Congestive Cardiac Failure

Heart failure in newborn infants is caused not only by structural heart disease but also by other systemic disorders. Causes of congestive heart failure include (1) structural heart disease (most commonly transposition of the great vessels and hypoplastic left heart syndromes), (2) heart disease without structural abnormalities (myocarditis, cardiac dysrhythmias, glycogen storage disease, and endocardial fibroelastosis), (3) respiratory disease with patent ductus arteriosus with left-to-right shunt, (4) anemia (hemoglobin < 3.5 g/dL), (5) polycythemia, (6) cerebral or other arteriovenous malformation, and (7) sepsis.

The most frequent symptoms are feeding difficulties, tachypnea, increased sweating, tachycardia, rales and rhonchi, liver enlargement, and cardiomegaly. Less common signs and symptoms are ascites, gallop rhythm, pulsus alternans, and increase in central venous pressure. Peripheral edema is exceedingly rare. A clear distinction between right heart failure (characterized by liver enlargement, tachycardia, and dependent edema) and left heart failure (cardiomegaly, rales, tachypnea, and tachycardia) is not as obvious in the neonate as in the older child or adult.

TREATMENT It is essential to monitor the heart and respiratory rates and blood pressure closely. Blood gas levels should be determined frequently to identify and treat hypoxemia or acidosis. Fluid intake should be restricted to 100 (mL/kg)/day and adjusted according to the weight, liver size, and urine output. Electrolyte levels should be monitored closely. Anemia should be corrected with packed red blood cell transfusions. The neonate should be on a 10 to 30° incline with the head elevated inside the incubator.

Infants with heart failure should receive digoxin unless the heart rate is below 100 beats per minute. The digitalizing oral dose of digoxin is 0.03 mg/kg for term neonates. For digitalization, half the calculated digitalizing dose should be given initially, a fourth in 8 h, and another fourth in 8 h, with maintenance started 12 h after the last digitalizing dose. The maintenance dose is one-fourth of the total digitalizing dose in two divided doses. Serum K + levels should be checked and monitored.

Furosemide (Lasix) is the drug of choice for a rapid response and should be used intravenously (1 to 3 mg/kg). Maintenance therapy with hydrochlorothiazide (Diuril) and spironolactone (Aldactone) to help conserve potassium may be necessary.

Neonates with severe heart failure from left-to-right shunts with cardiogenic shock and bradycardia may require b-adrenergic drugs for inotropic action. Isoproterenol (Isuprel) may be infused at 0.1 (pg/kg)/min, increased to 0.4 (pg/kg)/min until the heart rate is 140 beats per min. Dopamine is useful in hypotensive shock and should be infused at 5 to 15 (pg/kg)/min. Both medications should be discontinued slowly while heart rate and blood pressure are monitored.

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