1. Moderator – Dr Bhalla Presentor – Dr Priya www.anaesthesia.co.in anaesthesia.co.in@gmail.com

2.  Harneet  8m male child  Resident of Ludhiana  Informant : mother

3.  Difficulty in feeding × 7 m  Increased respiratory rate × 7m

4.  H /O sweating while feeding, frequent interruption while feeding  H/O fast breathing with chest retractions  H/O visible cardiac pulsation  H/O poor weight gain

5.  No H/O bluish discolouration while crying  No H/O abdominal distention  ↓urine output  swelling of face and feet  No H/O fever with spots over body

6.  No history of any other illness in past  Family history : first child, no similar complaints  Antenatal history :  Regular follow up  No intake of drugs, no H/O fever with rash  USG normal

7.  Birth history : full term vaginal delivery at hospital  Cried immediately after birth  Developmental history :  Can sit without support and hold head  Immunization history :  Adequately immunized for age

8.  Treatment history :  Furosemide + spironolactone and digoxin

9.  Conscious lying on bed  Pallor – absent  No cyanosis,ikterus, clubbing or edema  VITALS:  PR :120 /min regular rhythm,normal volume,no delay  BP: 86/ 50 mm hg right arm supine  RR : 48/min subcostal retractions present

10.  Temp : afebrile to touch  Height : 64 cm  Weight : 6.2kg  Anterior fontanalle : not depressed  Venous access : adequate  No other visible malformations

11. Systemic Examination :-  Cardiovascular system :  Inspection :- precordial bulge - present visible pulsation + no scar mark abnormality of skeletal structure.  Palpation :- Apex beat – left 5 th ICS in MCL palpable thrill. parasternal lift. 11

12.  Auscultation :- S1 & S2 audible S2 accentuated & split over pulmonary area. Pan-systolic murmur at apex & LLSB. 12

13.  Inspection : no visible chest wall deformity  No visible pulsation seen  Auscultation: B/L vesicular air sounds +, no added sounds Central nervous system :-  conscious, apathetic  no sensory or motor deficit  reflexes normal.

14.  Provisional diagnosis :- Acyanotic congenital heart disease with left to right shunt without CHF or infective endocarditis 14

15.  Hb – 11.2  TLC – 9600  Na /K – 146/ 4.6  CXR - cardiomegaly, ↑ pulmonary vascularity  Echo : LA + LV enlarged, RA/ RV normal, 8 mm mid muscular VSD, mild MR

17. Congenital Incidence of CHD :8 / 1000 live birth  Cyanotic: 22%  Acyanotic: 68% ◦ VSD25% ◦ ASD6% ◦ PDA6% ◦ PS5% ◦ AS5%

18.  Most common CHD  2.6 to 5.7 /1000 live birth  10 % of adult CHD  TYPES :- 1. Subpulmonary (5-7 % )- with AV insufficiency 2. Perimembranous (80 %)-with tricuspid valve abnormality 3. A-V canal (5-8%) 4. Muscular (5 -20 % )- multiple defect  Restrictive, non- restrictive  Small, medium, large (in relation to aortic root )

20.  Extra cardiac malformation in 20-45 % - Trisomy 21,18,13 - CHARGE syndrome - Fetal hydantion syndrome - Fetal alcohol syndrome - Fetal valproate syndrome - Apert syndrome

21. Severity of VSD :– - loud P2, parasternal lift/heave - duration of murmur - diastolic murmur at mitral area - features of CCF

22. LARGE L- R SHUNT ↑ PVR ↑ LA SIZE ↑ LA PRESSURE INTERSTITIAL AND ALVEOLAR EDEMA ↑ PA FLOW ↑ PA PRESSURE ENLARGEMENT OF VESSELS BRONCHIAL HYPERTROPHY AIRWAY OBSTRUCTION ↑ AIRWAY RESISTANCE ↓ PULMONARY COMPLIANCE INCREASED WORK OF BREATHING GAS TRAPPING, ATELECTASIS, INFECTION

23.  Spontaneous closure of defects less than 5mm before 5 yrs of age (40-50%).  Natural course depends on – size, change in PVR, age  Large defects – CHF in infancy (2-6 wks), when PVR falls  Tachypnea, Distress, Sweating while feeding, Failure to thrive  CHF- apathetic, no movement, weak cry, diaphoretic, hepatomegaly  Indications for surgical closure- >6.5 mm, Qp:Qs ratio >2

25. Preload HR HRContractilityPVRSVR VSD (L → R) unrepaired ↑NN↑↓ VSD (L → R) repaired ↑NNNN VSD (R → L) ↑NN↓↑