heart dysfunction protocol

1. Heart failure
Occurs when the heart is unable to maintain output, necessary for the metabolic
need of the body (systolic dysfunction) and inability to receive blood in ventricular
cavities at low pressure during diastole (diastolic dysfunction)
Signs
Left sided Either side Right side
Tachypnea
Tachycardia
Cough
Wheezing
Rales
Small volume pulse
cardiac enlargement
Peripheral cyanosis
Gallop
Hepatomegaly
Face oedema
Jugular venous
engorgment
Symptoms
Difficulty in feeding
Rapid breathing
Persistent cough and wheezing
Irritability, restlessness
Pedal oedema

4. Step wise management Congestive Heart Failure
Start digoxin and diuretics. Furesemide with spironolactone better
than furosemide with K+ supplement
Add ACE inhibitors, if persistant cough; change to ARB
Add isosorbite nitrate if ACE are not tolerated
Inadequate response especially if tachycardia, start carvedilol
Consider once or twice weekly infusion of dobutamine who
continue to deteriote. Add carnitine as supplement
Consider for surgical treatment
Rest, propped up position, humidified oxygen, diet, sodium
restriction
From : Ghai Paediatrics
Last 2 step applicable especially to rare condition e.g. DCM

5. Initial therapy based on the sign and symptoms
Suggestive sign and symptoms
of low output state
• Narrow pulse pressure
• Altered mental sensorium
• Cool extremities
• Decrease urine output
Suggestive sign and symptoms
of volume overload
• Dyspnoea
• Increased JVP
• Hepatomegaly
• Rales
• Peripheral odema
• Recent weight gain
• Increase BNP
Mild volume overload
IV Loop diuretics
Is patient was on oral
diuretics at home
Moderate to severe volume overload
• Fatigue
• Oral diuretics
• Spo2 <93%
• Raised creatinine levels
• May require CPCP,BIPAP,Ventilation
Mild to moderate
Consider very low output state
• Narrow pulse pressure
• Altered mental sense
• Pre – renal azotemia
• Cool extremities
• Decreased urine output
Management of Acute Decompensated Heart FailureFrom : AHA guideline

6. Give total oral
dose as IV
Give IV diuretics
Furesemide
1mg/kg
Adequate
response
NoYes
Milrinone
SBP normal
Inadequate response
Dobutamine
May require inotrope
support for BP
On beta blocker
therapy chronically
No
Yes
Yes
No
No
Step wise
management as
above
Yes
Add inotrops

7. IV DIURETICS + IVVASODILATOR
If Furesemide was given, double the dose
if not start with 1 mg/kg
If SBP > lower limit according to age
Start nitroglycerine 0.5-8mcg/min
Or
Nesiritide
0.01mcg/min
Consider
moderate to severe
overload
Or
Low cardiac output
state
Consider
moderate to severe
overload
Or
Low cardiac output
state

8. Doses (Nelson and Ghai)
• Dopamine 5-20 mcg/kg/min
• Dobutamine 5-20 mcg/kg/min
• Milrinone 0.25-1 mcg/kg/min
• Amrinone 3-10 mcg/kg/min
• Nitroglycerine 0.25-5 mcg/kg/min
• Isosorbide nitrate 0.01 mg/kg/day
• Enalapril 0.1-1 mg/kg/day
• Furesemide 1-3 mg/kg/day (oral)
1mg/kg/day (iv)
• Spinolactone 1-3 mg/kg/day
• Digoxin Premature 20 μg/kg
Full term 20-30 μg/kg
Infant and children 25-40 μg/kg
Digitalisation (orally ) ½ dose initially followed by ¼ after 8
hours followed by ¼ dose after 16 hrs of 1st dose
Maintainence 5-10 μg/kg/day

9. Comparison of Guidelines for the Management of Systolic Dysfunction*
Drug class Heart Failure Society of America4
ACE inhibitors All patients with systolic dysfunction
Beta blockers All patients in NYHA class II and III
Insufficient evidence to recommend for patients in NYHA
class IV
Considered for patients in NYHA class I
Spironolactone (Aldactone) “Considered for patients receiving standard therapy who
have severe heart failure (class IV)”
Diuretics All symptomatic patients, dosed as necessary to control
symptoms
Digoxin (Lanoxin) “Considered for patients who have symptoms of heart
failure and NYHA class IV…while receiving standard
therapy”