Neonat Engl

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Dr.LORN TRY Patrich,pediatriciDr.LORN TRY Patrich,pediatrici

PERINATAL ASPHYXIAPERINATAL ASPHYXIA

Dr.LORN TRYDr.LORN TRY

Patrich,Pediatrician.DHMPatrich,Pediatrician.DHM


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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.


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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


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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.


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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)


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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.


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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


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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


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NEONATAL HYPOGLYCEMIANEONATAL HYPOGLYCEMIA

Dr.LORN TRY Patrich,Pediatrician,DHMDr.LORN TRY Patrich,Pediatrician,DHM


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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.


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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


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CLINICAL DIAGNOSISCLINICAL DIAGNOSIS

IrritabilityIrritability

Apnea and cyanosisApnea and cyanosis

Hypotonia and poor feedingHypotonia and poor feeding ConvulsionsConvulsions


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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 .


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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.


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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


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RESUSCITATIONRESUSCITATION

Dr.LORN TRY Patrich,pediatrician,DHMDr.LORN TRY Patrich,pediatrician,DHM


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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


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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.


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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


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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


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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.


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CCD

Newborn Life Support

Airway

&

BreathingAB

CD

cover

Dry &

RC (UK) NLS Resus 31

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