section name header

Questions

  

B.7. How would you optimize the preoperative treatment of HF?

Answer:

The typical manifestations of CHF in infants (ie, tachycardia, tachypnea, subcostal retractions, and rhonchi) are also cardinal signs of pulmonary infection in this age group. They can be difficult to distinguish. Often, they coexist, and treatment must address both conditions. In this patient, the structural abnormality of the IAA needs surgical correction; however, correction must be deferred until the neck mass is resected. In this infant, CHF is caused by pressure overload from the IAA, and the hypocalcemia is due to parathyroid hormone insufficiency. Calcium must be normalized by intravenous infusion. If glucose is low, as would be expected in an infant who is unable to feed by mouth, has glycogen depletion from the stress of illness, has an immature liver that is unable to generate sufficient gluconeogenesis, and has an increased utilization from a baseline higher metabolic rate (compared to adults), a glucose source should be continuously provided by slow intravenous administration. Myocardial work is compromised by the presence of metabolic acidosis, which occurs as a consequence of the increased lactic acid production during anaerobic metabolism, resulting from lower body hypoperfusion. The pH should be normalized with sodium bicarbonate.

With the guidance of a pediatric cardiologist, myocardial function should be optimized with angiotensin converting enzyme (ACE) inhibitors, β-blockers, and digoxin in infants with HF. A catecholamine (eg, epinephrine, dopamine, or dobutamine) can be infused to boost contractility. Pulmonary symptoms should be treated with antibiotics and positive pressure ventilation (ie, high-flow nasal cannula, nasal continuous positive airway pressure [CPAP]) with oxygen titrated to arterial blood gas measurements. Intubation and mechanical ventilation might be necessary in many infants with HF. Diuresis with furosemide, in conjunction with fluid restriction, will promote restoration of pulmonary compliance by decreasing lung water.

References