Neonatology:

AsphyxiaofTheNewborns

atbirthNeonatology:

AsphyxiaofThe1LecturePointsClinicaldefinitionandEpidemiology:incidence/mortalityEtiologyandPathophysiologyApgar’sscoresignificanceofclinicalusereevaluationofthescoreResuscitationComplicationandprognosisLecturePointsClinicaldefinit2ClinicalDefinition/EpidemiologyClinicaldefinitionFailuretoinitiaterespirationno/irregularbreathingwithhypoxemiaandacidosisIncidence:6-10%,inlivebirthMortality:leadingdeathinneonatesaccountfor1/3inneonatesdeathClinicalDefinition/Epidemiolo3EtiologyMaternal：Systematicdiseaseshypertension/hypoxiaObstetric/pregnantcomplicationAddictionAgeatpregnancy/multiplepregnancyEtiologyMaternal：4EtiologyIntrapartumAbnormalumbilicalcordAbnormalfetalpositionProcedure:ForcepsMedication：narcotic，SedativesEtiologyIntrapartum5EtiologyFetusPremature,SGA,LGA,MacrosomiaVariousabnormalityIntrauterineaspirationNervesinjuryEtiologyFetus6PathophysiologyHypoxic/IschemiaOrgan/systeminjuryHypoxemia/acidosisO2,CO2ExchangeObstacleFailuretoinitiate

breath

PathophysiologyHypoxic/Isch7Pathophysiology

repirationchangeHRHRstopPrimaryapneaSecondaryapneaSystem/organIschemia/hypoxicBiochemical/metabolism________

Hypoxemia,acidosisOrgan/systemdamageBloodredistribution:compensationdecompensationCatecholamineGlucagonFreefattyacidsANPPCO2AcidosisHyperglycemiaHypoglycemiaHypocalcemiaHyponatremiaPathophysiologyrepirationchan8ApgarScoringSystemSCORE012HeartrateAbsent<100/min>100/minRespirationsAbsentSlow,irregularGood,cryingMuscletoneLimpSomemotionActivemotionReflexirritabilityNoresponseGrimaceCough,sneeze,cryColorBlue,paleBodypink,bluelimbsCompletelypinkApgarScoringSystemSCORE012He9ApgarScoringSystemApgarScoreMethods:at1and5min.postbirth till>7min.or20min.afterbirthApgarScoringSystemApgarSco10ClinicalManifestationFetaldistress：FetalmotionornoFetalHRorMeconium-stainedamnioticfluidApgarScore<3at1or5min.:severe4-7at1or5min.:

slightClinicalManifestationFetaldi11ReevaluationofApgarScoreDoesApgarScorereflect:AccuracyofPredictthedeathTheseverityofperinatalhypoxicTheprocessandseverityofintrauterinefetalhypoxicFacts:ThesubjectivityofthescoringandexperiencebasedLowscoringalwaysforprematuresAmericanAcademyofPediatrtics,AmericanCollegeofObstetriciansandGynecologists.Pediatrics1996,98:141-2

ReevaluationofApgarScoreDoe12InconsistentoftheApgarscorewithbraindamageIflowerscoreat5min.,>4at10min.BrainDamageonly1%inchildrenat7yearsoldInbraindamagedchildren75%werenormalforApgarscore.ReevaluationofApgarScoreAmericanAcademyofPediatrtics,AmericanCollegeofObstetriciansandGynecologists.Pediatrics1996,98:141-2

InconsistentoftheApgarsc13Therelevancetotheoutcomeofasphyxiawithsurvivalandsystem/organfunctionUmbilicalartery

PH＜7.00BE:-20mEq/LPapileLA.TheApgarscoreinthe21stcentury.NEnglJMed2001;344:519-20ReevaluationofApgarScoreTherelevancetotheoutcome14NRP5thedition20062006:5thedition;SuctionwhenMeconiumpresentResuscitationwithoxygenorroomairEpinaphrineforbradycardiaorcardiacarrestNRP5thedition20062006:5th15NRP5thedition2006NRP5thedition200616NeonatalResuscitation5thedition

Birth

Termgestation？Clearamnioticfluid

？Breathingorcrying？Goodmuscletone？

yesNoRoutinecareProvidewarmthClearairwayDryAssesscolorNeonatalResuscitation5thedi17NeonatalResuscitation5theditionProvidewarmthPosition，Clearairway

EIT(ifnecessary)Dry，stimulateRepositionNoEvaluaterespiration，HRandcolorApneaOrHR<100

GivesupplementaloxygenObservationalcareBreathingHR>100andpinkCyanosis30sPersistentcyanosisPinkNeonatalResuscitation5thedi18NeonatalResuscitation5theditionPositivepressureventilationEITAdministerchestcompressionsEITHR<60AdministerepinephrineEIT

HR<6030sPositivepressureEITventilation30sEffectiveventilationHR>100andpinkPostresuscitationcarePersistentcyanosis

HR>60ApneaOrHR<100NeonatalResuscitation5thedi19OxygenConcentrationforPPV2006GuidelineSupplementaryoxygenisrecommendedwheneverpositive-pressureventilationisindicatedforresuscitation.Thereisinsufficientevidencetospecifytheconcentrationofoxygentobeusedattheinitiationofresuscitation.100%-standardapproach<100%-acceptablealternative21%-acceptablealternativeOxygenConcentrationforPPV2020Meconium-stainedfluidMeconium-stainedfluid21SuctionwhenMeconiumpresentMeconium

present?Babyvigorous?SuctionmouthandtracheaContinuowithremainderofinitialstepsClearmouthandnosesecretionDry,stimulateandrepositonRespirationeffortHR>100bpmGoodmuscletoneNoYesYesNoSuctionwhenMeconiumpresent22SuctioningMeconiumSuctioningMeconium23EpinephrineforBradycardia2006GuidelineIntravenousadministrationofepinephrine0.01–0.03mg/kg/doseisthepreferredroute(ClassIIa).Whileaccessisbeingobtained,administrationofahigherdose(upto0.1mg/kg)throughtheendotrachealtubemaybeconsidered.EpinephrineforBradycardia20024NeonatalResuscitation5theditionSpO2Monitoring:Onceper30Sec.To95%fornewabornbaby:10min.Premature:UseBlendandOxygenairAdjusttheoxygenairtoSpO2near90%InternationalLiaisonCommitteeonResuscitation.Part13:Neonatalresuscitationguidelines.

Circulation2005:112(24,Suppl):IV188-IV195NeonatalResuscitation5thedi25ResuscitationtechnologySuction：beginningfromOralthenNasalResuscitationtechnologySuctio26ResuscitationtechnologyTactilestimulation：TaptheplantarResuscitationtechnologyTactil27ResuscitationtechnologyTactilestimulation：RubbertheBackResuscitationtechnologyTactil28ResuscitationtechnologyO2

supplyvia

PPVbagResuscitationtechnologyO2sup29ResuscitationtechnologyChestcompress:ResuscitationtechnologyChest30ResuscitationtechnologyEndotrachealintubation：Method：bynasalorbyoralIndication：MeconiumaspirationNormalSaO2only

maintainedbyPPVSerioushypoxemiaPersistentirregularbreathingResuscitationtechnologyEndotr31ResuscitationtechnologyEndotrachealintubationbyoral：ResuscitationtechnologyEndotr32ResuscitationtechnologyEndotrachealintubation:VocalandTrachealResuscitationtechnologyEndotr33ResuscitationtechnologyMonitoringpostresuscitationTemp,Respiration,HRBP,UrinevolumeSkincolorCNSsignsAcidbase,Balanceofelectrolytes,InfectionResuscitationtechnologyMonito34AmericanAcademyofPediatrtics,AmericanCollegeofObstetriciansandGynecologists.Pediatrics1996,98:141-2

IndicationsofpooroutcomeorCNSdamage

Umbilicalarteryshowedsevereacidosis(PH<7.00)Apgarscore0-3persistsover5min.ManifestingsignsofacuteCNSdamage(convulsion)MODS>3PrognosisAmericanAcademyofPediatrtic35PreventionofAsphyxiaAntenatalcareToavoidprematuredeliveringandobstetricprocedure(forceps)MonitoringhighriskprehnentPreandpostbornpreparationsandadequatecarePreventionofAsphyxiaAntenata36SummaryTheimportanceofearlydetectionandrecognitionofthefetaldistressPathophysiologicalChangesoftheasphyxiaUseandreevaluationoftheApgar’sscoreMainprocedureofthedeliveryresuscitation(NewguidelineandABCssequence)PrognosisSummaryTheimportanceofearly37Thanks

andquestions?Thanks

andquestions?38Neonatology:

AsphyxiaofTheNewborns

atbirthNeonatology:

AsphyxiaofThe39LecturePointsClinicaldefinitionandEpidemiology:incidence/mortalityEtiologyandPathophysiologyApgar’sscoresignificanceofclinicalusereevaluationofthescoreResuscitationComplicationandprognosisLecturePointsClinicaldefinit40ClinicalDefinition/EpidemiologyClinicaldefinitionFailuretoinitiaterespirationno/irregularbreathingwithhypoxemiaandacidosisIncidence:6-10%,inlivebirthMortality:leadingdeathinneonatesaccountfor1/3inneonatesdeathClinicalDefinition/Epidemiolo41EtiologyMaternal：Systematicdiseaseshypertension/hypoxiaObstetric/pregnantcomplicationAddictionAgeatpregnancy/multiplepregnancyEtiologyMaternal：42EtiologyIntrapartumAbnormalumbilicalcordAbnormalfetalpositionProcedure:ForcepsMedication：narcotic，SedativesEtiologyIntrapartum43EtiologyFetusPremature,SGA,LGA,MacrosomiaVariousabnormalityIntrauterineaspirationNervesinjuryEtiologyFetus44PathophysiologyHypoxic/IschemiaOrgan/systeminjuryHypoxemia/acidosisO2,CO2ExchangeObstacleFailuretoinitiate

breath

PathophysiologyHypoxic/Isch45Pathophysiology

repirationchangeHRHRstopPrimaryapneaSecondaryapneaSystem/organIschemia/hypoxicBiochemical/metabolism________

Hypoxemia,acidosisOrgan/systemdamageBloodredistribution:compensationdecompensationCatecholamineGlucagonFreefattyacidsANPPCO2AcidosisHyperglycemiaHypoglycemiaHypocalcemiaHyponatremiaPathophysiologyrepirationchan46ApgarScoringSystemSCORE012HeartrateAbsent<100/min>100/minRespirationsAbsentSlow,irregularGood,cryingMuscletoneLimpSomemotionActivemotionReflexirritabilityNoresponseGrimaceCough,sneeze,cryColorBlue,paleBodypink,bluelimbsCompletelypinkApgarScoringSystemSCORE012He47ApgarScoringSystemApgarScoreMethods:at1and5min.postbirth till>7min.or20min.afterbirthApgarScoringSystemApgarSco48ClinicalManifestationFetaldistress：FetalmotionornoFetalHRorMeconium-stainedamnioticfluidApgarScore<3at1or5min.:severe4-7at1or5min.:

slightClinicalManifestationFetaldi49ReevaluationofApgarScoreDoesApgarScorereflect:AccuracyofPredictthedeathTheseverityofperinatalhypoxicTheprocessandseverityofintrauterinefetalhypoxicFacts:ThesubjectivityofthescoringandexperiencebasedLowscoringalwaysforprematuresAmericanAcademyofPediatrtics,AmericanCollegeofObstetriciansandGynecologists.Pediatrics1996,98:141-2

ReevaluationofApgarScoreDoe50InconsistentoftheApgarscorewithbraindamageIflowerscoreat5min.,>4at10min.BrainDamageonly1%inchildrenat7yearsoldInbraindamagedchildren75%werenormalforApgarscore.ReevaluationofApgarScoreAmericanAcademyofPediatrtics,AmericanCollegeofObstetriciansandGynecologists.Pediatrics1996,98:141-2

InconsistentoftheApgarsc51Therelevancetotheoutcomeofasphyxiawithsurvivalandsystem/organfunctionUmbilicalartery

PH＜7.00BE:-20mEq/LPapileLA.TheApgarscoreinthe21stcentury.NEnglJMed2001;344:519-20ReevaluationofApgarScoreTherelevancetotheoutcome52NRP5thedition20062006:5thedition;SuctionwhenMeconiumpresentResuscitationwithoxygenorroomairEpinaphrineforbradycardiaorcardiacarrestNRP5thedition20062006:5th53NRP5thedition2006NRP5thedition200654NeonatalResuscitation5thedition

Birth

Termgestation？Clearamnioticfluid

？Breathingorcrying？Goodmuscletone？

yesNoRoutinecareProvidewarmthClearairwayDryAssesscolorNeonatalResuscitation5thedi55NeonatalResuscitation5theditionProvidewarmthPosition，Clearairway

EIT(ifnecessary)Dry，stimulateRepositionNoEvaluaterespiration，HRandcolorApneaOrHR<100

GivesupplementaloxygenObservationalcareBreathingHR>100andpinkCyanosis30sPersistentcyanosisPinkNeonatalResuscitation5thedi56NeonatalResuscitation5theditionPositivepressureventilationEITAdministerchestcompressionsEITHR<60AdministerepinephrineEIT

HR<6030sPositivepressureEITventilation30sEffectiveventilationHR>100andpinkPostresuscitationcarePersistentcyanosis

HR>60ApneaOrHR<100NeonatalResuscitation5thedi57OxygenConcentrationforPPV2006GuidelineSupplementaryoxygenisrecommendedwheneverpositive-pressureventilationisindicatedforresuscitation.Thereisinsufficientevidencetospecifytheconcentrationofoxygentobeusedattheinitiationofresuscitation.100%-standardapproach<100%-acceptablealternative21%-acceptablealternativeOxygenConcentrationforPPV2058Meconium-stainedfluidMeconium-stainedfluid59SuctionwhenMeconiumpresentMeconium

present?Babyvigorous?SuctionmouthandtracheaContinuowithremainderofinitialstepsClearmouthandnosesecretionDry,stimulateandrepositonRespirationeffortHR>100bpmGoodmuscletoneNoYesYesNoSuctionwhenMeconiumpresent60SuctioningMeconiumSuctioningMeconium61EpinephrineforBradycardia2006GuidelineIntravenousadministrationofepinephrine0.01–0.03mg/kg/doseisthepreferredroute(ClassIIa).Whileaccessisbeingobtained,administrationofahigherdose(upto0.1mg/kg)throughtheendotrachealtubemaybeconsidered.EpinephrineforBradycardia20062NeonatalResuscitation5theditionSpO2Monitoring:Onceper30Sec.To95%fornewabornbaby:10min.Premature:UseBlendandOxygenairAdjusttheoxygenairtoSpO2near90%InternationalLiaisonCommitteeonResuscitation.Part13:Neonatalresuscitationguidelines.

Circulation2005:112(24,Suppl):IV188-IV195NeonatalResuscitation5thedi63ResuscitationtechnologySuction：beginningfromOralthenNasalResuscitationtechnologySuctio64ResuscitationtechnologyTactilestimulation：TaptheplantarResuscitationtechnologyTactil65ResuscitationtechnologyTactilestimulation：RubbertheBackResuscitationtechnologyTactil66ResuscitationtechnologyO2

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PPVbagResuscitationtechnologyO