Epidemiological, Diagnostic and Therapeutic Aspects of Cardiogenic Shock in Children at the Albert Royer Children’s Hospital in Dakar ()
1. Introduction
Cardiogenic shock is an acute circulatory failure due to impaired myocardial contractility resulting in decreased cardiac output and pulmonary congestion [1]. It is an immediate life-threatening emergency. More frequent in adults, in whom it represents the main cause of mortality of patients hospitalised for myocardial infarction, cardiogenic shock is much rarer in children [2]. In children and infants, it can occurde novo in a healthy heart or in pre-existing congenital or chronic heart disease [3]. Heart failure in paediatric populations is a major public health problem. It is associated with high rates of hospitalisation, disability and mortality in high-income countries, but its burden is poorly documented in developing countries [4]. There are few published studies on cardiogenic shock in children worldwide and none in Senegal. It is in this context that we conducted this study to evaluate the epidemiological, diagnostic and therapeutic aspects of cardiogenic shock in children.
2. Methodology
This work was carried out at the Centre Hospitalier National d’Enfants Albert Royer (CHNEAR), which is the only exclusively paediatric level 3 public health establishment (EPS) in the Dakar region. It houses a paediatric cardiology department where the majority of children with congenital or acquired heart disease are followed. The study was retrospective, descriptive and analytical over a period of 14 months (from 01 January 2020 to 28 February 2021). Epidemiological, diagnostic, therapeutic and evolutionary parameters were collected from medical records and hospital registers. We included all children aged 2 months to 16 years hospitalised for cardiogenic shock confirmed on the basis of clinical criteria such as: tachycardia, prolonged skin recolouration time, arterial hypotension associated with signs of heart failure (hepatomegaly, gallop rhythm, cardiomegaly, oedema of the lower limbs) and echographic criteria: alteration of the RF (shortening fraction). The data were entered in Excel and analysed using SPSS (Statistical Package for Social Sciences) Statistics version 25. The significance threshold was retained for a p-value < 0.05. Patients were initially hospitalised in the reception and emergency department for stabilisation before being transferred to the paediatric cardiology department for follow-up. The duration of follow-up will depend on the patient’s progress and the type of heart disease.
3. Results
During the period of our study 894 patients were hospitalised, of whom 164 for heart disease and 38 for cardiogenic shock, i.e. a hospital prevalence of 4.2%. Cardiogenic shock occurred in 23% of patients hospitalised for heart disease. The mean age was 64 months with a standard deviation of 67, the sex ratio was 1.92 in favour of girls. Parental consanguinity was found in 16 (42%) of our patients. The socio-economic level of our patients was considered low in 28 patients (74%), 26 (68%) of the patients came from the suburbs of Dakar. The socio-demographic characteristics are summarised in Table 1. Heart disease was diagnosed before the onset of cardiogenic shock in 24 (89%) patients. Infection
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Table 1. Socio-demographic characteristics.
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Table 2. Distribution according to the triggering factor of cardiogenic shock.
was identified as a trigger for cardiogenic shock in 18 (52.9%) of our patients (Table 2). The most common type of heart disease was rheumatic heart disease in 12 (32%) of the patients (Figure 1). The most common clinical signs were tachycardia, which was present in all our patients, as well as dyspnoea and cold extremities (Table 3). Respiratory distress was severe in 31 patients (81.6%) according to the clinical classification (CRS). All our patients had received dobutamine and oxygen therapy, 36 patients had received furosemide, 16 (42%) were intubated and ventilated. The evolution was marked by death in 25 of our patients; that is 65.8% (Table 4). All our deceased patients had respiratory distress classified as moderate or severe according to the CRS. All patients with a shock duration of more than 12 hours died (Table 5). All patients admitted with a shortening fraction (RF) on cardiac ultrasound of less than 16 (44%) died. Patients admitted with a RF of more than 22 had a favourable outcome.
4. Discussion
During the study period, 894 patients were hospitalised at the CHNEAR reception and emergency department, including 164 for heart disease and 38 for cardiogenic shock, i.e. a hospital prevalence of 4.2%. This prevalence is comparable
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CMDH: Hypokinetic Dilated Cardiomyopathy; PCA: Persistence of the Arterial Canal; T21: Down syndrome.
Figure 1. Type of heart disease found.
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Table 3. Clinical signs of cardiogenic shock.
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Table 5. Evolution according to the duration of the shock.
to that found by Abrik et al. in Morocco in 2017 (3.7%) [5]. The higher prevalence in our study could be explained by the lack of paediatric cardiologists in the periphery. Most of our patients, 31% or 81%, came from the Dakar region. These results are comparable to the results of Sylla et all in 2017 [6]. Dakar is the location of the CHNEAR which is a referral centre that polarises the population of Dakar and its suburbs. The socio-economic level was low in 73% of our patients. Azagoh-Kouadio et al. [7] found 61% of low socio-economic level in Côte d’Ivoire. Our results are in line with the literature which identifies low socio-economic level as a risk factor for the occurrence of acquired heart disease [8] [9]. Cardiogenic shock in children occurs most often in the presence of known heart disease [1] [10]. Indeed, in our series, 89% of the patients already had a known heart disease. However, we noted that 11% of our patients had no known cardiac disease. This could be explained by the number of under-diagnosed heart diseases linked to the lack of cardio pediatricians in Senegal. In our series, the etiologies found are similar to the data found in the literature. Indeed, Paut et al. in 2010, found 30% of congenital heart disease in the etiologies of cardiogenic shock [11] [12]. Furthermore, Chebab et al. in 2005 found a predominance of rhythm disorders and coronary birth defects (ALCAPA) in the etiologies of cardiogenic shock in children. These aetiologies were not found in our series and this could be due to an under-diagnosis because of the lack of exploration means such as the paediatric ECG. Rhythm disorders and coronary birth defects have been found in several European series and constitute the main etiology of cardiogenic shock in children [13] [14]. Blood pressure was unstoppable in 39% of our patients. However, Randrianarison et al. in 2013 found unstoppable blood pressure in 22% of patients [15]. The higher rate of impregnable blood pressure in the study could be explained by the fact that the majority of our patients came from the periphery, which delayed management. However, the recognition of cardiogenic shock is a diagnostic and above all a therapeutic emergency, as any delay in initiating appropriate treatment may lead to irreversible visceral damage. The presence of arterial hypotension is a sign of the advanced stage of cardiogenic shock in children [5].
The main therapeutic means used in our study were dobutamine and noradrenaline. In addition, 16 of our patients received mechanical ventilation. Other molecules are increasingly used in the treatment of cardiogenic shock, notably phosphodiesterase III (PDE III) inhibitors such as milrinone [16]. None of our patients benefited from ECMO (Extracorporeal Membrane Oxygenation) which is a therapeutic means indicated in refractory cardiogenic shock [17] [18]. The death rate in our series was 65%. The higher mortality in our study could be explained by several factors. Indeed, in our study, several therapeutic means were not used, notably second-line means in case of refractory shock, and the delay in the management of patients coming from the periphery. This can be explained by the technical platform which is still at a low level in our developing countries. Several means of resuscitation are not available in our hospitals.
The evolution of the patients depended on the severitý of the cardiac damage. Indeed, in our study, all the patients who had an RF below 16 died and those with an RF above 22 evolved well. In several scientific series, the RF was considered as a prognostic element. Indeed, Bounhoure et al. in 2002 demonstrated that the lower the RF, the higher the risk of death [19].
5. Conclusion
Cardiogenic shock is a diagnostic and therapeutic emergency. It is a rare pathology in the pediatrics setting with little data available, especially in developing countries. Its diagnosis is often late in our country and its mortality is still very high. The improvement of the mortality rate could be achieved by improving the technical platform and the training of health personnel.