Q1. Suggest the best therapeutic regimen to control/overcome the current situation.
Ans: Major goals in the treatment of congestive heart failure:
- relief of pulmonary and systemic venous congestion,
- improvement of myocardial performance, and
- reversal of the underlying disease process (if possible).
a. Digoxin 10 mcg/kg/24 hr
-Exerts positive ionotropic effect
-Digoxin also exerts beneficial effects via sympathetic-inhibiting actions via baroreceptor, central, and adrenergically mediated mechanisms.
**Digoxin “holiday” (5/7) is generally not needed in children.
b. Furosemide 1mg/kg/dose IV 24hrly
-monitor closely (digoxin and electrolyte level)
(**Spironolactone therapy can be used. *Refer pdf.: ref-3)
c. Captopril 15-0.3 mg/kg/dose PO
(2.5-6 mg/kg/day usually required)
– For afterload reduction.
** The benefits of diuretic therapy include improvement in systemic, pulmonary (cough management), and venous congestion.
**If respiratory distress condition is not suppressed, then the alternative means to treat is to increase the air pressure within the alveolus to counterbalance the excessive hydrostatic pressure with positive pressure ventilation via mask CPAP (continuous positive airway pressure) or through an endotracheal tube with a ventilator.
Other non-pharmacologic therapeutic measures that may be considered:
- elevation of the head and shoulders to 30ᵒ to 45ᵒ,
- dietary changes
- packed red blood cell transfusion (if required),
- iron supplementation, and
- the administration of supplemental oxygen.
Other useful laboratory studies may include:
- Serum electrolytes (including calcium and magnesium levels), and
- Complete Blood Count
**Pediatric patients with heart failure will often have a mild hyponatremia, resulting from increased renal water retention rather than a true negative sodium balance. Mild hyponatremia, therefore, does not need to be treated. Administering supplemental sodium may actually worsen the patient's fluid retention and heart failure.
NOTE: Ondansetron(EMESET) is approved for patients aged more than 6 months old. Or if given for age group for 1month, dose should be 0.1mg/kg (single). Diarrhea can be seen. (Ref- Ciplamed).
**For IVF use, see ref-2
**For further follow up, see ref-1
Q2. Should she be referred for surgical correction of Ventricular Septal Defect after the drug regimen has been started?
Ans: If the VSD condition is not compensated by medical therapy. She should be
referred for surgical correction of the ventricular septal defect at/after 6 months of age (recommended).