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Moderator – Dr Bhalla Presentor – Dr Priya www.anaesthesia.co.in anaesthesia.co.in@gmail.com
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Harneet 8m male child Resident of Ludhiana Informant : mother
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Difficulty in feeding × 7 m Increased respiratory rate × 7m
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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
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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
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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
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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
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Treatment history : Furosemide + spironolactone and digoxin
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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
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Temp : afebrile to touch Height : 64 cm Weight : 6.2kg Anterior fontanalle : not depressed Venous access : adequate No other visible malformations
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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
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Auscultation :- S1 & S2 audible S2 accentuated & split over pulmonary area. Pan-systolic murmur at apex & LLSB. 12
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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.
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Provisional diagnosis :- Acyanotic congenital heart disease with left to right shunt without CHF or infective endocarditis 14
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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
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Congenital Incidence of CHD :8 / 1000 live birth Cyanotic: 22% Acyanotic: 68% ◦ VSD25% ◦ ASD6% ◦ PDA6% ◦ PS5% ◦ AS5%
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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 )
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Extra cardiac malformation in 20-45 % - Trisomy 21,18,13 - CHARGE syndrome - Fetal hydantion syndrome - Fetal alcohol syndrome - Fetal valproate syndrome - Apert syndrome
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Severity of VSD :– - loud P2, parasternal lift/heave - duration of murmur - diastolic murmur at mitral area - features of CCF
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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
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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
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Preload HR HRContractilityPVRSVR VSD (L → R) unrepaired ↑NN↑↓ VSD (L → R) repaired ↑NNNN VSD (R → L) ↑NN↓↑
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