Dr.Afnan Shamraiz
Contents
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Introduction
Central, Peripheral and Differential
cyanosis
Mechanism
Etiology
Approach
Principles ...
Introduction
Cyanosis is derived from the colour ‘cyan’, which
comes from ‘kyanous’, the Greek word for blue
It is defined...
Sites to detect cyanosis
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Lips
Nail beds
Ears
Malar Prominences
Palms and Soles
Tongue
Mucous membranes of g...
Types of Cyanosis
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Central Cyanosis
Peripheral Cyanosis
Mixed Cyanosis
Other Types
Enterogenous/Pigment Cy...
Central cyanosis
Pathologic condition
caused by reduced arterial
oxygen saturation.
 Involves highly vascularized
tissues...
Mechanism


Decreased arterial oxygen saturation due to
marked decrease in oxygen tension in the
arterial blood(arterial ...
Peripheral cyanosis
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Causes○ vasomotor instability,

vasoconstriction caused by
exposure to cold, venous
obstruction, el...
Mechanism
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Normal systemic arterial oxygen saturation and
increased oxygen extraction, resulting in a wide
systemic arte...
Mixed Cyanosis
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Cardiogenic shock+ pulmonary oedema
CCF due to lt.sided heart failure
Polycthemia (rare)

Orthocyan...
Enterogenous/pigment cyanosis
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Due to presence of excessive –
sulphaemoglobin(>0.5g/dl),methaemoglobin(
>1.5g...
Differential Cyanosis
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Hands red (less blue) and feet blue seen in PDA with
reversal of shunt (Differential Cyanosis) Re...
Reverse Differential Cyanosis
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Hands blue and feet red seen in
Coarctation of Aorta with TGA(Reverse
Differential Cyanos...
Central Vs Peripheral Cyanosis
SITES

TONGUE,ORAL CAVITY

TONGUE UNAFFECTED

HANDSHAKE

FEELS WARM

FEELS COLD

APPLICATIO...
Acrocyanosis
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Condition in which there is arterial
vasoconstriction,and secondary dilation
of capillaries and venules wi...
Psuedocyanosis
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Bluish tinge to the skin and or mucous
membranes that is not associated with
either Hyoxemia or Peripher...
Factors altering cyanosis
Colour of the cutaneous pigment
 Thickness of the skin
 State of cutaneous capillaries
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

C...
Factors affecting the detection of
cyanosis in the newborn
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Hemoglobin concentration Detected at higher levels of satur...
The arterial oxygen saturation level at which cyanosis is
detectable at different total hemoglobin concentrations is
illus...
Factors affecting the detection of
cyanosis in the newborn


Fetal hemoglobin —
Binds oxygen more avidly than adult hemo...
Factors affecting the detection of
cyanosis in the newborn




Other physiologic factors common in
sick newborns affect ...


These factors
include alkalosis,
hyperventilation (low
PC02), cold
temperature, and
low levels of 2,3
diphosphoglycerat...
Cyanosis…

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

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Cyanosis is
dependent on HCT
and % Sat
Florescent light
makes cyanosis
hard to see.
Except in the
extr...


In contrast, acidosis,
fever, or increased
adult hemoglobin shift
the curve to the right.
As a result, at a given
arter...
Factors affecting the detection of
cyanosis in the newborn


Skin pigmentation Less apparent in the skin of patients wit...
Etiology Can be divided in to,,


Site of cynosis



Central causes
Peripheral causes





Mecanism of
cynosis



Alv...
Central Cyanosis:
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Decreased arterial oxygen saturation
Decreased atmospheric pressure-High altitude
...
Peripheral Cyanosis
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Decreased Cardiac Output
Cold Exposure
Redistribution Of blood from extremities...
Non- cardiac causes
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Alveolar hypoventilation
Central nervous system depression:

asphyxia, maternal sedation, intraven...
Non- cardiac causes
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Ventilation/perfusion mismatch
Airway disease: pneumonia, aspiration, cystic

adenomatoid malforma...
Non-cardiac causes
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Hemoglobinopathy
Methemoglobinemia: congenital or secondary to

toxic exposure
Other hemoglobinopa...
Cardiac causes
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Decreased pulmonary blood flowTetralogy of Fallot
Tricuspid valve anomaly
Pulmonary valve atresia
Cr...
Cardiac causes


Severe heart failureHypoplastic left heart syndrome
Coarctation of the aorta
Interrupted aortic arch
...
The 6 T’s
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Total Anomalous Pulmonary Veins
Tetrology of Fallot
Tricuspid Atresia
Transposition
Truncus Arteriosu...
Mnemonic
A 7T" is often added for "tons" of other diseases,
such as double outlet right ventricle, pulmonary
atresia, mult...
Differential cyanosis
With normally related great arteries, oxygen
saturation may be higher in the upper than
lower extrem...
Differential cyanosis




Reversed differential cyanosis is a rare
finding that may occur in patients with
transposition...
Aim




Differentiate physiologic from pathologic
cyanosis
Differentiate cardiac from non- cardiac
cause of cyanosis
Fi...
Not so serious


Acrocyanosis
Bluish color in the hands and feet and around

the mouth (circumoral cyanosis). The mucus
...
Perinatal history


Drug intake
 Causing neonatal depression
 Lithium- Ebstein anomaly
 Phenytoin- PS and AS Fetal hyd...
History






Methemoglobinemia may be acquired
following exposure to aniline dyes,
nitrobenzene, nitrites, and nitrate...
Onset of cyanosis in cardiac lesions

Depends onNature and severity of the anatomic defect
In utero effects of the stru...
Labour Hx

Associated causes of cyanosis

•PROM, fever, GBS +ve

•Sepsis

•Sedatives/anesthetics

•Respiratory depression,...
Onset of cyanosis in cardiac lesions
Age on admission

In order of frequency

0-6 days

D- transposition of great arteries...
History- Risk factors
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Pneumonia/ sepsis-

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 PROM
 Foul smelling liquor
 Maternal pyrexia
 Maternal GBS

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TTN –
...
History
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Choanal atresiaCyanosis decreases during crying
Confirmed by failure to pass a soft No. 5F to

8F catheter th...
Physical Examination
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Vital signsHypothermia or hyperthermia- infection.
Tachycardia-hypovolemia.
Weak pulses- Hypopl...
Physical Examination
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Congenital heart disease-

Respirations often are unlabored unless there is

pulmonary congestion...
Physical Examination
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Inspiratory stridorupper airway obstruction

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ChestAsymmetric chest movement combined with

se...
Physical Examination
P/AScaphoid abdomen
○ Congenital diaphragmatic hernia
Hepatosplenomegaly○ congestive heart failure,...
Physical Examination


Central nervous depressionCauses shallow, irregular respirations and

periods of apnea.
Affected...
Investigations
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CBC & diff :
Increase or decrease WBC : sepsis
Hematocrit > 65% : polycythemia
Serum ...
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If central cause- appropriate scan and
drug levels
Hb electropheresis…..Hb M
Decrease pH: sepsis, circulatory ...
Pulse oximetry screening
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Difficulty in visual detection of cyanosis
Potentially severe consequences of
missing an...
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Oxygen saturation should be performed
initially on room air to serve as a
baseline.

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Subsequently can be served to
d...
Terms
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PaO2

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Arterial Oxygen Pressure
 Measured on an ABG machine
 Oxygen dissolved in plasma
○ 0.003 ml O2/mmHg/dl...
Hyperoxia test
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If a low-pulse oximeter reading persists, it
may be appropriate to proceed to a
hyperoxia test. It is in...
Hyperoxia test
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Arterial oxygen tension is measured in the
right radial artery (preductal) and in a lower
extremity arte...
Hyperoxia Test

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Infant on Room Air, get ABG
Infant on 100% oxygen, get ABG
PaO2 unchanged = fixed shunt = CCHD

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Max ...
Hyperoxia test
Disease
Lung disease is more likely than
CHD

Result- Increase
in PaO2
>150 mmHg

TGA or severe pulmonary o...
Differential cyanosis
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To detect differential cyanosis, oxygen
saturation should be measured in sites
that receive blood...
Chest X-Ray
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To identify pulmonary causes of cyanosis:
pneumothorax, pulmonary hypoplasia, diaphragmatic
hernia, pu...
Chest X- Ray
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Pulmonary vascular markingsDecreased in CHD with obstructed

pulmonary blood flow such as tetralogy of
Fa...
Total Anomalous Pulmonary Venous
Return
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Snowman
Tetralogy of Fallot
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Boot
shape
Transposition of Great Arteries
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Egg on a
string
Echocardiography
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Indicated if abnormal cardiac
examination suggestive of congenital
heart defect, failed hyperoxia test...
Treatment
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GoalsProvide adequate tissue oxygen and CO2

removal
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PrinciplesEstablish airway
Ensure oxygenation
Ens...
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Monitor Airway, breathing, circulation (ABCs) with
respiratory compromise, establish an airway & provide
sup...
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An infant who fails the hyperoxia test & does
not have PPHN or a CXR showing pulmonary
disease likely has a congenital ...
Treatment

Prostaglandin E1
For ductal dependant CHD/ reduced

pulmonary blood flow- Fail hyperoxia
test( An arterial PO...
Treatment

Prostaglandin E1S/E- hypoventilation, apnea, edema and low

grade fever
Benefits- Can be stabilized more eas...
Conclusion
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Identify those that are life-threatening.
complete maternal and newborn history
perform a thorough...
References
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Nelson textbook of pediatrics
Cloherty manual of neonatal care
Approach To Cyanotic Heart Disease ...
Approach to a Neonate with Cyanosis
Approach to a Neonate with Cyanosis
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Approach to a Neonate with Cyanosis

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  • Methemoglobinemia- An oxidized form of hemoglobin, cannot carry oxygen and, when present in significant quantities, will cause cyanosis. Acquired or congenital disorder due to nicotinamide adenine dinucleotide (NADH) cytochrome b5 reductase deficiency and hemoglobin M disorder.
  • Lithium- Ebstein anomaly
    Fetal hydantoin synd- PS, AS
    Fetal alcohol- VSD,ASD
    Connective tissue disorder- congenital complete heart block associated with anti-Ro/SSA and anti-La/SSB antibodies.
    Congenital infections- cytomegalovirus, herpesvirus, rubella, or coxsackie virus can lead to cardiac structural abnormalities or functional impairment.
  • several of the most serious anatomic abnormalities, such as transposition of the great arteries, produce only a very soft murmur or no murmur at all.
  • Probe site — Postductal probe placement is the optimal site because defects with right-to-left shunting of desaturated blood through the ductus arteriosus will not be detected with preductal placement.
    Signal quality and infant behavior [28] — Measurements should not be performed when the infant is crying or moving as it reduces the quality of the signal and the accuracy of the test.
  • Approach to a Neonate with Cyanosis

    1. 1. Dr.Afnan Shamraiz
    2. 2. Contents        Introduction Central, Peripheral and Differential cyanosis Mechanism Etiology Approach Principles of Treatment Conclusion
    3. 3. Introduction Cyanosis is derived from the colour ‘cyan’, which comes from ‘kyanous’, the Greek word for blue It is defined as the bluish discoloration of the skin and the mucous membranes, resulting from an increase in the reduced Haemoglobin or of haemoglobin derivatives in the small vessels of those areas. Bluish discoloration of the tissues that results when the absolute level of reduced hemoglobin in the capillary bed exceeds 3- 4 g/dL  Depends upon the total amount of reduced hemoglobin rather than the ratio of reduced to oxygenated hemoglobin.
    4. 4. Sites to detect cyanosis        Lips Nail beds Ears Malar Prominences Palms and Soles Tongue Mucous membranes of gum,soft palate,cheeks
    5. 5. Types of Cyanosis         Central Cyanosis Peripheral Cyanosis Mixed Cyanosis Other Types Enterogenous/Pigment Cyanosis Differential Cyanosis Acrocyanosis Orthocyanosis
    6. 6. Central cyanosis Pathologic condition caused by reduced arterial oxygen saturation.  Involves highly vascularized tissues, such as the lips and mucous membranes, through which blood flow is brisk and the arteriovenous difference is minimal.  Cardiac output typically is normal, and patients have warm extremities. 
    7. 7. Mechanism  Decreased arterial oxygen saturation due to marked decrease in oxygen tension in the arterial blood(arterial PaO2 is reduced)  Sites- Tongue (margins & undersurface)  Inner aspect of lips  Mucous membranes of gums,soft palate,cheeks 
    8. 8. Peripheral cyanosis  Causes○ vasomotor instability, vasoconstriction caused by exposure to cold, venous obstruction, elevated venous pressure, polycythemia, and low cardiac output,  Affects the distal extremities and circumoral or periorbital areas .
    9. 9. Mechanism  Normal systemic arterial oxygen saturation and increased oxygen extraction, resulting in a wide systemic arteriovenous oxygen difference  The increased extraction of oxygen results from sluggish movement of blood through the capillary circulation • Sites Tip of nose Ear lobules Outer aspect of lips,chin,cheek Tips and nailbeds of fingers,toes Palms,soles • • • • •
    10. 10. Mixed Cyanosis    Cardiogenic shock+ pulmonary oedema CCF due to lt.sided heart failure Polycthemia (rare) Orthocyanosis  Present in upright position due to hypoxia occuring in erect posture in Pulmonary Arteriovenous Malformation
    11. 11. Enterogenous/pigment cyanosis       Due to presence of excessive – sulphaemoglobin(>0.5g/dl),methaemoglobin( >1.5g/dl Causes Hereditary haemoglobin M disease Poisoning by aniline dyes Drugsnitratres,nitrites,phenacetin,sulphonamides Carboxyhaemoglobinaemia
    12. 12. Differential Cyanosis  Hands red (less blue) and feet blue seen in PDA with reversal of shunt (Differential Cyanosis) Requires pulmonary vascular resistance elevated to a systemic level and a patent ductus arteriosus L R shunt Pulmonary hypertension Reversal of shunt R to L Desaturated blood from the ductus enters the aorta distal to the left subclavian artery, sparing the brachiocephalic circulation.
    13. 13. Reverse Differential Cyanosis  Hands blue and feet red seen in Coarctation of Aorta with TGA(Reverse Differential Cyanosis  Intermittent Cyanosis seen in Ebstein’s Anomaly
    14. 14. Central Vs Peripheral Cyanosis SITES TONGUE,ORAL CAVITY TONGUE UNAFFECTED HANDSHAKE FEELS WARM FEELS COLD APPLICATION OF WARMTH,COLD NO CHANGE WARMTH-CYANOSIS INCR,COLDDECREASES APPLICATION PURE O2 MAY IMPROVE NO RESPONSE CLUBBING,POLYCYTHA EMIA USUALLY PRESENT ABSENT PULSE VOLUME MAYBE HIGH LOW VOL DYSPNOEA PT BREATHLESS NO RESPIRATORY PROBLEM
    15. 15. Acrocyanosis  Condition in which there is arterial vasoconstriction,and secondary dilation of capillaries and venules with resulting persistant cyanosis of the hands and less fequently the feet. part of normal transition may last 72hr beware APGAR of 10 ○ hypoperfused ○ severe anemia
    16. 16. Psuedocyanosis  Bluish tinge to the skin and or mucous membranes that is not associated with either Hyoxemia or Peripheral Vasoconstriction  Metals Drugs 
    17. 17. Factors altering cyanosis Colour of the cutaneous pigment  Thickness of the skin  State of cutaneous capillaries   Cyanosis becomes apparent when the concenteration of the reduced haemoglobin in capillary blood vessels exceeds 40 g/l or 4g/dl
    18. 18. Factors affecting the detection of cyanosis in the newborn  Hemoglobin concentration Detected at higher levels of saturation in polycythemic than in anemic patients. Significant oxygen desaturation can be present in an anemic patient without clinically detectable cyanosis. As an example, 3 g/dL of reduced hemoglobin is associated with an oxygen saturation of 67 percent when the total hemoglobin concentration is 9 g/dL, and 85 percent when the hemoglobin concentration is 20 g/dL.
    19. 19. The arterial oxygen saturation level at which cyanosis is detectable at different total hemoglobin concentrations is illustrated above. The solid red portion of each bar represents 3 gm/dL reduced hemoglobin.
    20. 20. Factors affecting the detection of cyanosis in the newborn  Fetal hemoglobin — Binds oxygen more avidly than adult hemoglobin. The oxygen dissociation curve is shifted to the left, so that for a given level of oxygen tension (PO2), the oxygen saturation (SO2) is higher in the newborn than older infants or adults It also follows that for a given level of oxygen saturation, the PO2 is lower in newborns. As a result, cyanosis is detected at a lower PO2 in newborns compared with older patients. Thus, in evaluating a cyanotic newborn, PO2 should be measured in addition to SO2 to provide more complete data.
    21. 21. Factors affecting the detection of cyanosis in the newborn   Other physiologic factors common in sick newborns affect the oxygen dissociation curve. Those that increase the affinity of hemoglobin for oxygen (shifting the oxygen dissociation curve to the left), decrease the concentration of reduced hemoglobin at a given arterial P02, and lower the PO2 at which cyanosis first appears.
    22. 22.  These factors include alkalosis, hyperventilation (low PC02), cold temperature, and low levels of 2,3 diphosphoglycerate For fetal hemoglobin, the normal curve (a) is shifted to the left (b)
    23. 23. Cyanosis…    Cyanosis is dependent on HCT and % Sat Florescent light makes cyanosis hard to see. Except in the extreme, cyanosis is not obvious Any question, check a pulse ox 100 90 80 70 % Saturation  Cyanosis 60 50 40 30 20 10 0 0 20 40 HCT 60 80
    24. 24.  In contrast, acidosis, fever, or increased adult hemoglobin shift the curve to the right. As a result, at a given arterial PO2, there is increased oxygen delivery to the tissues resulting in a greater concentration of reduced hemoglobin, and cyanosis appears more readily. For fetal hemoglobin, the normal curve (a) is shifted to the left (b)
    25. 25. Factors affecting the detection of cyanosis in the newborn  Skin pigmentation Less apparent in the skin of patients with darker pigmentation. Examination should include the nail beds, tongue, and mucous membranes, which are less affected by pigmentation.
    26. 26. Etiology Can be divided in to,,  Site of cynosis  Central causes Peripheral causes   Mecanism of cynosis  Alveolar hypoventilation Diffusion impairment Ventilation-perfusion mismatch Right-to-left shunting at the intracardiac, great vessel, or intrapulmonary level Hemoglobinopathy (including methemoglobinemia) that limits oxygen transport    
    27. 27. Central Cyanosis:           Decreased arterial oxygen saturation Decreased atmospheric pressure-High altitude Impaired pulmonary function Alveolar hypoventilation Pulmonary ventilation perfusion imbalance Impaired oxygen diffusion Anatomic Shunts –ASD,VSD,PDA Congenital Heart Diseases-Fallots Tetrology,TGA Pulmonary AV fistulas Mutiple small intrapulmonary shunts Haemoglobin Abnormalities
    28. 28. Peripheral Cyanosis            Decreased Cardiac Output Cold Exposure Redistribution Of blood from extremities Arterial Obstruction-embolus,raynauds phenomenon Venous Obstruction-thrombophlebitis,SVC syndrome Frost bite CCF,shock,Peripheral Circulatory Failure Hyperviscosity -Multiple myeloma,Polycythemia Peripheral Vascular Diseasesatherosclerosis,buerger’s Mitral Stenosis Cryoglobulinemia
    29. 29. Non- cardiac causes  Alveolar hypoventilation Central nervous system depression: asphyxia, maternal sedation, intraventricular hemorrhage, seizure, meningitis, encephalitis Neuromuscular disease: Werdnig-Hoffman disease, neonatal myasthenia gravis, phrenic nerve injury Airway obstruction: choanal atresia, laryngotracheomalacia, macroglossia, Pierre Robin syndrome
    30. 30. Non- cardiac causes  Ventilation/perfusion mismatch Airway disease: pneumonia, aspiration, cystic adenomatoid malformation, diaphragmatic hernia, pulmonary hypoplasia, labor emphysema, atelectasis, pulmonary hemorrhage, hyaline membrane disease, transient tachypnea of the newborn Extrinsic compression of lungs: pneumothorax, pleural effusion, chylothorax, hemothorax, thoracic dystrophy
    31. 31. Non-cardiac causes  Hemoglobinopathy Methemoglobinemia: congenital or secondary to toxic exposure Other hemoglobinopathies  Diffusion impairment Pulmonary edema: left-sided obstructive cardiac disease, cardiomyopathy Pulmonary fibrosis Congenital lymphangiectasia
    32. 32. Cardiac causes  Decreased pulmonary blood flowTetralogy of Fallot Tricuspid valve anomaly Pulmonary valve atresia Critical valvular pulmonary steanosis  Increased pulmonary blood flowTransposition of great arteries Truncus arteriosus Total anomalous pulmonary venous connection
    33. 33. Cardiac causes  Severe heart failureHypoplastic left heart syndrome Coarctation of the aorta Interrupted aortic arch Critical valvular aortic steanosis
    34. 34. The 6 T’s      Total Anomalous Pulmonary Veins Tetrology of Fallot Tricuspid Atresia Transposition Truncus Arteriosus Total Acardia
    35. 35. Mnemonic A 7T" is often added for "tons" of other diseases, such as double outlet right ventricle, pulmonary atresia, multiple variations of single ventricle, hypoplastic left heart syndrome, or anomalous systemic venous connection (left superior vena cava connected to the left atrium
    36. 36. Differential cyanosis With normally related great arteries, oxygen saturation may be higher in the upper than lower extremity in patients if there is right-toleft shunting through the ductus arteriosus.  Seen with severe coarctation or interrupted aortic arch.  May also occur in patients persistent pulmonary hypertension of the newborn  The differential effect is reduced if there is also right-to-left shunting at the level of the foramen ovale, or if there is left-to-right shunting across a coexisting ventricular septal defect 
    37. 37. Differential cyanosis   Reversed differential cyanosis is a rare finding that may occur in patients with transposition of the great arteries associated with either coarctation or pulmonary hypertension. In these infants, oxygen saturation is higher in the lower than upper extremity.
    38. 38. Aim    Differentiate physiologic from pathologic cyanosis Differentiate cardiac from non- cardiac cause of cyanosis Find cause which needs urgent treatment or referral
    39. 39. Not so serious  Acrocyanosis Bluish color in the hands and feet and around the mouth (circumoral cyanosis). The mucus membranes generally remain pink. Reflects benign vasomotor changes in the diffuse venous structures in the affected areas. Does not indicate pathology unless cardiac output is extremely low, resulting in cutaneous vasoconstriction   Cyanosis soon after birth- transition from intrauterine to extrauterine life Hand or leg prolapse
    40. 40. Perinatal history  Drug intake  Causing neonatal depression  Lithium- Ebstein anomaly  Phenytoin- PS and AS Fetal hydantoin synd Fetal alcohol- VSD,ASD  Maternal diabetes TGA, ventricular septal defect (VSD), and hypertrophic cardiomyopathy Connective tissue disorder- Heart blocks associated with anti-Ro/SSA and anti-La/SSB antibodies. Congenital intrauterine infections cytomegalovirus, herpesvirus, rubella, or coxsackie virus can lead to cardiac structural abnormalities or functional impairment Antenatal fetal echocardiography   
    41. 41. History    Methemoglobinemia may be acquired following exposure to aniline dyes, nitrobenzene, nitrites, and nitrates. Advanced maternal age Trisomy 21 associated with many congenital heart defects (cyanotic and acyanotic) Oligohydramnios …..Pulmonary hypoplasia
    42. 42. Onset of cyanosis in cardiac lesions Depends onNature and severity of the anatomic defect In utero effects of the structural lesion Alterations in cardiovascular physiology secondary to the effects of transitional circulation like closure of ductus arteriosus and the fall in pulmonary vascular resistance  A ductal dependent lesion is one that depends on the ductus to get adequate blood flow to the pulmonary and systemic circuits, or provide mixing ○ PS ○ CoA ○ TGA
    43. 43. Labour Hx Associated causes of cyanosis •PROM, fever, GBS +ve •Sepsis •Sedatives/anesthetics •Respiratory depression, apnea •C-section •TTN, PPHN •Preterm infant •RDS •Meconium •MAS (pneumonia)
    44. 44. Onset of cyanosis in cardiac lesions Age on admission In order of frequency 0-6 days D- transposition of great arteries Hypoplastic left ventricles Tetralogy of fallot 7-13 days Coarctation of aorta Hypoplastic left ventricle D-transposition of great arteries Tetralogy of fallot 14-28 days Coarctation of aorta Tetralogy of fallot D- transposition of great arteries Neonatology- Pathophysiology and management of newborn, 5th edition ed. 1999. Philadelphia; Lippincott Williams and Wilkins
    45. 45. History- Risk factors  Pneumonia/ sepsis-   PROM  Foul smelling liquor  Maternal pyrexia  Maternal GBS  TTN –  Post maturity  Small for gestational age  Placental dysfunction  Fetal distress  Meconium stained liquor  Birth by cesarean section  Polycythemia-  with or without labor  Male sex  Family history of asthma (especially in mother)  Macrosomia  Maternal diabetes   small-for-gestational age MAS- Pneumothorax Aggressive resucitation  IPPV  Meconiun aspiration  HMD  Hypoplastic lung  Staph pneumonia Hyaline membrane disease-  Premature infant  Infant of diabetic mother
    46. 46. History  Choanal atresiaCyanosis decreases during crying Confirmed by failure to pass a soft No. 5F to 8F catheter through each nostril
    47. 47. Physical Examination  Vital signsHypothermia or hyperthermia- infection. Tachycardia-hypovolemia. Weak pulses- Hypoplastic left heart syndrome or hypovolemia. Pulses or blood pressures stronger in the upper than in the lower extremitiescoarctation of the aorta.
    48. 48. Physical Examination  Congenital heart disease- Respirations often are unlabored unless there is pulmonary congestion or complicated by the development of heart failure or acidosis, which will affect the respiratory pattern.  CVS- Presence or absence of a heart murmur is of little assistance. Loud S2 suggests pulmonary or systemic hypertension or malposition of the aorta.  several of the most serious anatomic abnormalities, such as transposition of the great arteries, produce only a very soft murmur or no murmur at all
    49. 49. Physical Examination  Inspiratory stridorupper airway obstruction  ChestAsymmetric chest movement combined with severe distress○ alarming sign for tension pneumothorax, diaphragmatic hernia Transillumination of the chest○ Pneumothorax on an emergent basis
    50. 50. Physical Examination P/AScaphoid abdomen ○ Congenital diaphragmatic hernia Hepatosplenomegaly○ congestive heart failure, maternal diabetes, or congenital infection.
    51. 51. Physical Examination  Central nervous depressionCauses shallow, irregular respirations and periods of apnea. Affected infants typically appear hypotonic and lethargic.
    52. 52. Investigations           CBC & diff : Increase or decrease WBC : sepsis Hematocrit > 65% : polycythemia Serum glucose: to detect hypoglycemia Arterial Blood Gases (ABGs): Arterial PO2: to confirm central cyanosis : SaO2 not as good an indicator due to Increase fetal Hb affinity for O2 (left-shift) Increase PaCO2: may indicate pulmonary or CNS disorders, heart failure Decrease pH: sepsis, circulatory shock, severe hypoxemia Methemoglobinemia: Decrease SaO2, normal PaO2, chocolate-brown blood
    53. 53.      If central cause- appropriate scan and drug levels Hb electropheresis…..Hb M Decrease pH: sepsis, circulatory shock, severe hypoxemia Decrease pH: sepsis, circulatory shock, severe hypoxemia Sepsis screening
    54. 54. Pulse oximetry screening     Difficulty in visual detection of cyanosis Potentially severe consequences of missing an early sign of CHD “5th vital sign” Sensitivity and specificity variesCriteria used for abnormal test Timing of screening Probe site Quality of the equipment Signal quality and neonate behaviour Health care workers expertise Signal quality and infant behavior — Measurements should not be performed when the infant is crying or moving as it reduces the quality of the signal and the accuracy of the test.
    55. 55.  Oxygen saturation should be performed initially on room air to serve as a baseline.  Subsequently can be served to differentiate between cardiogenic and non-cardiogenic causes
    56. 56. Terms  PaO2  Arterial Oxygen Pressure  Measured on an ABG machine  Oxygen dissolved in plasma ○ 0.003 ml O2/mmHg/dl plasma  SaO2  Percent Oxygen Saturation  Measured by saturation monitor (pulse-Ox)  ~1.34ml O2/g Hb
    57. 57. Hyperoxia test  If a low-pulse oximeter reading persists, it may be appropriate to proceed to a hyperoxia test. It is indicated if the pulse oximeter reading is less than 85% in both room air and 100% oxygen  Useful in distinguishing cardiac from pulmonary causes of cyanosis.
    58. 58. Hyperoxia test  Arterial oxygen tension is measured in the right radial artery (preductal) and in a lower extremity artery while the patient breathes 100 percent oxygen (postductal).
    59. 59. Hyperoxia Test  Infant on Room Air, get ABG Infant on 100% oxygen, get ABG PaO2 unchanged = fixed shunt = CCHD  Max PaO2 <100 = CCHD  Max PaO2 >200 = No CCHD  
    60. 60. Hyperoxia test Disease Lung disease is more likely than CHD Result- Increase in PaO2 >150 mmHg TGA or severe pulmonary outflow obstruction <50 to 60 mmHg In lesions with intracardiac mixing and increased pulmonary blood flow such as truncus arteriosus- >75 to 150 mmHg
    61. 61. Differential cyanosis  To detect differential cyanosis, oxygen saturation should be measured in sites that receive blood flow from both preductal (right hand) and postductal (foot) vessels. It is preferable to use the right (rather than left) upper extremity, since the left subclavian artery arises close to the ductus arteriosus, and some of its flow may come from the ductus and thus not reflect preductal values
    62. 62. Chest X-Ray    To identify pulmonary causes of cyanosis: pneumothorax, pulmonary hypoplasia, diaphragmatic hernia, pulmonary edema, pleural effusion, etc. Useful in evaluating congenital heart disease: e.g., cardiomegaly & vascular congestion: heart failure Aberrancy of the cardiothymic silhouette Suggest the presence of structural heart disease, and  Abnormalities of the lung fields may be helpful in distinguishing a primary pulmonary problem such as meconium aspiration
    63. 63. Chest X- Ray  Pulmonary vascular markingsDecreased in CHD with obstructed pulmonary blood flow such as tetralogy of Fallot, severe pulmonary stenosis or atresia, and tricuspid atresia. Increased in admixture lesions like transposition of the great arteries, total anomalous pulmonary venous connection, and truncus arteriosus.
    64. 64. Total Anomalous Pulmonary Venous Return  Snowman
    65. 65. Tetralogy of Fallot  Boot shape
    66. 66. Transposition of Great Arteries  Egg on a string
    67. 67. Echocardiography  Indicated if abnormal cardiac examination suggestive of congenital heart defect, failed hyperoxia test (cardiac disease suspected) or has unclear diagnosis
    68. 68. Treatment  GoalsProvide adequate tissue oxygen and CO2 removal  PrinciplesEstablish airway Ensure oxygenation Ensure adequate ventilation Correct metabolic abnormalities Alleviate the cause of respiratory distress
    69. 69.      Monitor Airway, breathing, circulation (ABCs) with respiratory compromise, establish an airway & provide supportive therapy (e.g., oxygen, mechanical ventilation) Monitor Vital signs Establish vascular access for sampling blood & administering meds (if needed): umbilical vessels convenient for placement of intravenous & intraarterial catheters If sepsis is suspected or another specific cause is not identified, start on broad spectrum antibiotics (e.g., ampicillin and gentamycin) after obtaining a CBC, urinalysis, blood & urine cultures (if possible). Left untreated, sepsis may lead to pulmonary disease & left ventricular dysfunction. .
    70. 70.  An infant who fails the hyperoxia test & does not have PPHN or a CXR showing pulmonary disease likely has a congenital heart defect that’s ductus-dependent. If cardiac disease is suspected, immediately start PGE1 infusion. Complications of PGE1 infusion include hypotension, tachycardia, apnea. Secure a separate intravenous catheter to provide fluids for resuscitation and ensure accessibility of intubation equipment should they be required
    71. 71. Treatment Prostaglandin E1 For ductal dependant CHD/ reduced pulmonary blood flow- Fail hyperoxia test( An arterial PO2 of less than 100 torr in the absence of clear- cut lung disease) Infusion of prostaglandin E1 at a dose of 0.05- 0.1mcg/kg/min intravenously to maintain patency
    72. 72. Treatment Prostaglandin E1S/E- hypoventilation, apnea, edema and low grade fever Benefits- Can be stabilized more easily, allowing for safe transport to a tertiary care center. More time is also available for thorough diagnostic evaluation and patients can be brought to surgery in a more stable condition.
    73. 73. Conclusion       Identify those that are life-threatening. complete maternal and newborn history perform a thorough physical examination recognize the common respiratory and cardiac disorders differentiate among various diagnostic entities For ductal dependent lesion, start prostaglandin E1 and early referral
    74. 74. References      Nelson textbook of pediatrics Cloherty manual of neonatal care Approach To Cyanotic Heart Disease In The First Month Of Life , Harry J. D'Agostino, Jr., M.D. and Eric L. Ceithaml, M.D. Pediatrics in Review. 1999;20:350-352.) © 1999, Consultation with the Specialist, Nonrespiratory Cyanosis, Jon Tingelstad, MD UpToDate
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