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AsphyxiaofNewborn新生兒窒息AsphyxiaofNewborn新生兒窒息1DefinitionofPerinatalAsphyxiaAneventorconditionduringtheperinatalperiodthatislikelytoseverelyimpairedgasexchangeandleadstothreebiochemicalcomponents:

AND

Afailureoffunctionofatleasttwoorgans.Hypoxemia,Hypercapnia,metabolicacidosisDefinitionofPerinatalAsphyx2Etiology

Allfactorsleadingtoaninterruptionofoxygensupplyorbloodflowtothefetusduringperinatalperiod(prenatal,intrapartumandpostnatal)—RiskFactors-MaternalSystemicdisease:diabetes,heartorrenaldiseases,anemia,infectiousdiseasesObstetricConditions:hypertensionofpregnancyorpre-eclampsia,placentalabruptionSubstanceabuse:drugaddiction,smokingAgeorother:>35y,or<16y,multiplepregnancyEtiology

Allfactorsleadingt3—RiskFactors-FetalPremature,SGA,macrosomiaCongenitalmalformation:noseandlaryngo-pharynxmalformation,lunghypoplasia,heartdiseaseAmnioticfluidormeconiumaspirationIntrauterineinfection:Torchsyndrome—RiskFactors-Fetal4—RiskFactors-IntrapartumUmbilicalcord:prolapsed,aroundneckObstetricprocedures:forcepsdelivery,breechextraction,vacuumextractionMedication:

analgesicandoxytocicmedicine—RiskFactors-Intrapartum5PathophysiologyRespiratoryAlteration:

primaryhyperpnea,primaryapnea,secondaryapneaHypoxic-ischemicChangesofMulti-organicsystem:

“divingreflex”,redistributionofbloodflow,inter-organshunting,organfailure

BiochemicalandmetabolicConsequences:

acidosis,hyper-orhypoglycemia,hypocalcaemia,hyperbilirubinemia,hyperkalemia,hyponatremiaPathophysiologyRespiratoryAlt6ClinicalManifestationFetusasphyxia(intrauterineasphyxia):

earlystage:

increasedmovement,fetalheartrate>160bpm

latestage:

decreasedmovement,fetalheartrate<100bpmNeonatalasphyxia:lowApgarScore,hypoperfusion,Multi-SystemDysfunctionClinicalManifestationFetusas7ApgarScoringSystem

Sign0Points1Point2PointsActivity(muscletone)absentarmsandlegsflexedactivemovementPulse(heartrate)absentbelow100bumabove100bumGrimace(reflexirritability)noresponsegrimacesneeze,cough,pullsawayAppearance(skincolor)blue-gray,paleallovernormal,/-extremitiesnormaloverentirebodyRespirationabsentslow,irregulargood,cryingAPGARApgarScoringSystem

Sign0Poi8TheSignificanceofApgarScore

Apgar8~10,normal;4~7,mildasphyxia;0~3,severeasphyxiaAssignedat1,5,and10min,untilscoreupto>7

1’scoreindicatetheseverityofasphyxiaandguideforresuscitationscoreat5’andlaterismorepredictivetoprognosisPrematureinfantsintendtohavelowerscores0lowApgarscoresmayleadedby:asphyxia,drugs,trauma,hypovolemia,infectionoranomaliesTheSignificanceofApgarScor9MultiorganSystemDysfunctionRenalcompromise:oliguriaandelevatedcreatinine

Acutetubularnecrosis

Hypoxiccardiomyopathy(ECHOorECGabnormality)Hypoxicischemicencephalopathy(HIE)Pulmonarycomplications:respiratorydistress(RDS),persistentpulmonaryhypertension(PPHN)Disseminatedintravascularcoagulation(DIC)Hepaticfailure,hyperbilirubinemiaNecrotizingenterocolitis(NEC),feedintolerance

Fluidoverload,hyperkalemia,hypoglycemia,andacidosisMultiorganSystemDysfunctionR10Bloodgas(pH、PaO2、PaCO2

）Serumsugar,electrolyte（Calcium、Natrium）Serum:BUN,Cr,DIC-coagulationprofile,ALTHeadimage(Ultrasonic,CT,MRI)ChestX-rayECGExaminationBloodgas(pH、PaO2、PaCO2）11Theassessmentofasphyxiashouldcombine:

AhistoryofmaternalandintrapartumriskfactorsApgarscoreat1‘,5‘(0to3forlongerthan5minutes)ScalppH(<7),orumbilicalarterialbloodgasClinicalmanifestation:neurologicalstatusforHIEgrading;featuresoforganinjureExamination(assessmentoforgandysfunction)DiagnosisTheassessmentofasphyxiasho12TreatmentAim:firstcorrectingtheoriginalhypoxiasecondalleviatingtissueischemiamaintainingorrestoringcerebralperfusionManagementoforgandysfunctionsManagements:

Acontinoussupplyofbothoxygenandglucose;Normalizingbloodpressure,volumeexpansion,pressoragents,sodiumbicarbonateCarefulfluidandelectrolytemonitoring

TreatmentAim:13ResuscitationPrinciples:

Attendanceofneonatalstaffduringallhigh-riskdeliveriesNeedofresuscitationdependsonthesignsofrespiration,heartrate,colorProcesses:evaluation→decision→management→reassess(→newcircle)Method:ABCDEprotocolResuscitation14GuidelinestoResuscitationInfantwithanApgarScoreof7ormoregenerallydonotrequireresuscitationabriefperiodofoxygenblownoverthefaceoxygenincreasespulmonarybloodflowavoidexcessivesuctioningofamnioticfluidInfantwithanApgarScoreof4to6

stimulationadministrationofoxygenbyfacemask,orbagemptythestomachwhenusingbagormaskventilationGuidelinestoResuscitationIn15

InfantwithanApgarScoreof1to3

resuscitationcommencedwithoutdelayusuallyrequireintubationandchestexpansionfurtherstepsdependontheresponsetoventilation

InfantwithanApgarScoreof0

noliveborninfantshouldbeassignedascoreof0resuscitationshouldproceedasforascoreof1immediatelycardiaccompression

InfantwithanApgarScoreof16Resuscitation–theABCDEProtocolAirwayBreathingCirculationDrugsEvaluation&EnvironmentResuscitation–theABCDEProt17Advanced

Life

Support(ALS)TheNeonatalResuscitationGuidelinesPediatrics,2000Advanced

Life

Support(ALS)Th18NeonatalResuscitationMedicationsMedicationConcentrationtoAdministerPreparationDosage&RouteRate&PrecautionsEpinephrine1:10,000(0.1mg/l)1ml0.1-0.3ml/kgIVorITGiverapidly,mayrepeatevery5-10minutes.VolumeExpanderswholeblood,5%albumin,saline,Ringer'slactateVaries10ml/kgIVGiveover5-10minutes.Repeatasneeded.SodiumBicarbonate0.5me/ml(4.2%solution)20mlortwo10mlprofiledsyringes2me/kg(4ml/kg)IVGiveslowly,overatleast2minutes,mayrepeatevery10minutes.Ventilateinfant.Arcane(Saloon)0.4mg/ml1ml0.1mg/kg(0.25ml/kg)IV,IM,SQ,ITGiverapidly.CalciumGlaciate100mg/ml(10%solution,0.465me/ml)10ml100mg/kg(1ml/kg)IVGiveover3-5minutes,mayrepeatevery15min.Donotmixwithsodiumbicarbonateinline.NeonatalResuscitationMedicat19Post-resuscitationIssuesandMoreContinuingCareoftheNewlyBornInfant

supportiveorongoingcaremonitoringappropriatediagnosticevaluation

DocumentationofResuscitation

ContinuingCareoftheFamily

Ethics:NoinitiationofResuscitationDiscontinuationofResuscitationTosave,ornottosave???Post-resuscitationIssuesand20Preventheatloss:Neutralthermalenviroment，maintainbodytemperaturein37℃Oxygensupply：PaO260～80mmHgforterminfant,50～60mmHgforpreterminfant，normallevelofPaCO2Correctingacidosis:ventilation,infusionofNaHCO3Normalizingthesystemicperfusion:extensionofvolume,Dopamine5～20μɡ/(kg.min)Supportivecare:monitoringelectrolyte,fluidinfusion60～80ml/kg.dordependonurineV.OthermanagementPreventheatloss:Neutralth21PrognosisNosinglefactormaypredictmortalityorCNSabnormalitywithabsolutecertainty.

Apgarscore:0-3,morbidity5%at1‘a(chǎn)nd53%at20‘0-3,cerebralpalsy1%at5‘,9%at15‘,57%at20‘

Timetosustainedspontaneousrespiration

Cordbloodgas:pH<7.05mayindicateabadresultswithincreasingincidenceofdeathandseizures

Gestationage

PrognosisNosinglefactormay22Youshouldbeableto:DefinitionofneonatalasphyxiaAppreciatetheimportanceofneonatalasphyxiaListthedangers(riskfactors)ofhypoxia.

ListwhichinfantsarelikelytoneedresuscitationatbirthResuscitateaninfant

Youshouldbeableto:23Thankyou!Thankyou!24AsphyxiaofNewborn新生兒窒息AsphyxiaofNewborn新生兒窒息25DefinitionofPerinatalAsphyxiaAneventorconditionduringtheperinatalperiodthatislikelytoseverelyimpairedgasexchangeandleadstothreebiochemicalcomponents:

AND

Afailureoffunctionofatleasttwoorgans.Hypoxemia,Hypercapnia,metabolicacidosisDefinitionofPerinatalAsphyx26Etiology

Allfactorsleadingtoaninterruptionofoxygensupplyorbloodflowtothefetusduringperinatalperiod(prenatal,intrapartumandpostnatal)—RiskFactors-MaternalSystemicdisease:diabetes,heartorrenaldiseases,anemia,infectiousdiseasesObstetricConditions:hypertensionofpregnancyorpre-eclampsia,placentalabruptionSubstanceabuse:drugaddiction,smokingAgeorother:>35y,or<16y,multiplepregnancyEtiology

Allfactorsleadingt27—RiskFactors-FetalPremature,SGA,macrosomiaCongenitalmalformation:noseandlaryngo-pharynxmalformation,lunghypoplasia,heartdiseaseAmnioticfluidormeconiumaspirationIntrauterineinfection:Torchsyndrome—RiskFactors-Fetal28—RiskFactors-IntrapartumUmbilicalcord:prolapsed,aroundneckObstetricprocedures:forcepsdelivery,breechextraction,vacuumextractionMedication:

analgesicandoxytocicmedicine—RiskFactors-Intrapartum29PathophysiologyRespiratoryAlteration:

primaryhyperpnea,primaryapnea,secondaryapneaHypoxic-ischemicChangesofMulti-organicsystem:

“divingreflex”,redistributionofbloodflow,inter-organshunting,organfailure

BiochemicalandmetabolicConsequences:

acidosis,hyper-orhypoglycemia,hypocalcaemia,hyperbilirubinemia,hyperkalemia,hyponatremiaPathophysiologyRespiratoryAlt30ClinicalManifestationFetusasphyxia(intrauterineasphyxia):

earlystage:

increasedmovement,fetalheartrate>160bpm

latestage:

decreasedmovement,fetalheartrate<100bpmNeonatalasphyxia:lowApgarScore,hypoperfusion,Multi-SystemDysfunctionClinicalManifestationFetusas31ApgarScoringSystem

Sign0Points1Point2PointsActivity(muscletone)absentarmsandlegsflexedactivemovementPulse(heartrate)absentbelow100bumabove100bumGrimace(reflexirritability)noresponsegrimacesneeze,cough,pullsawayAppearance(skincolor)blue-gray,paleallovernormal,/-extremitiesnormaloverentirebodyRespirationabsentslow,irregulargood,cryingAPGARApgarScoringSystem

Sign0Poi32TheSignificanceofApgarScore

Apgar8~10,normal;4~7,mildasphyxia;0~3,severeasphyxiaAssignedat1,5,and10min,untilscoreupto>7

1’scoreindicatetheseverityofasphyxiaandguideforresuscitationscoreat5’andlaterismorepredictivetoprognosisPrematureinfantsintendtohavelowerscores0lowApgarscoresmayleadedby:asphyxia,drugs,trauma,hypovolemia,infectionoranomaliesTheSignificanceofApgarScor33MultiorganSystemDysfunctionRenalcompromise:oliguriaandelevatedcreatinine

Acutetubularnecrosis

Hypoxiccardiomyopathy(ECHOorECGabnormality)Hypoxicischemicencephalopathy(HIE)Pulmonarycomplications:respiratorydistress(RDS),persistentpulmonaryhypertension(PPHN)Disseminatedintravascularcoagulation(DIC)Hepaticfailure,hyperbilirubinemiaNecrotizingenterocolitis(NEC),feedintolerance

Fluidoverload,hyperkalemia,hypoglycemia,andacidosisMultiorganSystemDysfunctionR34Bloodgas(pH、PaO2、PaCO2

）Serumsugar,electrolyte（Calcium、Natrium）Serum:BUN,Cr,DIC-coagulationprofile,ALTHeadimage(Ultrasonic,CT,MRI)ChestX-rayECGExaminationBloodgas(pH、PaO2、PaCO2）35Theassessmentofasphyxiashouldcombine:

AhistoryofmaternalandintrapartumriskfactorsApgarscoreat1‘,5‘(0to3forlongerthan5minutes)ScalppH(<7),orumbilicalarterialbloodgasClinicalmanifestation:neurologicalstatusforHIEgrading;featuresoforganinjureExamination(assessmentoforgandysfunction)DiagnosisTheassessmentofasphyxiasho36TreatmentAim:firstcorrectingtheoriginalhypoxiasecondalleviatingtissueischemiamaintainingorrestoringcerebralperfusionManagementoforgandysfunctionsManagements:

Acontinoussupplyofbothoxygenandglucose;Normalizingbloodpressure,volumeexpansion,pressoragents,sodiumbicarbonateCarefulfluidandelectrolytemonitoring

TreatmentAim:37ResuscitationPrinciples:

Attendanceofneonatalstaffduringallhigh-riskdeliveriesNeedofresuscitationdependsonthesignsofrespiration,heartrate,colorProcesses:evaluation→decision→management→reassess(→newcircle)Method:ABCDEprotocolResuscitation38GuidelinestoResuscitationInfantwithanApgarScoreof7ormoregenerallydonotrequireresuscitationabriefperiodofoxygenblownoverthefaceoxygenincreasespulmonarybloodflowavoidexcessivesuctioningofamnioticfluidInfantwithanApgarScoreof4to6

stimulationadministrationofoxygenbyfacemask,orbagemptythestomachwhenusingbagormaskventilationGuidelinestoResuscitationIn39

InfantwithanApgarScoreof1to3

resuscitationcommencedwithoutdelayusuallyrequireintubationandchestexpansionfurtherstepsdependontheresponsetoventilation

InfantwithanApgarScoreof0

noliveborninfantshouldbeassignedascoreof0resuscitationshouldproceedasforascoreof1immediatelycardiaccompression

InfantwithanApgarScoreof40Resuscitation–theABCDEProtocolAirwayBreathingCirculationDrugsEvaluation&EnvironmentResuscitation–theABCDEProt41Advanced

Life

Support(ALS)TheNeonatalResuscitationGuidelinesPediatrics,2000Advanced

Life

Support(ALS)Th42NeonatalResuscitationMedicationsMedicationConcentrationtoAdministerPreparationDosage&RouteRate&PrecautionsEpinephrine1:10,000(0.1mg/l)1ml0.1-0.3ml/kgIVorITGiverapidly,mayrepeatevery5-10minutes.VolumeExpanderswholeblood,5%albumin,saline,Ringer'slactateVaries10ml/kgIVGiveover5-10minutes.Repeatasneeded.SodiumBicarbonate0.5me/ml(4.2%solution)20mlortwo10mlprofiledsyringes2me/kg(4ml/kg)IVGiveslowly,overatleast2minutes,mayrepeatevery10minutes.Ventilateinfant.Arcane(Saloon)0.4mg/ml1ml0.1mg/kg(0.25ml/kg)IV,IM,SQ,ITGiverapidly.CalciumGlaciate100mg/ml(10%solution,0.465me/ml)10ml100mg/kg(1ml/kg)IVGiveover3-5minutes,mayrepeatevery15min.Donotmixwithsodiumbicarbona

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