurysms Stages
Acute phase-high fever Subacute-fever resolves Convalescent-all s/s resolved Kawasaki Video 2005 by Mosby, Inc., an affiliate of Elsevier
Inc.

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Kawasaki conjunctivitis, edema, rash, desquamation

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Kawasaki Disease
Management
ASA

IVIG

Nursing considerations
Teaching, follow-up, no live vaccines

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