In this episode of PICU DOC on Call, Dr. Rahul Damania and Dr. Pradip Kamat chat about a challenging case involving a 15-year-old girl dealing with acute myocarditis and worsening respiratory failure. They explore the intricate dance between the heart and lungs, especially how positive pressure ventilation can affect heart function. They cover important topics like cardiac output, preload, and afterload, and discuss the delicate balance needed to manage myocarditis effectively. The episode offers practical tips for optimizing care for critically ill children, underscoring the importance of personalized treatment plans and teamwork in pediatric critical care. Tune in!

Show Highlights:

Clinical case of a 15-year-old girl with acute myocarditis and respiratory failure
Importance of understanding cardiopulmonary interactions in pediatric critical care
Effects of positive pressure ventilation on cardiac function
Key concepts of cardiac output, preload, and afterload in the context of myocarditis
Challenges of managing hemodynamic instability in critically ill pediatric patients
Differences between spontaneous breathing and positive pressure ventilation
Strategies for optimizing preload and fluid management in myocarditis patients
Tailoring ventilatory support and transitioning to invasive mechanical ventilation
Monitoring for arrhythmias and managing myocardial function with inotropic support
Importance of frequent assessments and collaboration with cardiac ICU teams for patient care

Management Strategies

Optimizing Preload:

Volume depletion is common in patients with hypotension and tachycardia. A careful fluid challenge is important to restore circulatory volume, but fluid overload should be avoided, especially with impaired left ventricular function.

Tailoring Ventilatory Support:

Adjust BiPAP settings to improve oxygenation without overloading the heart with excessive positive pressures.
Use the optimal level of PEEP to recruit alveoli while maintaining adequate venous return to the heart.

Supporting Myocardial Function:

Inotropic support (e.g., milrinone) may be necessary to improve myocardial contractility. Milrinone also provides vasodilation, which can reduce afterload but must be used cautiously due to its potential to lower blood pressure.

Frequent Reassessments:

Bedside echocardiography and regular monitoring of biomarkers (lactate, BNP) and clinical status are essential for ongoing evaluation.
In severe cases, advanced therapies like ECMO may be required if the patient’s hemodynamic status continues to deteriorate.

Cardiopulmonary Interactions (basics) in the PICU

PICU Doc On Call