View
223
Download
0
Category
Preview:
Citation preview
8/14/2019 Neonat Engl
1/25
Dr.LORN TRY Patrich,pediatriciDr.LORN TRY Patrich,pediatrici
PERINATAL ASPHYXIAPERINATAL ASPHYXIA
Dr.LORN TRYDr.LORN TRY
Patrich,Pediatrician.DHMPatrich,Pediatrician.DHM
8/14/2019 Neonat Engl
2/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
DEFINITIONDEFINITION
Perinatal asphyxia as condition in thePerinatal asphyxia as condition in theneonate where there is the followingneonate where there is the followingcombination:combination:
An event or condition during the perinatal periodAn event or condition during the perinatal periodthat is likely to severely reduce oxygen deliverythat is likely to severely reduce oxygen deliveryand lead to acidosis.and lead to acidosis.
A failure of function of at least two organsA failure of function of at least two organs(include lung, heart, liver, brain, kidneys, and(include lung, heart, liver, brain, kidneys, andhematological) consistent with the effects ofhematological) consistent with the effects ofacute asphyxia.acute asphyxia.
8/14/2019 Neonat Engl
3/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
RISK FACTORRISK FACTOR Hypertensive disease of pregnancy or preeclampsia.Hypertensive disease of pregnancy or preeclampsia.
Intrauterine growth restrictionIntrauterine growth restriction Placental abruptionPlacental abruption
Fetal anemia (eg rhesus incompatible)Fetal anemia (eg rhesus incompatible)
Post maturityPost maturity
MalpresentationMalpresentation cord compressioncord compression
transplacental anaesthetic or narcotic administrationtransplacental anaesthetic or narcotic administration
severe meconium aspirationsevere meconium aspiration
congenital cardiac or pulmonary anomaliescongenital cardiac or pulmonary anomalies
birth traumabirth trauma
intrauterine pneumoniaintrauterine pneumonia
8/14/2019 Neonat Engl
4/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
DAPGAR SCOREDAPGAR SCORE Dapgar Scoreis based on 5 vital signs :Dapgar Scoreis based on 5 vital signs :
Heart rateHeart rate
Respiratory effortRespiratory effort Present or absence of central or peripheral cyanosisPresent or absence of central or peripheral cyanosis
Muscle toneMuscle tone
Response to stimulationResponse to stimulation
Each vital signs is given a score 0 or 1 or 2. A vitalEach vital signs is given a score 0 or 1 or 2. A vitalsign score of 2 is normal.A score 1 mildlysign score of 2 is normal.A score 1 mildlyabnormal .A score 0 is severity abnormal.abnormal .A score 0 is severity abnormal.
Normally Dapgare score is of 7 to 10:Normally Dapgare score is of 7 to 10: 4 6 Moderate depression4 6 Moderate depression
0-3 severely depress vital signs and great risk of dying0-3 severely depress vital signs and great risk of dyingunless actively resuscitated.unless actively resuscitated.
8/14/2019 Neonat Engl
5/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
CLINICAL DIAGNOSISCLINICAL DIAGNOSIS
At deliveryAt delivery Abnormal fetal heart rateAbnormal fetal heart rate
Meconium staining of the liquorMeconium staining of the liquor
At birthAt birth Apgar score < 7 at 5 minutesApgar score < 7 at 5 minutes
Acidosis pH< 7Acidosis pH< 7
Post natalPost natal
Hypoxic ischemic encephalopathyHypoxic ischemic encephalopathy Multiorgan system dysfonctionnement (Liver, Kedney,Multiorgan system dysfonctionnement (Liver, Kedney,
heart, brain)heart, brain)
8/14/2019 Neonat Engl
6/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
INTERVENTIONINTERVENTION
Principle:Principle: Correct of hypoglycemiaCorrect of hypoglycemia
Correction of acidosisCorrection of acidosis
Treatment of seizuresTreatment of seizures
Temperature: Maintain core temperature 36-37Temperature: Maintain core temperature 36-37 oo- 37- 37o .o .
Respiratory status : Meconium aspiration, oxygeneRespiratory status : Meconium aspiration, oxygene
Cardiac status : Cardiac ECHOCardiac status : Cardiac ECHO
Fluid therapy and renal impairment:electrolytes andFluid therapy and renal impairment:electrolytes andcreatinine should be performed.creatinine should be performed.
Gastro-intesinal-feeding: Brest milk is preferred.Gastro-intesinal-feeding: Brest milk is preferred.
8/14/2019 Neonat Engl
7/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
PREDICTION OF OUTCOMEPREDICTION OF OUTCOME
During resuscitationDuring resuscitation
a)a) Apgar scoresApgar scores
Although the 1 and 5 minutes Apgar scores, areAlthough the 1 and 5 minutes Apgar scores, are
poor predictors of neonatal.poor predictors of neonatal. Apgars score 0-3 at 20 minutes ,59% of survivorsApgars score 0-3 at 20 minutes ,59% of survivorsdied before 1 year, and 57 % of the survivors haddied before 1 year, and 57 % of the survivors hadcerebral palsy.cerebral palsy.
b)b) Time to spontaneous respirationsTime to spontaneous respirations
The overall risk of death or handicap was 72% inThe overall risk of death or handicap was 72% inthe pooled seri of infants with > 30 minutes tothe pooled seri of infants with > 30 minutes tosubstained spontaneous resppirationsubstained spontaneous resppiration
8/14/2019 Neonat Engl
8/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
PREDICTION OF OUTCOMEPREDICTION OF OUTCOME(Count)(Count) Clinical assessment of encephalopathy the overall risk ofClinical assessment of encephalopathy the overall risk of
death or severe handicap in a pooled serie of infant was:death or severe handicap in a pooled serie of infant was: Grade 1 : HIE 1.6%Grade 1 : HIE 1.6%
Grade 2 : HIE 24%Grade 2 : HIE 24%
Grade 3 : HIE 78%Grade 3 : HIE 78%
Grade of HIEGrade of HIE Grade 1 : Mild encephalopathy with infant hyperalert,Grade 1 : Mild encephalopathy with infant hyperalert,
and over sensitive to stimulation EEG isand over sensitive to stimulation EEG isnormal,tarchycardia,dilated pupils.normal,tarchycardia,dilated pupils.
Grade 2 : moderate encephalopathy with the infantGrade 2 : moderate encephalopathy with the infantdisplaying lethargy, hypotonie. EEG abnormal , 70% ofdisplaying lethargy, hypotonie. EEG abnormal , 70% ofinfants will have seizure, small pupils.infants will have seizure, small pupils.
Grade 3 : Severe encephalopathy with a stuporousGrade 3 : Severe encephalopathy with a stuporousabsent reflexes .The infant may have seizures and hasabsent reflexes .The infant may have seizures and has
abnormal EEG with decreased background activityabnormal EEG with decreased background activity
8/14/2019 Neonat Engl
9/25
Dr.LORN TRY Patrich,pediatriciDr.LORN TRY Patrich,pediatrici
NEONATAL HYPOGLYCEMIANEONATAL HYPOGLYCEMIA
Dr.LORN TRY Patrich,Pediatrician,DHMDr.LORN TRY Patrich,Pediatrician,DHM
8/14/2019 Neonat Engl
10/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
DEFINITIONDEFINITION
Glycemia < 1.1 mmol/l(1mmol/l=180mg/l) inGlycemia < 1.1 mmol/l(1mmol/l=180mg/l) in
growth retarded and preterm; < 1.7 mmol/l in termgrowth retarded and preterm; < 1.7 mmol/l in term
baby :baby :
In at risk asymptomatic term or near term baby ( 36In at risk asymptomatic term or near term baby ( 36weeks ) BGL should be maintained about 1.5 mmol/lweeks ) BGL should be maintained about 1.5 mmol/l
In preterm babies ( < 35 weeks) or sick term babiesIn preterm babies ( < 35 weeks) or sick term babies
BGL should be maintained about 2.5 mmol/l.BGL should be maintained about 2.5 mmol/l.
8/14/2019 Neonat Engl
11/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
RISKS FACTORSRISKS FACTORS
Infants of diabetic mothersInfants of diabetic mothers
Growth restricted babiesGrowth restricted babies
Preterm babiesPreterm babies
Macrosomie babies (may have hyperinsulinism)Macrosomie babies (may have hyperinsulinism)
Sick babies including these with:Sick babies including these with:
Pernatal asphyxiaPernatal asphyxia
Rhesus diseasRhesus diseas
SepsisSepsis
PolycythaemiaPolycythaemia
8/14/2019 Neonat Engl
12/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
CLINICAL DIAGNOSISCLINICAL DIAGNOSIS
IrritabilityIrritability
Apnea and cyanosisApnea and cyanosis
Hypotonia and poor feedingHypotonia and poor feeding ConvulsionsConvulsions
8/14/2019 Neonat Engl
13/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
PREVENTION and TREATMENTPREVENTION and TREATMENT
Prevention at risk infantPrevention at risk infant
Infant of all diabetic mothersInfant of all diabetic mothers
Small for gestational age infantsSmall for gestational age infants
Wasted babies( < 3Wasted babies( < 3rdrd centil)centil)
Preterm babies (< 37 weeks )Preterm babies (< 37 weeks )
Macrosomies babyMacrosomies baby
Need attention paid to early establishement of breastNeed attention paid to early establishement of breastfeeding .feeding .
8/14/2019 Neonat Engl
14/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
WHEN SHOULD ACTIVEWHEN SHOULD ACTIVE
INTERVENTION BE STARTED?INTERVENTION BE STARTED?
Glycemia =1.5-2mmol/lGlycemia =1.5-2mmol/l
Admit to NICUAdmit to NICU
Continue breast, complements or tube feedsContinue breast, complements or tube feeds
Commence IV 10% dextrose if BSL not maintainedCommence IV 10% dextrose if BSL not maintainedabout 2 mmol/labout 2 mmol/l
Glycemia = 1 1.5 mmol/lGlycemia = 1 1.5 mmol/l
Admit to NICUAdmit to NICU
Continue IV 10% dextrosee at 60-90mls/kg/day toContinue IV 10% dextrosee at 60-90mls/kg/day to
maintain normal blood glucose.maintain normal blood glucose.
8/14/2019 Neonat Engl
15/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
WHEN SHOULD ACTIVEWHEN SHOULD ACTIVE
INTERVENTION BE STARTEDINTERVENTION BE STARTED??(Counti)(Counti) Glycemia < 1 mmol/lGlycemia < 1 mmol/l
Admit to NICU urgentlyAdmit to NICU urgently
Give IV bolus of 10% dextrose at 2.5mls/kgGive IV bolus of 10% dextrose at 2.5mls/kg
Ensure BSL has increased to > 1.5 mmol/lEnsure BSL has increased to > 1.5 mmol/l Contious IV 10% dextrose at 60-90 mls/Kg/day toContious IV 10% dextrose at 60-90 mls/Kg/day tomaintain normal blood glucose.maintain normal blood glucose.
Persistent severe hypoglycemia: We should interpretationPersistent severe hypoglycemia: We should interpretationof hormone levels and take some blood for : Insulin,of hormone levels and take some blood for : Insulin,
Cortisol, Growth hormone. The treatment :Cortisol, Growth hormone. The treatment : Increase volume by 30 ml/kg/day.Increase volume by 30 ml/kg/day.
Increase the glucose concentration to 12.5%Increase the glucose concentration to 12.5%
If still persisting.Start aIf still persisting.Start a glucagonglucagon infusioninfusion
8/14/2019 Neonat Engl
16/25
Dr.LORN TRY Patrich,pediatriciDr.LORN TRY Patrich,pediatrici
RESUSCITATIONRESUSCITATION
Dr.LORN TRY Patrich,pediatrician,DHMDr.LORN TRY Patrich,pediatrician,DHM
8/14/2019 Neonat Engl
17/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
INTRODUCTIONINTRODUCTION
Approximately 1-10% of in hospital delivered newbornsApproximately 1-10% of in hospital delivered newbornsrequire resuscitation. The aim of resuscitation is to preventrequire resuscitation. The aim of resuscitation is to prevent
neonatal death and adverse long term neurodevelopmentalneonatal death and adverse long term neurodevelopmental
sequelae associated with asphyxia.sequelae associated with asphyxia.
Substantial physiologic changes occur in the transitionSubstantial physiologic changes occur in the transitionfrom fetal to extra uterine life including:from fetal to extra uterine life including:
Changes from fluid-filled to air filled alveolar sacsChanges from fluid-filled to air filled alveolar sacs
Reduction in pulmonary vascular bed pressureReduction in pulmonary vascular bed pressure
Reduction of intra and extra cardiac shuntingReduction of intra and extra cardiac shunting Establishment of adequate lung volumeEstablishment of adequate lung volume
Surfactant productionSurfactant production
8/14/2019 Neonat Engl
18/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
8/14/2019 Neonat Engl
19/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
PREPARATIONPREPARATION PersonnelPersonnel
At least two trained people are required for adequateAt least two trained people are required for adequateresuscitation involving ventilation and cardiacresuscitation involving ventilation and cardiaccompression.compression.
Check equipmentCheck equipment
Resuscitation equipment should be checked daily afterResuscitation equipment should be checked daily after
each usage.each usage. When use is anticipated at birth recheck equipment,When use is anticipated at birth recheck equipment,
including : Oxygen supply, laryngoscope, bag and maskincluding : Oxygen supply, laryngoscope, bag and maskcircuit and endotracheal tubs.circuit and endotracheal tubs.
Communication: with anesthetic and obstetric staffCommunication: with anesthetic and obstetric staffregarding maternal condition and therapie, fetal conditionregarding maternal condition and therapie, fetal condition
Environment: Prevention of heat loss, dry infant,warmEnvironment: Prevention of heat loss, dry infant,warmtowels.towels.
8/14/2019 Neonat Engl
20/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
ASSESSMENTASSESSMENT
Evaluation begins immediately after birth andEvaluation begins immediately after birth andcontinues throughout the resuscitation processcontinues throughout the resuscitation process
until vitals signs have normalized:until vitals signs have normalized:
Respiration : the newly infant should establish regularRespiration : the newly infant should establish regular
respirations in order to maintain 30 100
bpm.bpm.
Color: A central pink color in room airColor: A central pink color in room air
8/14/2019 Neonat Engl
21/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
MANAGEMENTMANAGEMENT
Stimulation: Most infants respond to stimulation withStimulation: Most infants respond to stimulation withmovement of extremities.movement of extremities.
Airway : The head should in a neutral.Airway : The head should in a neutral.
Breathing: Attend to adequate inflation and ventilationBreathing: Attend to adequate inflation and ventilation
before oxygenation .Few infants require immediatebefore oxygenation .Few infants require immediateintubation .The majority of infants can be managed withintubation .The majority of infants can be managed with
bag and mask ventilation.bag and mask ventilation.
Circulation: The majority of infants establishment ofCirculation: The majority of infants establishment of
adequate ventilation will restore circulation. Begin chestadequate ventilation will restore circulation. Begin chestcompressions(3:1) for either:compressions(3:1) for either:
Absent HR or HR < 60 for 30 secondsAbsent HR or HR < 60 for 30 seconds
8/14/2019 Neonat Engl
22/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
8/14/2019 Neonat Engl
23/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
8/14/2019 Neonat Engl
24/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
MEDICATIONMEDICATION
Route of delivery : Umbilical venous catheterRoute of delivery : Umbilical venous catheter
Adrenaline : For HR < 60 for > 30 Sec despite compressionAdrenaline : For HR < 60 for > 30 Sec despite compression
Naloxone : 0.1 ml/kg of 0,4 mg/ml solution and contra-Naloxone : 0.1 ml/kg of 0,4 mg/ml solution and contra-
indication infant of narcotic dependant mothers.indication infant of narcotic dependant mothers.
Bicarbonate : Currently there is insufficient evidence forBicarbonate : Currently there is insufficient evidence forroutine use.routine use.
Stopping resuscitations : If the infant has not respondedStopping resuscitations : If the infant has not responded
with a spontaneous circulation by 15 minutes of age.with a spontaneous circulation by 15 minutes of age.
8/14/2019 Neonat Engl
25/25
Dr.LORN TRY Patrich,pediatricianDr.LORN TRY Patrich,pediatrician
CCD
Newborn Life Support
Airway
&
BreathingAB
CD
cover
Dry &
RC (UK) NLS Resus 31
Recommended