АВ-блокада 1-3ст.Ребенок 11 мес.

[Korzun]

Распечатайте и показывайте всем единственное стоящее руководство по брадикардиям в мире. Чтобы избежать глупых и опасных фантазий.
https://forums.rusmedserv.com/attach...8&d=1523610809
Вот всё, что касается детей из этого руководства:

2.5. Pacing in Children, Adolescents, and Patients
With Congenital Heart Disease

The most common indications for permanent pacemaker
implantation in children, adolescents, and patients with
congenital heart disease may be classified as 1) symptomatic
sinus bradycardia, 2) the bradycardia-tachycardia synedromes, and 3) advanced second- or third-degree AV block,
either congenital or postsurgical. Although the general
indications for pacemaker implantation in children and
adolescents (defined as less than 19 years of age) (248) are
similar to those in adults, there are several important
considerations in young patients. First, an increasing number
of young patients are long-term survivors of complex
surgical procedures for congenital heart defects that result in
palliation rather than correction of circulatory physiology.
The residua of impaired ventricular function and abnormal
physiology may result in symptoms due to sinus bradycardia
or loss of AV synchrony at heart rates that do not produce
symptoms in individuals with normal cardiovascular physiology
(249,250). Hence, the indications for pacemaker
implantation in these patients need to be based on the
correlation of symptoms with relative bradycardia rather
than absolute heart rate criteria. Second, the clinical significance
of bradycardia is age dependent; whereas a heart rate
of 45 bpm may be a normal finding in an adolescent, the
same rate in a newborn or infant indicates profound
bradycardia. Third, significant technical challenges may
complicate device and transvenous lead implantation in very
small patients or those with abnormalities of venous or
intracardiac anatomy. Epicardial pacemaker lead implantation
represents an alternative technique for these patients;
however, the risks associated with sternotomy or thoracotomy
and the somewhat higher incidence of lead failure must
be considered when epicardial pacing systems are required
(251). Fourth, because there are no randomized clinical
trials of cardiac pacing in pediatric or congenital heart
disease patients, the level of evidence for most recommendations
is consensus based (Level of Evidence: C). Diagnoses
that require pacing in both children and adults, such as
long-QT syndrome or neuromuscular diseases, are discussed
in specific sections on these topics in this document.
Bradycardia and associated symptoms in children are
often transient (e.g., sinus arrest or paroxysmal AV block)
and difficult to document (252). Although SND (sick sinus
syndrome) is recognized in pediatric patients and may be
associated with specific genetic channelopathies (206), it is
not itself an indication for pacemaker implantation. In the
young patient with sinus bradycardia, the primary criterion
for pacemaker implantation is the concurrent observation of
a symptom (e.g., syncope) with bradycardia (e.g., heart rate
less than 40 bpm or asystole more than 3 seconds)
(53,86,253). In general, correlation of symptoms with bradycardia
is determined by ambulatory ECG or an implantable
loop recorder (254). Symptomatic bradycardia is an
indication for pacemaker implantation provided that other
causes have been excluded. Alternative causes to be considered
include apnea, seizures, medication effects, and neurocardiogenic
mechanisms (255,256). In carefully selected
cases, cardiac pacing has been effective in the prevention of
recurrent seizures and syncope in infants with recurrent
pallid breath-holding spells associated with profound bradycardia
or asystole (257).
A variant of the bradycardia-tachycardia syndrome, sinus
bradycardia that alternates with intra-atrial re-entrant
tachycardia, is a significant problem after surgery for congenital
heart disease. Substantial morbidity and mortality
have been observed in patients with recurrent or chronic
intra-atrial re-entrant tachycardia, with the loss of sinus
rhythm an independent risk factor for the subsequent
development of this arrhythmia (258,259). Thus, both
long-term atrial pacing at physiological rates and atrial ATP
have been reported as potential treatments for sinus bradycardia
and the prevention or termination of recurrent
episodes of intra-atrial re-entrant tachycardia (260,261).
The results of either mode of pacing for this arrhythmia
have been equivocal and remain a topic of considerable
controversy (262,263). In other patients, pharmacological
therapy (e.g., sotalol or amiodarone) may be effective in the
control of intra-atrial re-entrant tachycardia but also result
in symptomatic bradycardia (264). In these patients, radiofrequency
catheter ablation of the intra-atrial re-entrant
tachycardia circuit should be considered as an alternative to
combined pharmacological and pacemaker therapies (265).
Surgical resection of atrial tissue with concomitant atrial
pacing has also been advocated for congenital heart disease
patients with intra-atrial re-entrant tachycardia refractory to
other therapies (266).
The indications for permanent pacing in patients with
congenital complete AV block continue to evolve on the
basis of improved definition of the natural history of the
disease and advances in pacemaker technology and diagnostic
methods. Pacemaker implantation is a Class I indication
in the symptomatic individual with congenital complete AV
block or the infant with a resting heart rate less than 55
bpm, or less than 70 bpm when associated with structural
heart disease (267,268). In the asymptomatic child or
adolescent with congenital complete AV block, several
criteria (average heart rate, pauses in the intrinsic rate,
associated structural heart disease, QT interval, and exercise
tolerance) must be considered (208,269). Several studies
have demonstrated that pacemaker implantation is associated
with both improved long-term survival and prevention
of syncopal episodes in asymptomatic patients with congenital
complete AV block (270,271). However, periodic evaluation
of ventricular function is required in patients with
congenital AV block after pacemaker implantation, because
ventricular dysfunction may occur as a consequence of
myocardial autoimmune disease at a young age or
pacemaker-associated dyssynchrony years or decades after
pacemaker implantation (272,273). The actual incidence of
ventricular dysfunction due to pacemaker-related chronic
ventricular dyssynchrony remains undefined.
A very poor prognosis has been established for congenital
heart disease patients with permanent postsurgical AV
block who do not receive permanent pacemakers (209).
Therefore, advanced second- or third-degree AV block that
persists for at least 7 days and that is not expected to resolve
after cardiac surgery is considered a Class I indication for
pacemaker implantation (274). Conversely, patients in
whom AV conduction returns to normal generally have a
favorable prognosis (275). Recent reports have emphasized
that there is a small but definite risk of late-onset complete
AV block years or decades after surgery for congenital heart
disease in patients with transient postoperative AV block
(276,277). Limited data suggest that residual bifascicular
conduction block and progressive PR prolongation may
predict late-onset AV block (278). Because of the possibility
of intermittent complete AV block, unexplained syncope is
a Class IIa indication for pacing in individuals with a history
of temporary postoperative complete AV block and residual
bifascicular conduction block after a careful evaluation for
both cardiac and noncardiac causes.
Additional details that need to be considered in pacemaker
implantation in young patients include risk of paradoxical
embolism due to thrombus formation on an endocardial
lead system in the presence of residual intracardiac
defects and the lifelong need for permanent cardiac pacing
(279). Decisions about pacemaker implantation must also
take into account the implantation technique (transvenous
versus epicardial), with preservation of vascular access at a
young age a primary objective (280).

[Maksinna]

Я не знаю как Вас благодарить! Всё поняла!
Обследование проходили в НИКИ педиатрии им. Вельтищева (детское кардиологическое отделение нарушений сердечного ритма).
Преднизолон там назначили, на сегодня - снижаю дозировку, чтобы отменить постепенно, осталось 5 дней приема. Или резко бросать?
Про анемию поняла, буду лечить.

[Korzun]

По аритмиям лучше забыть НИИ педиатрии. Там кошмарные фантазеры, которым чихать на то, что делается в мире. По аритмиям для детей в Москве адекватен только Макаров Л.М.: [Ссылки доступны только зарегистрированным пользователям ]
Преднизолон постепенно.

[Korzun]

Продолжение:

Recommendations for Permanent Pacing in Children,
Adolescents, and Patients With Congenital
Heart Disease

CLASS I (Нужно!)
1. Permanent pacemaker implantation is indicated for advanced
second- or third-degree AV block associated with symptomatic
bradycardia, ventricular dysfunction, or low cardiac output.
(Level of Evidence: C)
2. Permanent pacemaker implantation is indicated for SND with
correlation of symptoms during age-inappropriate bradycardia.
The definition of bradycardia varies with the patient’s age and
expected heart rate. (Level of Evidence: B) (53,86,253,257)
3. Permanent pacemaker implantation is indicated for postoperative
advanced second- or third-degree AV block that is not
expected to resolve or that persists at least 7 days after cardiac
surgery. (Level of Evidence: B) (74,209)
4. Permanent pacemaker implantation is indicated for congenital
third-degree AV block with a wide QRS escape rhythm, complex
ventricular ectopy, or ventricular dysfunction. (Level of Evidence: B)
(271–273)
5. Permanent pacemaker implantation is indicated for congenital
third-degree AV block in the infant with a ventricular rate less
than 55 bpm or with congenital heart disease and a ventricular
rate less than 70 bpm. (Level of Evidence: C) (267,268)

CLASS IIa (Хорошо бы)
1. Permanent pacemaker implantation is reasonable for patients
with congenital heart disease and sinus bradycardia for the
prevention of recurrent episodes of intra-atrial reentrant tachycardia;
SND may be intrinsic or secondary to antiarrhythmic
treatment. (Level of Evidence: C) (260,261,264)
2. Permanent pacemaker implantation is reasonable for congenital
third-degree AV block beyond the first year of life with an average
heart rate less than 50 bpm, abrupt pauses in ventricular rate
that are 2 or 3 times the basic cycle length, or associated with
symptoms due to chronotropic incompetence. (Level of Evidence:
B) (208,270)
3. Permanent pacemaker implantation is reasonable for sinus bradycardia
with complex congenital heart disease with a resting
heart rate less than 40 bpm or pauses in ventricular rate longer
than 3 seconds. (Level of Evidence: C)
4. Permanent pacemaker implantation is reasonable for patients with
congenital heart disease and impaired hemodynamics due to sinus
bradycardia or loss of AV synchrony. (Level of Evidence: C) (250)
5. Permanent pacemaker implantation is reasonable for unexplained
syncope in the patient with prior congenital heart surgery
complicated by transient complete heart block with residual
fascicular block after a careful evaluation to exclude other
causes of syncope. (Level of Evidence: B) (273,276–278)

CLASS IIb (можно подумать)
1. Permanent pacemaker implantation may be considered for transient
postoperative third-degree AV block that reverts to sinus
rhythm with residual bifascicular block. (Level of Evidence: C) (275)
2. Permanent pacemaker implantation may be considered for congenital
third-degree AV block in asymptomatic children or adolescents
with an acceptable rate, a narrow QRS complex, and
normal ventricular function. (Level of Evidence: B) (270,271)
3. Permanent pacemaker implantation may be considered for
asymptomatic sinus bradycardia after biventricular repair of
congenital heart disease with a resting heart rate less than 40
bpm or pauses in ventricular rate longer than 3 seconds. (Level of
Evidence: C)

CLASS III (нельзя!)
1. Permanent pacemaker implantation is not indicated for transient
postoperative AV block with return of normal AV conduction in
the otherwise asymptomatic patient. (Level of Evidence: B)
(274,275)
2. Permanent pacemaker implantation is not indicated for asymptomatic
bifascicular block with or without first-degree AV block
after surgery for congenital heart disease in the absence of prior
transient complete AV block. (Level of Evidence: C)
3. Permanent pacemaker implantation is not indicated for asymptomatic
type I second-degree AV block. (Level of Evidence: C)
4. Permanent pacemaker implantation is not indicated for asymptomatic
sinus bradycardia with the longest relative risk interval
less than 3 seconds and a minimum heart rate more than 40
bpm. (Level of Evidence: C)

[Maksinna]

Почитала, насколько смогла, поняла без медицинского образования.
Александр Иванович, я правильно понимаю - я ребенка оставляю в покое и не провожу над ним больше никаких обследований и прочее. Если появляются вопросы, обращаюсь в ЦДКБ к Макарову Л.М.
Через 3 месяца после приема актифферина сдаем ферритин и делаем холтер?
А как часто потом нужно будет мониторить состояние и делать холтер, раз в год?
Из противопоказаний по жизни только профессиональный спорт, он может жить и развиваться как обычный здоровый ребенок?

[Korzun]

Сообщение от Maksinna

Почитала, насколько смогла, поняла без медицинского образования.
Александр Иванович, я правильно понимаю - я ребенка оставляю в покое и не провожу над ним больше никаких обследований и прочее. Если появляются вопросы, обращаюсь в ЦДКБ к Макарову Л.М.
Через 3 месяца после приема актифферина сдаем ферритин и делаем холтер?
А как часто потом нужно будет мониторить состояние и делать холтер, раз в год?
Из противопоказаний по жизни только профессиональный спорт, он может жить и развиваться как обычный здоровый ребенок?

Да. Как часто мониторить будет зависеть от того, что будет на том или ином Холтере. Может подправите анемию и все нормализуется, тогда можно будет забыть про Холтеры.

[Maksinna]

Александр Иванович, здравствуйте. По Вашим рекомендациям пропили актиферрин 3 месяца, по 17 кап 3 раза в день. На сентябрь такие результаты: гемоглобин 114, ферритин 110, железо 5.4. В мае было: гемоглобин 113, ферритин 26, железо 12.8. Сейчас ребёнку 1 г 5 мес
1. Каковы причины такого высокого ферритина и падения железа? Стоит волноваться?
2. Продолжать ли давать актиферрин?
Спасибо!
К сожалению, с телефона не могу прикрепить сами анализы.

[Korzun]

Анализ "железо" без ОЖСС не очень информативен.
Во время анализа была ли простуда или ОРВИ у ребенка?

[Maksinna]

Анализ сдавали в 11 утра, около 16.00 поднялась температура до 39 и держалась сутки, я сбивала несколько раз (она падала). Других симптомов ОРВИ нет. Ещё другие дети в доме тоже с температурой.
Какие мои дальнейшие действия? Продолжаю давать актиферрин? Или пересдать анализы через какое-то время?
В мае ожсс 68,9. А сейчас в сентябре мы не сдавали, я не знала, что это нужно.

[Korzun]

Актиферрин продолжайте.
Ферритин, ОЖСС и железо пересдайте через месяц. Нужно, чтобы ребенок был здоров. Иначе ферритин ложно повышается по типу СОЭ.

[Maksinna]

Всё поняла. Спасибо большое!

[Maksinna]

Александр Иванович, добрый день. Пересдали анализы, ребенок абсолютно здоров. Прикрепила анализы. Здесь продублирую на всякий случай - ферритин 44,30, железо - 17,60, ОЖСС - 60,00. Ребенку сейчас 1г6мес. Пьем актифферин 4 мес. Прокомментируйте, пожалуйста, результаты. Нужно ли дальше пить лекарство? И каких цифр мы в конечном итоге добиваемся?

[Korzun]

Железодефицит ликвидирован, еще месяц для закрепления результата попринимайте и можно прекращать. Где-то в середине или ближе к концу декабря можно повторить Холтер.

[Maksinna]

Я очень рада.
Подскажите, а нужно ли мониторить железодефицит, сдавать анализы допустим раз в год? Или только если есть какие-то симптомы у ребёнка.
Холтер сделаем.

[Korzun]

Я младшей дочке до школы раз в год мониторил: клинический анализ крови на автоанализаторе (там будут кроме гемоглобина еще эритроцитарные индексы MCV и MCH) и ферритин.