Pediatric heart murmurs: evaluation and management in primary care

The ability of the NP to discern pediatric heart murmurs is critical for accurate assessment of etiology, appropriate diagnostic testing, and prudent referral when indicated. This review includes an overview of cardiac assessment, distinguishing features of innocent and pathologic murmurs, differential diagnosis of murmurs, and current referral recommendations.     

Interrater and intrarater agreement on heart murmurs

ObjectiveTo investigate interrater and intrarater agreement between physicians and medical students on heart sound classification from audio recordings, and factors predicting agreement with a reference classification.DesignIntra- and interrater agreement study.SubjectsSeventeen GPs and eight cardiologists from Norway and the Netherlands, eight medical students from Norway.Main outcome measuresProportion of agreement and kappa coefficients for intrarater agreement and agreement with a reference classification.ResultsThe proportion of intrarater agreement on the presence of any murmur was 83% on average, with a median kappa of 0.64 (range k = 0.09–0.86) for all raters, and 0.65, 0.69, and 0.61 for GPs, cardiologist, and medical students, respectively.The proportion of agreement with the reference on any murmur was 81% on average, with a median kappa of 0.67 (range 0.29–0.90) for all raters, and 0.65, 0.69, and 0.51 for GPs, cardiologists, and medical students, respectively.Distinct murmur, more than five years of clinical practice, and cardiology specialty were most strongly associated with the agreement, with ORs of 2.41 (95% CI 1.63–3.58), 2.19 (1.58–3.04), and 2.53 (1.46–4.41), respectively.ConclusionWe observed fair but variable agreement with a reference on heart murmurs, and physician experience and specialty, as well as murmur intensity, were the factors most strongly associated with agreement.

Key points:

• Heart auscultation is the main physical examination of the heart, but we lack knowledge of inter- and intrarater agreement on heart sounds.
• • Physicians identified heart murmurs from heart sound recordings fairly reliably compared with a reference classification, and with fair intrarater agreement.
• • Both intrarater agreement and agreement with the reference showed considerable variation between doctors
• • Murmur intensity, more than five years in clinical practice, and cardiology specialty were most strongly linked to agreement with the reference.

     

Intensive care management of children following heart and heart-lung transplantation

We report the intensive care management of 23 children (age 3–15 years) following orthotopic heart (HT) and combined heart and lung transplantation (HLT) performed at our 2 institutes between February 1985 and August 1989. Cyclosporin A, azathioprine and steroids were given as routine immunosuppression, whilst anti-thymocyte globulin (ATG) was used for the first 3 post-operative days. Mean ventilation time was 24.6 h (range 4–74 h). Cardiovascular support comprised isoprenaline infusions in all patients (mean period 65.7 h) whilst dopamine and other inotropic agents were used less frequently. Sequential atrioventricular pacing was required more often in the HT patients (n=9) than in the HLT patients (n=4). Fluid input was restricted to maintain a plasma osmolality of 290–300 mosm/kg. There were 2 perioperative deaths both due to acute right heart failure. Other post-operative complications included: bleeding (n=3); acute graft rejection (n=4); infection (n=3); systemic hypertension (n=6); neurological abnormalities (n=2); renal dysfunction (n=6) and hyperglycaemia (n=6).     

Evaluation and management of infants and young children with fever

A practice guideline for the management of febrile infants and children younger than three years of age sparked controversy when it was published in 1993. Surveys indicate that many office-based physicians do not agree with recommendations for venipuncture and bladder catheterization in nontoxic febrile children, and that many employ watchful waiting rather than empiric antibiotic therapy. Surveys of parents note a preference for less testing and treatment. More aggressive management may be appropriate in febrile infants younger than three months old; however, criteria have been proposed to identify infants older than one month who are at low risk for serious bacterial infection. Because of widespread vaccination against Haemophilus influenzae infection, Streptococcus pneumoniae has become the cause of most cases of bacteremia. The risk of serious bacterial infection is greater in younger children and in those with higher temperatures and white blood cell counts. Controversy persists regarding the age, temperature and white blood cell count values that serve as indications for further evaluation or empiric antibiotic therapy.     

Evaluation of internal behaviors of children with congenital heart disease

This study was designed to determine how internal behaviors of children with congenital heart disease were handled by their mothers. The study group included the mothers of 96 children randomly selected (ages ranging from 4 to 11 years) who were being monitored at the Institute of Cardiology. A 21-item questionnaire was administered to obtain information about the mother and the child. Internal subsets of the Child Behavior Check List (CBCL)/4-18 were performed, including withdrawn aggressive behaviors, somatic complaints, and anxiety/depression tests. The results showed that factors influencing withdrawn aggressive behavior were low parent education (p =.000), poor economic status of the family (p =.02), and aggravation of the hemodynamic status of the disease (p =.003). The factors influencing somatic complaints were low parent education (p =.000) and severity of the hemodynamic status of the disease (p =.02). An increase in the number of children in the family seemed to have an effect on anxiety/depression levels (p =.009).     

Evaluation of Web sites on management of pain in children.

Increasingly, consumers access the Internet for information about their health problems and treatments and to learn more about their health care. Although Web sites can be valuable resources, the information may not be accurate or current. The purpose of this project was to evaluate the quality of Web sites for parents on the management of children's pain. The Health Information Technology Institute criteria were used to evaluate 40 Web sites identified from two search engines: MSN and Google. After the evaluation process was completed, the readability of the sites was determined. Of the 40 sites, 29 (72.5%) provided useful information for parents searching to educate themselves about pain management. Other sites advertised the pain management services of their facility or were not relevant for patient education. The reading levels of the Web sites ranged from grade 7.7 to 12; the mean reading grade level of the 40 sites was 10.8, too high for many consumers. This article discusses the role of the nurse in evaluating health Web sites and teaching patients how best to use the Web for their health information.     

低龄、低体重先天性心脏病患儿体外循环管理体会

目的 探讨低龄、低体重先天性心脏病患儿在心内直视手术中的体外循环管理方法.方法 收集2016年12月至2018年6月68例低龄、低体重先天性心脏病患儿进行心内直视手术的体外循环资料,观察分析体外循环转流时间、升主动脉阻断时间、转中尿量、平均滤液、呼吸机辅助时间、胸腔引流量和死亡病例等情况.结果 全组患儿均顺利完成手术,...     

心脏不停跳小儿先天性心脏病姑息手术的体外循环管理

目的总结心脏不停跳下行复杂先天性心脏病姑息手术的体外循环(cardiopulmonary bypass,CPB)管理特点。方法我院2011年1月至2013年12月在CPB心脏不停跳下行复杂先天性心脏病姑息手术30例,术中维持红细胞压积0.22~0.25,温度34~36℃,血浆胶体渗透压在正常范围,监测指标包括平均动脉压﹑中心静脉压、心率﹑静脉混合血氧饱和度﹑乳酸、尿量﹑血浆胶体渗透压、鼻咽温和肛温。结果全组CPB时间12~140 min[(45.06±27.27)min],术后气管插管时间4~50 h[(17.26±8.29)h],监护时间46~160 h[(93.05±32.92)h],超滤量400~1200 ml[(713.66±209.80)ml],尿量5~100 ml[(33.33±20.98)ml],住院时间10~30 d[(18.83±4.43)d],术后24 h胸引量30~120 ml[(70.40±27.07)ml]。患儿术中、终止CPB时红细胞压积(HCT)、氧分压(Pa O2)、二氧化碳分压(Pa CO2)、剩余碱(BE)、乳酸等指标与术前比较差异有统计学意义(P<0.01)。所有患儿均顺利脱离CPB,无CPB相关并发症,术后恢复顺利。结论采用合适的预充方案,合理的血液稀释,严密监测术中指标,心脏不停跳下行复杂先天性心脏病姑息手术有更好的心肌保护,是安全可行的,可促进患儿早期恢复。