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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)
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