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1. Baby is blue ..
What to do ?
Approach to a cyanotic newborn
Dr Bharathi
2. Case Scenario 1
• B/o X
• Term / male /AGA born to primi mother by
vaginal delivery .
• Baby cried immediately after birth and is
otherwise well .
• There is cyanosis of peripheries alone….
Acrocyanosis
4. Although peripheral cyanosis is seen in conditions
in which the infant is exposed to a cold
environment, it could also be the presenting sign
of serious conditions such as
• sepsis,
• hypoglycemia,
• hypoplastic left-heart syndrome
Peripheral cyanosis should not be
ignored unless other conditions have
been ruled out.
5. Case scenario 2
• A concerned mother brings her newborn
to you
“ One side of my baby is blue and the other
side is red . What is this ?”
6. Harlequin skin change
• One quadrant or one half of the body may
become cyanotic or pale while the rest of
the body remains pink.
• Hands and feet remain warm.
• Exact reason not known
• Thought to be - vasomotor instability
7. What would you call it if the upper half is
pink and the lower half is blue ?
• Differential cyanosis
• Seen in PDA with R – L shunting
8. Case scenario 3
• Term / AGA baby born to primi mother by
SVD . Cried well at birth . Was well for 1st
3 days.
• On day 4 child develops lethargy , poor
feeding , cold extremities and is blue over
face , tongue , hands and feet .
• How will you approach ?
9. Cyanosis
• Cyanosis (from the Greek word meaning
‘‘dark blue’’) is a blue to dusky hue in the
newborn
• Colour of the reduced hemoglobin gives
rise to the colour seen in cyanosis.
• Lees reported that cyanosis would be
visible if the deoxygenated hemoglobin
content is greater than 3 g% (3 g per 100
mL).
Sasidharan P. An approach to diagnosis and management of cyanosis and tachypnea in
term infants. Pediatr. Clin. North Am. 2004 Aug;51(4):999–1021, ix.
10. Cyanosis is evident in polycythemic
babies at higher oxygen saturation
Sasidharan P. An approach to diagnosis and management of cyanosis and tachypnea in term infants.
Pediatr. Clin. North Am. 2004 Aug;51(4):999–1021, ix.
12. Physiology of oxygen transport
• Variables for gas
exchange at the alveolar
level
• Concentration of oxygen
in the gas entering the
alveolus
• Concentration of oxygen
in the mixed venous
blood entering the
capillaries
• Quantities of the gas flow
and blood flow
13. Causes of cyanosis -
pathophysiology
• Hypoventilation
• Significant right-to-left intracardiac or
intrapulmonary shunting
• Ventilation perfusion unevenness
• Inadequate transport of oxygen by the
hemoglobin.
Sasidharan P. An approach to diagnosis and management of cyanosis and tachypnea in term infants.
Pediatr. Clin. North Am. 2004 Aug;51(4):999–1021, ix.
15. Aetiology of cyanosis
Parenchymal
• Transient tachypnea of
newborn (TTN)
• Hyaline membrane disease
(HMD)
• Aspiration—meconium, blood,
mucus, or milk
• Pneumonia
• Pulmonary hemorrhage
• Pulmonary edema
• Pulmonary hypoplasia
• Pulmonary lymphangiectasia
Nonparenchymal
• Tracheo esophageal fistula
(TEF)
• Choanal atresia
• Laryngeal web
• congenital diaphragmatic
hernia (CDH)
• Congenital cystic adenomatoid
malformation (CCAM)
• Pulmonary sequestration
• Pneumothorax,
pneumomediastinum
• Pleural effusion
• Lobar emphysema
Pulmonary
Sasidharan P. An approach to diagnosis and management of cyanosis and tachypnea in term infants.
Pediatr. Clin. North Am. 2004 Aug;51(4):999–1021, ix.
16. CYANOTIC CHD
IN NEONATE
CRITICAL NON-CRITICAL
↓PBF ↑PBF
TOF
TA-PS
SV-PS
DORV-PS
TRUNCUS ARTERIOSUS
SINGLE VENTRICLE
TRI ATRESIA
TAPVC(NO
OBSTR)
DDSC
TGATAPVC
OBST
DDPC
17. Duct Dependent pulmonary circulation:Duct Dependent pulmonary circulation:
Clinical ConditionsClinical Conditions
ANATOMIC OBSTRUCTIONANATOMIC OBSTRUCTION
• Pulmonary Atresia :Pulmonary Atresia :
1.1. Intact ventricular septum (hypoplastic right heart)Intact ventricular septum (hypoplastic right heart)
2.2. With VSD (TOF-PA)With VSD (TOF-PA)
3.3. With Tricuspid AtresiaWith Tricuspid Atresia
4.4. With Single VentricleWith Single Ventricle
• Severe Tetralogy of FallotSevere Tetralogy of Fallot
• Critical pulmonary stenosisCritical pulmonary stenosis
FUNCTIONAL OBSTRUCTIONFUNCTIONAL OBSTRUCTION
• Ebstein’s anomalyEbstein’s anomaly
18. Duct Dependent Systemic circulation:Duct Dependent Systemic circulation:
Clinical ConditionsClinical Conditions
• Critical aortic stenosis
• Coarctation of aorta
• Interrupted aortic arch
• Hypoplastic left heart
Manual of neonatalogy – John P Cloherty – 17 th edition
19. Aetiology of cyanosis
Central nervous system
(CNS)
• Cerebral edema
• Hemorrhage
• Infection
• Hypoventilation
• Vocal cord paralysis or
paresis
Miscellaneous
• Methemoglobinemia
• Hemoglobin M
• Metabolic acidosis
• Sulfhemoglobinemia
• Hypoglycemia
• Sepsis
• Polycythemia
• Associated with feeding,
gastroesophogeal reflux
(GER)
20. Initial assessment of infants who
have cyanosis
•History
•Physical examination
•Chest radiograph
•CBC with differential count
•Blood glucose, calcium
•Arterial blood gas (ABG)/hyperoxia test
•Blood culture/sepsis screen
•EKG and echocardiogram
21. History
Sasidharan P. An approach to diagnosis and management of cyanosis and
tachypnea in term infants. Pediatr. Clin. North Am. 2004 Aug;51(4):999–1021, ix.
22. Physical examination
• Examined in neutral thermal environment
• Away from blue phototherapy lights
• Asses capillary refill time- <3 sec
• Temperature , pallor, polycythemia, femoral pulses, BP of all 4
limbs
• Barrel shaped chest –post term-MAS
• Bell shaped thorax – neurologic abnormalities
• Scaphoid abdomen-CDH
• Look for nasal flaring,grunting & retractions
• Airway – choanal atresia.
• Pulse oximetry.
Sasidharan P. An approach to diagnosis and management of cyanosis and tachypnea in term infants. Pediatr. Clin.
North Am. 2004 Aug;51(4):999–1021, ix.
23. CARDIAC PULMONARY
Early
< 4 hours
> 4 hours
presentation
Resp distress
> cyanosis
Cyanosis >
Resp distress
Type of
cyanosis
CentralCentral/diff
complicated
labor More likelyunlikely
CLINICAL DIFFERNCES: CARDIAC VS PULMONARY
ONSET
24. CCHD in Newborns:CCHD in Newborns:
Clues based on presentationClues based on presentation
Cyanosis
No Resp Distress
Cyanosis
+
Resp Distress
Shock
Differential
cyanosis
TGA
DDPC
TAPVC
obstructed
DDSC
25. CCHD in Newborns:CCHD in Newborns:
Clues Based on S2 splitClues Based on S2 split
S2
single fixed
DDPC
TGA
DDSC
TAPVC
26. CCHD in Newborns:CCHD in Newborns:
Clues based on Onset of CyanosisClues based on Onset of Cyanosis
0-6 days
TGA
HLHS
TOF
COA
VSD
others
7- 13 days
COA
VSD
HLHS
TGA
TOF
Others
14-28 days
VSD
COA
TOF
TGA
PDA
Manual of neonatalogy – John P Cloherty – 17 th edition
28. • Small heart- hypovolemia, adrenal insufficiency,
pulmonary interstitial emphysema, congenital lobar
emphysema.
• Egg-on-end - transposition of the great vessels
• Snowman sign – TAPVC
• Boot-shaped heart - tetralogy of Fallot.
• Severe cardiomegaly -Ebstein’s anomaly
• Moderate cardiomegaly - Infants of diabetic mothers
(hyperinsulinemia), cardiomyopathy (caused by
infections,metabolic disorders or asphyxia)
29.
30. 2 DAY OLD NEONATE WITH SAO2 OF 40% WITH
SINGLE S2
AND SOFT 2/6 ESM
TRANSPOSITION OF GREAT ARTERIES
31. CYANOTIC NEONATE WTH SIGNS OF RESPIRATORY
DISTRESS
AND CHF WITH SEVERE PAH
OBSTRUCTED TAPVC
32. 3 day neonate with profound
cyanosis , ECG shows slurred
upslope of qrs
NEONATAL EBSTEIN S
33. Hyperoxia test
100% O2 via hood
~15 min..
Take ABG – pO2 /
Transcutaneous po2
PO2
< 100 mmHg
CHD likely
PO2
>250mmHg,
CHD
unlikely
100 to
250
±
< 70
mmHg
CHD very
likely
Manual of neonatalogy – John P Cloherty – 17 th edition
34. ECG
• Most conditions cause right axis deviationMost conditions cause right axis deviation
with RVHwith RVH
• Cyanotic infant with left axis deviation andCyanotic infant with left axis deviation and
LVH:LVH:
1.Tricuspid atresia1.Tricuspid atresia
2 Pulmonary atresia with intact ventricular2 Pulmonary atresia with intact ventricular
septum.septum.
• ArrhythmiaArrhythmia
36. Management
• Thermo-neutral environmentThermo-neutral environment
• Airway , breathing , circulationAirway , breathing , circulation
• Correct hypovolemia, metabolicCorrect hypovolemia, metabolic
derangements, treat sepsis.derangements, treat sepsis.
• Particular care of IV lines and infusions –Particular care of IV lines and infusions –
avoid flushing of air bubbles into IV lines.avoid flushing of air bubbles into IV lines.
• Feeding may be withheld in neonates withFeeding may be withheld in neonates with
duct dependent states if prostaglandin isduct dependent states if prostaglandin is
anticipated.anticipated.
37. PGE 1
• Neonate failing hyperoxia test
• Shock within 1st
3 weeks of life
• Start at 0.05 µg/kg/mt – 0.1mcg/kg/mt
• Anticipate apnea
• Can worsen TAPVC
• Available as 500 μg vialAvailable as 500 μg vial
Manual of neonatalogy – John P Cloherty – 17 th edition
38. Oxygen TherapyOxygen Therapy
• Can be dangerous in certain statesCan be dangerous in certain states
• Ductus dependent systemic lesionsDuctus dependent systemic lesions
• Pulmonary blood flow can increase at thePulmonary blood flow can increase at the
cost of systemic blood flow(DDSC)cost of systemic blood flow(DDSC)
• Tailor the FiO2, aTailor the FiO2, a SaO2 of 80-85% maySaO2 of 80-85% may
be adequate to balance systemic andbe adequate to balance systemic and
pulmonary circulationspulmonary circulations
• Cyanosis not associated with acidosisCyanosis not associated with acidosis
need not be correctedneed not be corrected
Manual of neonatalogy – John P Cloherty – 17 th edition
39. DiagnDiagn
osisosis
ClinicalClinical
presentationpresentation
CXRCXR ImmeImme
diatediate
TrtTrt
DefinitiveDefinitive
TrtTrt
DDPCDDPC
(Pulm(Pulm
Atresia)Atresia)
Cyanosis D2-7Cyanosis D2-7
No distressNo distress
S2 single; Short ESMS2 single; Short ESM
OligemicOligemic
LungLung
fieldsfields
PGE1PGE1 BT shunt/BT shunt/
PDAPDA
stentingstenting
TGATGA Cyanosis D1Cyanosis D1
Min. DistressMin. Distress
S2 single; Short ESMS2 single; Short ESM
Egg onEgg on
sideside
PlethoraPlethora
BAS +BAS +
PGE1PGE1
ASOASO
TAPVCTAPVC
(obstr)(obstr)
Cyanosis variableCyanosis variable
Marked distressMarked distress
Fixed split S2; noFixed split S2; no
murmurmurmur
GroundGround
glassglass
lunglung
fieldsfields
No PGE1No PGE1 surgerysurgery
DDSCDDSC Shock withShock with
diff.cyanosisdiff.cyanosis
S2 single;S2 single;
PlethoraPlethora
CE +CE +
PGE1PGE1 Repair/Repair/
NorwoodNorwood
40. Strategies to manage PPHN
• Avoid hyperoxemia (spo2 90 – 98)
• HFV
• iNO
• ECMO
• Sedation
• Hemodynamic support
• Correct acidosis ,polycythemia
• Drugs – sildenafil, mag sulph , adenosine,CCB,
tolazoline, prostacycline,inhaled ethyl
nitrite
Manual of neonatalogy – John P Cloherty – 17 th edition
41. Met hemoglobinemia
• Iron molecule in hemoglobin- normally in the
ferrous state (Fe2.
• The ferric (Fe3+) form combines with water
producing methemoglobin (MetHb).
• The predominant intracellular mechanism for the
reduction of MetHb is cytochrome 5b.
• MetHb may be increased in the red cell owing to
exposure to toxic substances or to absence of
reductive pathways
Nelson textbook of pediatrics – 19 th edition
42. Treatment
• Methylene blue given IV (1-2 mg/kg
initially) is used to treat toxic
methemoglobinemia.
• An oral dose can be administered (100-
300 mg PO per day) as maintenance
therapy.
Nelson textbook of pediatrics – 19 th edition
Capillary blood has an oxygen content that is between the venous and arterial
blood oxygen contents, but in states of poor perfusion there will be large arteriovenous
oxygen content difference. In such circumstances, it is possible to see
Fig. 1. peripheral cyanosis, because of the higher amount of deoxyhemoglobin in the
capillary blood, even though the arterial blood oxygen content may be normal
[5,6]. Arterial blood oxygen content will be normal in peripheral cyanosis,
whereas in central cyanosis there is decreased oxygen content in the arterial
blood. Peripheral cyanosis is likely to be seen with exposure to cold, polycythemia,
and hypoplastic left-heart syndrome (decreased peripheral perfusion)
When the degree of oxygenation or percentage of saturation of hemoglobin
with oxygen is plotted against the partial pressure of oxygen, it is referred to as
oxyhemoglobin dissociation curve. The changing oxygen affinity of hemoglobin
with oxygenation results in a sigmoid curve. The shape of its midportion is the
midportion of the saturation (ie, 50% saturation of the hemoglobin) and its
corresponding PO2 is called the P50. The adult hemoglobin has a P50 value of
27, which means that at 50% saturation the PO2 is 27 mm Hg. The P50 in thenewborn is 22; that is, at 50% oxygen saturation the PO2 is 22 mm Hg. Thus, if an infant is cyanotic, he or she may have a significantly lower PO2 value and
requires immediate attention compared with an older child. Because PO2 is the
driving force in oxygen exchange, a low PO2 will adversely affect the oxygen
delivery to the tissues. Oxygen delivery is also dependent upon the amount of
hemoglobin available to carry oxygen and the blood flow.
In the normal lung, the average ventilation-to-perfusion ratio is in the range of
0.8 to 1.0. The concentration of oxygen in the gas entering the alveolus, the
concentration of oxygen in the mixed venous blood entering the capillaries, and
the respective quantities of the gas flow and blood flow are the main variables for
gas exchange at the alveolar level [9]. Although diffusion abnormalities exist in
adults, they are not commonly seen in the newborn. In the normal physiologic
state, the pulmonary blood flow (QP) should be equal to systemic blood flow
(QS). In other words, the volume of blood entering the lungs should be equal to
the volume of blood leaving the left ventricle. This is given in the equation
QP = QS. The volume of blood that participates in gas exchange, however, may
not be equal to the volume of blood entering the pulmonary circulation. The
volume of blood that participates in actual gas exchange is called effective
P. Sasidharan / Pediatr Clin N Am 51 (2004) 999–1021 1003
pulmonary blood flow (QeP). In an ideal circumstance, the QP should be equal to
QeP; the total volume of blood that enters the lungs participates in gas exchange.
This does not take place normally, however. When there is a shunt between the
systemic venous return to the pulmonary veins, or the left ventricle, it is called
right-to-left shunt. In this case QP (QeP) is less than QS. This gives rise to
decreased oxygen content in arterial blood (Fig. 2) [17]. Conversely, with a shunt
from the left ventricle or aorta to the right ventricle or pulmonary artery (left-toright
shunt), there is increase in pulmonary blood flow, and hence QP is greater
than QS. In this condition, the infant will not develop cyanosis until the formation
of pulmonary congestion and pulmonary edema. Intrapulmonary shunting takes
place when nonventilated portions of the lungs are perfused, because the blood
return from those areas does not take part in gas exchange. Intrapulmonary
shunting or low ventilation to perfusion (V &lt; Q) is seen in pulmonary edema,
atelectasis, or pneumonia. During the newborn period, the total percentage of
shunting from right to left is approximately 2% to 5%, but this does not give rise
to hypoxia.