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Approach to the neonatal cyanosis


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Approach to the neonatal cyanosis topic presentation

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Approach to the neonatal cyanosis

  1. 1. Approach to the neonatal cyanosis Topic presentation By Ext. Sripada Kriangkhajorn Faculty of Medicine, Srinakharinwirot University
  2. 2. Objective • Definition, presentation, and abnormalities in cyanotic newborn • Approach cause of neonatal cyanosis; include history, risk, and initial evaluation • Initial management in neonatal cyanosis disease; pulmonary, cardiac cause
  3. 3. Cyanosis • A physical sign causing bluish discoloration of the skin and mucous membranes • Three factor causes cyanosis are • Total amount of Hb in blood • The degree of Hb saturation • State of circulation.
  4. 4. Central cyanosis • Increase in arterial deoxyhemoglobin, associated with decreased PaO2 and Hb oxygen saturation (SaO2) • Present when deoxyhemoglobin in blood reaches 3-5 g/dL.
  5. 5. Peripheral cyanosis • Discoloration of skin but sparing in mucous membrane, tongue. Usually normal in PaO2. • Peripheral vascular instability, cold exposure are common cause in the cyanosis
  6. 6. Differential Cyanosis • Asymmetrical cyanosis between upper and lower extremities, usually lower limbs more than the upper limbs. • This finding suggested of Rt.-to-Lt. Shunt from PDA Differential Cyanosis Cause1 -PPHN with PDA -PDA with severe pulmonary hypertension (Eisenmenger Syndrome) -Interrupted aortic arch -Severe coarchtation of aorta with VSD and PDA
  7. 7. Differential Cyanosis • Usually lower limbs more cyanosis than the upper limbs.
  8. 8. Reversed differential cyanosis • Cyanosis that appear in upper limbs more than lower limbs. • Found in complete TGA with severe pulmonary hypertension, D-TGA with VSD ,or Interrupted aortic arch or severe coarctation of aorta
  10. 10. 1. Identify kind of cyanosis Cyanosis Peripheral Cyanosis Central Cyanosis • Pink tongue, conjunctiva • Normal PaO2 • Cold peripheral Ext. • Cap. Refill > 2 sec. • Discoloration all skin and mucous • Decrease PaO2 ,SpO2 • Capillary refill <2 sec.
  11. 11. 2. Identify possible cause • Three common causes of central cyanosis are Cardiac disease,Respiratory disease, Central nervous system • Another cause is hematologic cause such as methemoglobinemia Central Cyanosis CNS Pulmonary disease Cardiac disease
  12. 12. CNS Causes and clinical finding of Central Cyanosis5 System Causes Clinical Findings CNS depression Perinatal asphyxia Hypoventilation Heavy maternal sedation Intrauterine fetal distress Shallow irregular respiration Poor muscle tone Cyanosis resolved when given oxygen or stimulated the patient
  13. 13. Pulmonary System Causes and clinical finding of Central Cyanosis5 System Causes Clinical Findings Pulmonary disease Parenchymal lung diseases Pneumonia Pneumothorax or pleural effusion Congenital lung abnormalities Persistent pulmonary hypertention Tachypnea, respiratory distress with chest retraction, or expiratory grunting Crackles,or decreased breath sound X-ray films may show some lung abnormalities Oxygen giving may improved cyanosis
  14. 14. Cardiac System Causes and clinical finding of Central Cyanosis5 System Causes Clinical Findings Cardiac disease Cyanosis CHD with right to left shunt (5 ‘T’s) Tachypnea, but not respiration effort Normal breath sound unless severe CHF A continuous murmur may present. X-ray may shows cardiomegaly, increased or decreased lung markings. Little or no improved in oxygen giving.
  15. 15. 3. History & risks evaluation Risk assessment in initial evaluation5,6 History Possible risks Maternal Diabetic Heart disease GBS and infectious screening PROM CHD, sepsis, fetal asphyxia, pneumonia Oligohydramnios Hypoplastic lung disease Polyhydramnios Airway, esophageal, neurological disorder Perinatal Difficult delivery Neurological cause; birth trauma, ICH, phrenic nerve paralysis Postnatal Polycythemia Hypoglycemia Hypoventilation
  16. 16. 4. Physical Examination • Complete examination but also pay focus on pulmonary, cardiac, and neurologic system • Growth curve for SGA, LGA which are prone for polycythemia, and associated congenital anomaly
  17. 17. Cardiac Examination • In cardiac auscultation, focus on S2, which will be loud and single (or narrowly split) in PPHN, TGA, PA • Heart murmurs is often not helpful to detect serious lesions such as TGA • Loud murmurs are frequently benign lesion such as a small VSD.
  18. 18. 5. Special Tests • Hyperoxia test • Hyperoxia-hyperventilation Test • Pre-/postductal PaO2 Test • Echocardiography
  19. 19. Hyperoxia test • Perform by given 100% oxygen for 5-10 minutes, then measure the before and after oxygen saturation Changes after performed Hyperoxia Test1 PaO2 SpO2 Pulmonary disease Pneumonia RDS, Hyaline membrane disease etc,. > 150-200 mmHg Up to 99% Rt.-to-Lt. Shunt Disease Congenital cyanosis heart disease PPHN Pulmonary AV Fistula < 50-150 mmHg < 80%
  20. 20. Hyperoxia-hyperventilation Test • Given the 100% O2 through ET-tube or oxygen bag, • Perform the patient hyperventilation, start at 100 times/min then keep monitor PaCO2 at 20-30 mmHg Changes after performed Hyperoxia-Hyperventilation Test Rt.-to-Lt. Shunt PaO2 SpO2 Congenital cyanosis heart disease < 50-150 mmHg < 80%, no improve PPHN > 100 mmHg Up to 95%
  21. 21. Pre-/postductal PaO2 Test Pre-/postductal PaO2 Test Pre-/postductal PPHN CHD PaO2 difference > 15-2o mmHg <15mmHg SpO2 difference > 10% <10%
  22. 22. 6. Investigation • Chest X-ray • Help differentiate lung parenchymal diseases, some congenital anomaly, and some congenital heart diseases • EKG • Useful to detect cardiac arrhythmias, but is not useful to detected serious neonatal cardiac condition such as TGA
  23. 23. Identify possible cause3 Central Cyanosis CNS Cardiac disease Cyanosis not improve when crying No respiratory effort +/- murmurs +SpO2, PaO2 do not improve after O2 support Abnormal S2 sound +/- CRX abnormal +/- EKG annormal Cyanosis improve when crying Respiratory effort; grunting, chest wall retraction, RR>60/min Normal cardiac examination +SpO2, PaO2 do improve after O2 support Normal CRX, EKG Perinatal asphyxia Hypoventilation Heavy maternal sedation Intrauterine fetal distress Difficult delivery Pulmonary disease
  25. 25. Respiratory distress in the neonates Common abnormalities in the Neonatal Respiratory Distress2 Initial management Specific treatment RDS On O2 support, with CPAP , or ET-tube Keep normal BT at 36.5-37.5c Correct metabolic disturbance IV fluid support Surfactant,mechanical ventilation MAS Keep PaO2 60-80 mmHg, adequate O2, ventilation Sepsis/Pneumonia Antibiotic Pneumothorax Pleural tapping Congenital diaphragmatic hernia Retain OG tube, definitive surgery Airway obstruction Definitive surgery
  26. 26. Cardiac cause of neonatal CHD Congenital Heart Disease7,1 Pulmonary BloodFlow Cyanotic Acyanotic High flow TA TGA TAPVR Common Atrium Common Ventricle ASD VSD PDA AVC Low flow TOF Tricuspid atresia Ebstein’s anomaly Pulmonary stenosis Normal - Coarctation of Aorta Aortic stenosis
  28. 28. Fetal and neonatal circulation • Structure and Function: The Heart Before and After Birth Source
  29. 29. ที่มา ภาวะวิกฤติทางหัวใจในเด็ก; มูลนิธิเพื่อสนับสนุนการผ่าตัดหัวใจในเด็ก; กรกฎาคม 2551
  30. 30. Cyanotic Congenital heart disease Common finding cyanotic congenital heart disease ที่มา ภาวะวิกฤติทางหัวใจในเด็ก; มูลนิธิเพื่อสนับสนุนการผ่าตัดหัวใจในเด็ก; กรกฎาคม 2551
  31. 31. Ductal Dependent Cardiac Lesions • Congenital cardiac abnormality that need the remain opening ductus arteriosus to maintain vital circulation. • Must be considered in any neonate (<28day) with sudden onset shock should be treated as having ductal dependent lesions until proved otherwise • PGE1 infusion, by maintaining patency of ductus arteriosus is life-saving in infants
  32. 32. Ductal Dependent Cardiac Lesions • Lt. to Rt. shunt pulmonary vascular resistance is lower than systemic vascular resistance. • Rt. to Lt. shunt pulmonary vascular resistance is suprasystemic.
  33. 33. Patent Ductus Arteiosus8,7,1,9 Dependent non-Dependent Initial Management Pulmonary Systemic Confirm cardiac cause of cyanosis. Initial resuscitation; ABC’s, but limit O2 support in preterm Identify whether it is ductal dependent lesion if possible Medication PGE1 IV continuous drip 0.05-0.1mcg, prefer start with 0.1mcg, then taper down Side effect; apnea, flushing, diarrhea. Intubation may be used in some patient Correct metabolic disturbance(acidosis) PA e IVS TGA e IVS TOF e PA Critical PS TA e PS/PA Severe Ebstein’s anomaly Univentricular Heart Coarctation of aorta Critical AS HLHS IAA TAPVR If can’t rule out the non- ductal dependent lesion, and the patient became more deteriorate, PGE1 may be used Truncus arterosus
  34. 34. TOF • Most common cyanosis CHD, 14% of all CHD • PE; Loud single S2, systolic ejection murmur Lt. mid-upper sternal border, clubbing of finger • Cyanosis with decrease pulmonary blood flow, no CHF • TOF with PA has early onset of cyanosis, ductal dependent lesion, no murmur Source Swatchz’s principal of surgery edition 10th
  35. 35. TOF
  36. 36. TGA • 3rd common cyanotic heart disease, associated with another CHD Source Swatchz’s principal of surgery edition 10th
  37. 37. TGA • A. The heart is enlarged with a narrow "pedicle" giving the so called "egg on a string" appearance. • The superior mediastinum appears narrow due to the antero- posterior relationship of the transposed great vessels and "radiologic-absence of the thymus".
  38. 38. Ebstein anomaly • an uncommon congenital cardiac anomaly, characterised by a variable developmental anomaly of the tricuspid valve
  39. 39. TAPVR(Totalanomalouspulmonaryvenousreturn) • Mixing blood circulation with increase pulmonary blood flow • Pulmonary vein obstruction is key to determine severity of disease
  40. 40. TAPVR
  41. 41. TAPVR (Supracardiac) Finding mild cardiomegaly, increased pulmonary vascular markings and "snowman" appearance
  42. 42. TAPVR(infradiaphragmatic-obstructed) • The heart is normal sized with increased pulmonary venous pattern preferentially in the right upper lobe
  43. 43. Truncus arteriosus • Single great vessel exit from heart, mixing blood circulation, rare, 0.9% of all cyanotic CHD • Present with late cyanosis, with congestive heart failure, or URI on top Source Swatchz’s principal of surgery edition 10th
  44. 44. Univentricular Heart • Group of abnormality such as; tricuspid atresia, pulmonary atresia, HPLS, single ventricle • 2nd most common with 10% of all CHD • Mixing blood lesion, variable severity
  45. 45. Tricuspid atresia • Complete absence of the communication between the right atrium and ventricle. This lesion occurs in approximately 1:15,000 live births
  46. 46. HPLS • Most severe cyanotic CHD
  47. 47. Univentricular Heart • Pulmonary atresia Source Swatchz’s principal of surgery edition 10th
  48. 48. Cyanosis neonate in cardiac disease • Most common cyanosis CHD in neonate is TOF • Most of early cyanosis in newborn <1wk is cyanosis CHD with ductal dependent lesion • Subacute cyanosis with CHF usually come from decrease pulmonary vascular resistant present at > 2wk of life • Hypercyanotic spell from TOF mostly present late, at 2mo.-6mo.
  49. 49. Before refer to specialist • If possible, identify ductal dependent lesion • Resuscitation; ABC’s, but limit O2 support in preterm • Medication; • PGE1 IV continuous drip 0.05-0.1mcg, prefer start with 0.1mcg, then taper down • Side effect; apnea, flushing, diarrhea • Correct metabolic disturbance(acidosis)
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  51. 51. THANK YOU
  52. 52. References 1.ภาวะวิกฤติทางหัวใจในเด็ก;มูลนิธิเพื่อสนับสนุนการผ่าตัดหัวใจในเด็ก; กรกฎาคม 2551 2.Cyanosisin neonate; คู่มือกุมารเวชศาสตร์ฉุกเฉิน; คณะแพทยศาสตร์ รามาธิบดี กันยายน 2554 3.Fetal Asphyxia; คู่มือทารกแรกเกิด; คณะแพทยศาสตร์ มหาวิทยาลัยของแก่น 4.Evaluationand management of the cyanotic neonate;ClinPediatr Emerg Med. ;Pubmed;Author manuscript;PMC 2009 Sep 1. 5.Pediatriccardiology; 6.Swatchz’sprincipal of surgery edition 10th 7.โรคหัวใจตั้งแต่กาเนิด; ตารากุมารเวชศาสตร์; คณะแพทยศาสตร์ มหาวิทยาลัยศรีนคริทรวิโรฒ 8.Identificationand Management of Ductal Dependant Cardiac Defects in the Transport Setting - Robyn Neely Funk, RN,BS/BSN,PHRN,CMTE 9.Ductal-dependent cardiac lesions/Hyperplasticleft heart syndrome; Atlasof pediatricemergency medicine; McGrawHill;second edition 10.Patent Ductus ArteriosusAortopulmonaryWindow; George A. Gibson9 11.