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新生儿窒息(英文)2009

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  • 1. Asphyxia of newborn Xin Yue PEDIATRIC DPT. GENERAL HOSPITAL TIANJIN MEDICAL UNIVERSITY
  • 2.
      • This is defined as a combination of hypoxemia, hypercapnia, and metabolic acidemia.
      • If lung expansion does not occur in the first few minutes following birth, and the infant is unable to establish ventilation and pulmonary perfusion, a progressive cycle of worsening hypoxemia, hypercapnia, and metabolic acidemia evolves.
    Definition
  • 3. Etiology Labor and delivery conditions Maternal conditions Fetal conditions
  • 4. Maternal conditions(1)
    • Maternal systemic diseases:
    • Diabetes Mellitus, Lupus, hypertention,
    • Maternal heart disease , chronic renal disease,
    • Anemia(i.e.,hemoglobin<10g/dl)
    • Gynecological and Obstetrical diseases:
    • Preeclampsia,
    • Abruption placenta, placenta previa,
    • or other antepartum hemorrhage,
    • Prolonged rupture of membranes ,
    • Maternal fever or other evidence of amnionitis
    • other antepartum hemorrhage
    • Narcotic, barbiturate, tranquilizer psychedelic
    • drug use or alcohol intoxication
  • 5. Maternal conditions(2)
    • Other Conditions:
    • History of previous perinatal loss
    • More than 35 or less than 16 years old
    • Abnormal umbilical artery doppler
    • velocity
    • Narcotic, barbiturate,
    • tranquilizer psychedelic drug use
    • or alcohol intoxication et al
  • 6. Labor and delivery conditions (1)
    • Forceps delivery other than low-elective or vacuum extraction delivery
    • Breech or other abnormal presentation and delivery
    • Cephalopelvic dysproportion, shoulder Dystocia, prolonged second stage Cesarean section
  • 7. Labor and delivery conditions (2)
    • Prolapsed umbilical cord,
    • Cord compression(e.g. nuchal cord, cord knot, compression by after-coming head in breech delivery)
    • Maternal hypotention or hemorrhage
    • Unaccommodated anesthetic, analgesic agents and oxytocin use during delivery
  • 8.  
  • 9. Fetal conditions (1)
    • Premature delivery , Postmature delivery
    • Small for gestational age infant,
    • Macrosomia
    • Acidosis determined by fetal scalp capillary
    • blood
    • Abnormal heart rate pattern or
    • dysrhythmia
    • Meconium-stained amniotic fluid,
    • Oligohydramnios, Polyhydramnios
  • 10. Fetal conditions (2)
    • Decreased rate of growth: uterine size or fetal size determined by ultrasonography
    • Immaturity of pulmonary surfactant system
    • Fetal malformations determined by sonography
    • Low biophysical profile
    • Multiple births, in particular, discordant, stuck, or monoamnionic
  • 11. Pathophysiology
  • 12.
    • Asphyxia of newborn
        • Hypoxemia, hypercapnia, metabolic acidemia
    • blood redistribution, high pulmonary resistance,
    • PDA (patent ductus arteriosus),
    • shunt through foramen ovale(right to left)
    • Fig.
    tissue acidosis, organ damage, low heart function and failure, hypotention, pale,low muscular tone, low liver function, HIE, rectal sphincter relaxation , Meconium passed into amniotic fluid
  • 13. Clinical features
  • 14. Clinical features(1)
    • Abnormal biophysical profile (BPP)
    • a score of 8-10 is reassuring.
    • a score of 6 is equivocal, and retesting
    • should be done in 12-24 hr.
    • a score of 4 or less warrants immediate
    • evaluation and possible delivery.
    Fetal(1)
  • 15.  
  • 16.  
  • 17. Clinical features(2)
    • Abnormal electronic fetal monitoring
    • Tachycardia (>160 beats/min): early fetal hypoxia, maternal fever, fetal anemia , et al.
    • Bradycardia (<120 beats/min): fetal hypoxia, placental transfer of local anesthetic agents , et al.
    • Early decelerations: head compression.
    • Late decelerations : compression of vessels.
    • Variable decelerations : cord compression.
    • Abnormal fetal acid-base status
    • <7.25: strongly suggests fetal distress.
    • <7.20: an indication for further assessment and interven- tion.
    Fetal(2)
  • 18.
    • Early deceleration that occurs during the peak of uterine contractions and is due to pressure on the fetal head. (a repetitive pattern of slowing, synchronous with and proportional to the amplitude of the uterine contraction.
  • 19.
    • Late decelerations occurs repetitively after a uterine contraction is well established, is proportional to its amplitude, and persists into the interval following contractions.
  • 20.
    • Variable decelerations is characterized by variable shape, abrupt onset and occurrence with consecutive contractions, and return to baseline at or after the conclusion of the contraction .
  • 21. Clinical features(3)
    • Evidence of asphyxia at birth
    • Failure to initiate respiration
    • Low Apgar score
    • State of consciousness
    • Ranges along a continuum from normal to hypoalertness, through obtundation, lethargy, stupor and coma.
    Postnatal(1)
  • 22. Clinical features(4)
    • Evidence of damage to other organ systems
    • Renal (oliguria)
    • Cardiac (myocardiopathy)
    • Liver (abnormal liver- function test results )
    • Imaging studies
    • Magnetic resonance imaging (MRI)
    • Ultrasound
    • Computed tomography(CT)
    • Electroencephalography abnormal (eg, burst suppression)
    Postnatal(2)
  • 23. Apgar Scoring system
    • Sign 0 1 2
    • Heart rate Absent <100 beats/min >100beats/min
    • Respiratory Absent Irregular, slow Regular,
    • effort weak cry strong cry
    • Color Blue, pale Body pink, Completely
    • extremities blue pink
    • Muscular Flaccid Some flexion of Active motion
    • tone (Limp) upper extremities
    • Reflex No response Grimace Cough or sneeze
    • irritability
  • 24. Notes of the Apgar Scoring system
    • Severity of asphyxia can be determined according to the Apgar score system.
    • Mild Newborns with Apgar score of 4-7 points.
    • Severe Newborns with Apgar score of 0-3 points.
  • 25.  
  • 26. the degree of asphyxia. the need for immediate resuscitation. neonatal morbidity, the probability of successfully resuscitating an infant. every 5 minutes for a total of 20 minutes have been recommended to assess response and the appropriateness of continued resuscitative measures.
    • 1-minute score
    • 5-minute score
    • additional scores
  • 27.
    • A Resuscitation
    • B Clinical assessment of severity of
    • asphyxia
    • C Initial medical management of infants
    • with severe perinatal asphyxia
    Management
  • 28.
    • Equipment and supplies:
    • Resuscitation table with heat source
    • Oxygen and air sources
    • Airway suction system, Laryngoscope
    • Monitors
    • All emergency medicines and fluids
    • Tube thoracostomy tray
    • Blood gas electrodes with a trained operator
    • Whole blood or packed erythrocytes
    Resuscitation team and equipment The resuscitation team: Members A, B, C
  • 29.  
  • 30.
    • The resuscitation steps: A, B, C, D, E
    • : airway--anticipate and establish a patent
    • airway by suctioning and, if necessary,
    • perform endotracheal intubation.
    • : breathing -- initiate breathing using tactile
    • stimulation or positive pressure ventilation
    • with a bag and mask or through an
    • endotracheal tube.
    • : circulation-maintain the normal circulation
    • with chest compression.
    • : drugs.
    • : evaluation.
    Resuscitation steps A B C D E
  • 31.
    • The initial steps —
    • provide warmth.
    • position the baby’s head to open the airway;
    • clear the airway as necessary.
    • dry the baby;
    • stimulate the baby to breathe;
    • reposition the baby’s head to open the airway.
    • give oxygen as necessary:
    • flow-inflating bag and mask
    • oxygen tubing
    • oxygen mask
    Resuscitation flow diagram 1 2 3 4
  • 32.  
  • 33.  
  • 34.  
  • 35. Mask ventilation— ( does not start to breathe, or if HR<100/min, or the color remains cyanotic) airway opened by placing the infant’s head in the neutral position. mask over mouth and nose. rate-40-60 breaths/min. pressure-to achive chest wall movement, the first few breaths may require higher pressures.
  • 36. Intubation— ( if effective mask ventilation not established, intubate and start artificial ventilation) The laryngoscope blade is advanced to lift the epiglottis, as shown, and the laryngoscope is then lifted upwards. Gentle pressure on the trachea with the little finger or by an assistant helps bring the vocal cords into view.
  • 37. External cardiac massage in a newborn infant External cardiac massage using with hands encircling the chest, the thumbs two fingers. on the sternum just below the nipple line. Circulation— external cardiac compression (start if pulse absent or heart rate <60 beats/min or 60-80 beats/min and not increasing) ratio of cardiac compression:lung inflation is 3:1
  • 38. Drugs– (if bradycardia persists in spite of adequate ventilation and external cardiac compression) Adrenaline: 1:10000, 0.1 ml/kg via endotracheal tube Cannulate umbilical vein Adrenaline: 1:10000, 0.1ml/kg via umbilical vein Adrenaline: 1:10000, 0.3ml/kg via umbilical vein Repeat if necessary Sodium bicarbonate (1-2 mmol/kg) Volume expander (20ml/kg of 0.9% saline or blood if acute blood loss
  • 39. Keep warm and dry Position,suction,stimulate Oxygen Establish effective ventiation : Mask ventilation Endotracheal ventilation Chest compression Drugs Always needed Rarely needed The inverted pyramid showing the relative frequency of procedures in neonatal resuscitation.
  • 40.
    • (1)
    • Apgar score (1)
    • The Apgar score was the first attempt at a systematic assessment of birth asphyxia.
    • There is a loose correlation between low Apgar scores and umbilical cord blood gases.
    • Some infants with severe acidosis have normal Apgar scores, and some with normal blood gases and pH have very low scores.
    Clinical Assessment of Severity of Asphyxia
  • 41.
    • maternal anesthetics,
    • sedatives,
    • other maternal drugs,
    • fetal sepsis, Apgar
    • central nervous system score
    • pathologic conditions
    • extremely premature
    Apgar score(2)
  • 42.
    • Regardless of the causes, an Apgar score that remains low calls for action.
    • The clinical significance of the Apgar score increases with time.
    • Scoring should continue every 5 minutes until the score increases to 7 or above.
    • The length of time it takes to reach a score of 7 is a rough indication of severity of asphyxia.
    Apgar score(3)
  • 43.
    • Umbilical cord blood gases
    • Commonly it can’t be available
    • until a few minutes after birth, so
    • their main value is in guiding
    • subsequent management of the
    • infant.
    Clinical Assessment of Severity of Asphyxia (2)
  • 44.
    • severe
    • perinatal hypoxic-ischemic
    • asphyxia encephalopathy
    • Their level of consciousness and neurologic exam, including neurovital signs and level of arousal, must be followed carefully.
    Initial medical management of infants with severe perinatal asphyxia
  • 45.
    • If clinical signs of increased intracranial pressure develop, a cranial - signs ultrasound should be performed to look for evidence of intraventricular or parenchymal hemorrhage, size of the lesion, generalized edema, or shift of the midline.
    • A head CT scan should be done if subdural hemorrhage is suspected, or if the cranial ultrasound study produces questionable findings.
  • 46.
    • steps to minimize cerebral edema during the first 48 to 72 hours of life:
    • hyperventilation of infants requiring
    • ventilatory support
    • fluid restriction to maintain serum
    • osmolality between 290 and 300
    • mOsm/L
  • 47.
    • Severely asphyxiated infants:
    • Mechanical ventilatory assistance with correction and stabilization of arterial pH, PO 2 , and PCO 2. aiming to maintain PaCO 2 between 20 and 30 mmHg for 40 to 72 hours.
    • Serial EEG monitoring .
    • Treatment for meconium aspiration pneumonia and persistent pulmonary hypertension.
  • 48.
    • severe asphyxia depressed cardiac activity
    • : inotropic support
    • Assessment of myocardial injury: echocardiography, ECG, and serial cardiac enzymes.
    • Central venous pressure monitoring: severe myocardial dysfunction, impaired renal status, and uncertain volume status.
  • 49.
    • severe asphyxia Acute renal failure
    • Renal function should be monitored closely by determining urine output (oliguria is less than 0.5 ml/kg/hr)
    • Performing serial laboratory measurements of BUN, serum creatinine, serum and urine electrolytes, and fractional excretion of sodium. Also, body weight should be measured at least once a day.
  • 50.
    • Asphyxia necrotizing enterocolitis
    • due to intestinal ischemia
    • Observed without enteral feedings for the first several days of life,
    • Feedings are initiated and cautiously advanced when the infant has active bowel sounds and is considered stable .
  • 51. severe hepatic damage asphyxia & coagulopathy
    • Hepatic injury:
    • serial serum bilirubin measurements
    • liver enzyme activity (ie, ALT [ SGPT ] , AST [ SGOP ] ).
    • Coagulation status:
    • evaluated clinically
    • platelet count.
    • if there is evidence of clinical bleeding or if there is thrombocytopenia, then coagulation studies should be performed.
  • 52. Complication and sequelae
    • Central nervous system : HIE and ICH are not uncommon.
    • Respiratory system : PFC, RDS and MAS.
    • Renal : Acute tubular necrosis irreversible acute renal failure.
    • Adrenal : Hemorrhage.
    • Gut : NEC and ulceration.
    • Metabolic : Hypoglycemia and ISADH.
    • Cardiac : Cardiac ischemic changes
    • cardiogenic shock heart failure.
  • 53. Keys to be remembered Etiology of asphyxia Clinical features of perinatal asphyxia: ------fetal and postnatal The Apgar scoring system The resuscitation steps: ABCDEs Complication and sequelae
  • 54. Thank You ! 4th Mar, 2009

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