Acute changes in condition: Caring for a child with myocarditis. Looking at the first 48 hours of admission

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Beverly Wood
5 years ago
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1 Acute changes in condition: Caring for a child with myocarditis Looking at the first 48 hours of admission

2 Demographics introduction Nosi TB GIRL HIVUNEXPOSED 5 years old 15kg, well nourished 1 of 4 children Born in Zimbabwe Now lives in Langa, informal housing. Toilet and H20 outside Mum is primary caregiver

3 All the children have had measles in the last two weeks Genogram

4 History Presented to S12 at Red Cross children s hospital on Sunday at 14h30 Mum says she was fine this morning but now breathing fast and noisy

5 Assessment on arrival Investigations: Arterial blood gas: Gas exchange satisfactory, Lactate 4.9, Glucose 20 Chest x-ray: extensive R side consolidation and gross cardiomegaly

6 Initial management in S12 1. Diagnosed to be in congestive cardiac failure with rightsided pneumonia that has led to CARDIOGENIC SHOCK. 2. Intubated and ventilated 3. IV access gained and antibiotics given and morphine commenced 4. Furosemide given to reduce the fluid load on the heart 5. Dobutamine commenced at 10mcg/kg/min to increase the contractility of the heart 6. Echo performed: Normal structure but dilated LA and LV ACUTE MYOCARDITIS, SECONDARY TO MEASLES? 7. Measles IGM sent to lab and Rapid performed 8. Referred to ICU

7 Transferred to ICU where. Normal values ph pco po Base excess Bicarb Lactate 8.2 Less than 2 Glucose 27 Less than 7 Pink frothy secretions (pulmonary oedema): Sats = 100% but HFO Temp up to 38.6 o C BP now 110/89. Milrinone added at 1.5mcg/kg/min Liver size reduced Arterial line and central line placed.

8 At midnight on Sunday/Monday Nosi suctioned and turned prone. BP and HR dropped and she had a cardiac arrest. After approx. 6 mins of CPR and x2 bolus of adrenaline her re-started Adrenaline 0.3 mcg/kg/min, dobulatime 10mcg/kg/min, Milrinone 1.5 mcg/kg/min Urine output post arrest to 0.2ml/kg/hr Mum counseled as to the severity of Nosi s condition

9 First blood gas post arrest was very poor Blood gases Initial ABG post switch poor 12h28 01h00 01h25 02h00 Normal values ph pco po Base excess Bicarb Lactate Less than 2 Decision made to switch her to conventional ventilation Repeated 30 mins later and better

10 12 hours later (Monday at midday)

11 20 hours later (Tuesday morning, less than 48 hours post admission) Important message: Children can deteriorate very quickly BUT children can also get better very quickly as well

12 What is myocarditis? Can be acute or chronic.

13 Pathophysiology of myocarditis The amount of damage determines the severity of symptoms and the prognosis of the illness

14 Concerns: cardiac output as a result of contractility Volume overload work on the heart Management: No treatment for myocarditis Support cardiac function Find and treat the cause

15 Nursing care focusing on the myocarditis Mother to Child Interaction: o Mum been counselled as to the severity of the situation o Needs updates + encouraged to be at the bedside for her and Nosi s comfort Pain and comfort: o Very deeply sedated initially to reduce the workload on the heart. o Midazolam, morphine, valium + vecuronium as required o Non-pharmacological analgesics as well

16 Hydration: o Fluid restricted to 45% of normal + Furosemide prescribed to reduce fluid pressure on the heart o Assess hydration regularly and urine output continuously. o Check urea and creatinine already abnormal + receiving many nephrotoxic medications Nutrition: o Re-starting feeding is important (12 hours later) o Increase slowly to check for tolerance post arrest.

17 Microbial Load: o Polygam prescribed to replace antibodies. o Steriods given to reduce inflammation and weaken immune system. o Strict VAP measures ( risk of infection due to weaken immune system +?aspirated during induction) o Administer prescribed gentamycin and check levels. o Observe infection markers (WBC, Hb, CRP and bands) and act empirically if raised. Mucosal Integrity: o Refer to dermatology for her peeling feet

18 Regulatory systems o Need to regulate the BP + heart rate and improve cardiac output o Dobutamine - increases HR but does reduce afterload Commenced in med reg but stopped once diagnosis made. o Milrinone - Doesn t affect HR as much AND acts as a effective afterload reducer Commenced in ICU following diagnosis. o Adrenaline - Required post arrest to increase HR and BP Important to reduce quickly as acts against the Milrinone.

19 Regulatory systems continued.. o Paracetamol given to reduce temperature o Observe glucose and lactate on the blood gases both reduced without intervention as Nosi improved. o Ensure that Nosi gets sleep/settled time provide quiet dark time in the ICU

20 Acute changes in condition Big changes can be happen in small amounts of time

21 THANK YOU! This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 2.5 South Africa License. To view a copy of this license, visit or send a letter to Creative Commons, 444 Castro Street, Suite 900, Mountain View, California, 94041, USA.

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