英新生兒窒息與新法復蘇第一頁，共五十六頁，編輯于2023年，星期三NeonatalAsphyxiaanditsNewConceptonResuscitation

ChongminXuDep.NewnatesUnionHospital第二頁，共五十六頁，編輯于2023年，星期三NewWordspregnantwomaninvalidApgarscoreumbilicalcordprimaryapneaasynersisHIE(hypoxic-ischemicencephalopathy)ICH(intracranialhemorrhage)MOD(multipleorgansfunctiondamage)hypercapniahypoxemia第三頁，共五十六頁，編輯于2023年，星期三

Neonatalasphyxiaisakindofgasexchangedisorder,thatcouldcausehypoxemia,hypercapniaandmetabolismacidosis,whichisaccountedonthatnewbornhasnoautorespirationoronlyhasirregular,intermittentandfeeblerespirationatbirth,orpresentrespiratorydepressionafterbirth.It’sincidenceisabout5%occupiedtheviablebirth,andcancause20%deathintoltalnewnataldeath.Thenatureofasphyxiaitselfishypoxia.UsuallyweadoptApgarscoretojudgethedegreeofasphyxiation.第四頁，共五十六頁，編輯于2023年，星期三AsphyxiacouldcausenotonlyHIE,butalsoMOD,andistheoneoftheimportantcausesofdeath,dysnoesiaandinvalid(cerebralpalsy)innewbornsallovertheworld.Neonatalmortalityisabout19.0‰(2005)inourcountry.Thefirstthreedeathcausesareprematurebirth&lowbirthweight,asphyxiaandpneumonia.

Thereare1millionnewborndeathcausedbyneonatalasphyxia(total4millionyearly-2005.WHO),and>1millionneonatessufferfromdysnoesia,cerebralpalsyandotherdeformitycausedbyittoo.第五頁，共五十六頁，編輯于2023年，星期三DeliveryfactorsPlacentafactorFetalfactorumbilicalcordfactorPregnantwoman

Asphyxialetiopatho-genisis第六頁，共五十六頁，編輯于2023年，星期三

tooolderoryoungRespiratorydiseasecardiacdiseasesevereanaemiaSmoking&druggestationalhypertensionPregnantwomanfactor

polycyesisdiabetes第七頁，共五十六頁，編輯于2023年，星期三placentapraeviaplacentalabruptioninfarctusageing

Placentafactor第八頁，共五十六頁，編輯于2023年，星期三shortcordknotofumbilicalcordumbilicalhangdownumbilicalcordcircleneckUmbilicalfactor第九頁，共五十六頁，編輯于2023年，星期三胎兒因素prematurelargefordateinfantintrauterineinfectionrespiratorytractobstructioncongenitalcardiopathy

congenitalabnormality

foetusfactor第十頁，共五十六頁，編輯于2023年，星期三suckingfetalheadforceps

aiddeliver

breechpresentation

unsuitablyusedrugsinlabor

laborextension&

precipitatelabor

cephalopelvicdisproportion

deliverfactor第十一頁，共五十六頁，編輯于2023年，星期三PathophysiologySwitchofrespiration&circulationfromfetustonewbornareblockedBreathalterbiochemistry&metabolismalterinblood第十二頁，共五十六頁，編輯于2023年，星期三

fetalpulmonaryfluidisremovedfromlungs

↓surfaceactivesubstance(SAS)secretes

↓functionalresidualcapacityofalveolussetup

↓pulmonarycirculationresistance↓genetalcirculationresistance↑

↓arterialduct&ovaleforamenshutfunctionalityNormalfetustransformtoneonateinrespiration&circulation

第十三頁，共五十六頁，編輯于2023年，星期三Blocked

switchofrespiration&circulationfromfetustonewborn

AsphyxiaRespirationceasesorinhibit

alveolarectasia

↓Hypoxia,acidosisSassecretes↓activity↓pulmonaryfluidremoves

↓Fetalcirculationreopen→durativePHTConstitutionhypoxia,ischemiaandacidosis↑↑Inconvertibledamageoforganspulmonaryvascularresistance↑第十四頁，共五十六頁，編輯于2023年，星期三Hypoxia-ischemiaalterindifferenceorgans

asasphyxia缺O(jiān)2PHPaO2PaCO2

潛水反射血液再分配無氧酵解低血糖兒茶酚胺血鈣心納素抗利尿激素細胞膜鈉泵鈣泵鈣離子內流高血糖腸血鈉NEC腎腎V血栓腎功能衰竭腎上腺腦缺O(jiān)2加重壓力被動性腦血流體循環(huán)壓體循環(huán)壓顱內出血HIE腦血流灌注大腦半球血流矢狀旁區(qū)及其下白質受損PVL心臟肺A壓心功能受損心衰休克PFC缺O(jiān)2加重↓↓↓血液高凝DIC第十五頁，共五十六頁，編輯于2023年，星期三

Breathalter

1．Primaryapnea

Whenhypoxia,thebabymaybreathdeeplyandquicklyatfirstl-2mins,ifnomanagementintime,itmayoccurbreathinhibitionandreflectiveheartratedecreasinginashorttime.．

2．Secondaryapnea

Ifthehypoxiapersistence,thebabymayoccurgaspingrespiration,heartratecontinuestepdown,theBPbegintodescend,musculartensionlost,thebabyispaleandrespiratorymovementasynersis,hemayoccuradeepgaspatlastandthenenterthe

secondaryapnea.(needpositivepressure)第十六頁，共五十六頁，編輯于2023年，星期三第十七頁，共五十六頁，編輯于2023年，星期三bloodgas

PaCO2↑，PH&PaO2↓mixedacidosis

Glucosemetabolicdisordercatecholamine&glucagonreleaseearly↑→bloodsugar

normalor↑thenglycogendepletion,bloodsugar↓HyperbilirubinemiaBilirubincombinewithalbumin↓、thevigorofliverenzyme↓→unconjugatedbilirubin↑

Hyponatremia

atrialnatriureticpeptide,ADHisparasecretion→dilutedhyponatremiaHypocalcemia

calciumchannelopen、calciumpumpdysfunction→calciuminflux↑Bloodbiochemistryandmetabolismalteration第十八頁，共五十六頁，編輯于2023年，星期三三Clinicalsituation

(一)intrauterineasphyxia

1.earlystagethefetalheartrateandfetalmovementincrease;

2.advancedstagefetalmovementdecreaseordisappear,fetalheartrateslowdown,amnioticfluidwaspollutedbymeconium.

(二)Apgarscore

Asimpleclinicalevaluationwaytodeterminethedegreeofasphyxiainbabyjustborned.0-3scoreissevereasphyxia,while4-7scores,mildasphyxia.1minscoreafterbirthcanjudgedegreeofasphyxia,5minsscoreishelpfulrojudgethebabyprognosis.第十九頁，共五十六頁，編輯于2023年，星期三physicalsignScoredenomscore0121min.5&10min.Skincolorcyanose/paleBodyred,limbscyanoseRedallover0～3severeasphyxia4～7mildasphyxia8～10normalJudgePrognosisH.R.(time/min)no<100>100ReactionafterstimulatesoleorintubatenoSomeactioneg.frownCry,sneezemusculartensionlaxitasLimbsflexalittleLimbsactiverespirationnoslow,irregularnormal,cryloudly第二十頁，共五十六頁，編輯于2023年，星期三Asphyxiadiagnosticcode

AAP(美國兒科學會)&ACOG(婦產科學會)1996Bloodinarteriaumbillicalisshowsseveremetabolismormixedacidosis,pH＜7

Apgarscoreis0～3points,andpersistencetime＞5min.Nervoussystemmanifestation,suchasconvulsion、comaormusculartensionlowetc.MOD

CommitteeonFetusandNewborn,AmericanAcademyofPediatrics,andCommitteeonObstetricPractice,AmericanCollegeofObstetriciansandGynecologists.UseandabuseoftheApgarscore.Pediatrics,1996,98(1):141-142

第二十一頁，共五十六頁，編輯于2023年，星期三㈢MOD

1.cardiovascularsystem(CVS)mildcasemaypresenceconductingsystemandcardiacmuscledamaged;severecasepresencecardiacshock(CS),heartfailureandpersistentfetalcirculation.

2.respiratorysystem(RS)Aspirationofamnioticfluidormeconiumsyndrome,pneumorrhagiaandpersistentpulmonaryhypertension,LBWImaypresencehyalinemembranediseaseandapneaetc.

第二十二頁，共五十六頁，編輯于2023年，星期三3.Kidney

acuterenalfailure(ARF,oliguria,proteinuria,Bloodureanitrogenandcreatinineincrease);thrombosisofrenalvein(grosshematuria).4.centralnervoussystem(C.N.S)

HIE(hypoxic-ischemicencephalopathy)andICH(intracranialhemorrhage)5.Metabolism

acidosis,hypoglycemiaandelectrolytedisturbances；6.gastrointestinaltract(GIT)

stressulcerNEC(necrotizingenterocolitis),jaundiceaggratate.

第二十三頁，共五十六頁，編輯于2023年，星期三

SystemsdamagedbyAsphyxiainperinatalperiod————————————————————————————

damagecentralnervoussystemhypoxic-ischemicencephalopathy,intracranialhemorrhage,encephaledemaurinarysystemglomerularfiltrationrateand/ortubularreabsorptionfunctiondamage,renaltubularnecrosis,renalfailurecardiovascularsystemmitralinsufficiency,myocardiolysis,cardiafailure，shockrespiratorysystempulmonaryhypertension,meconiumaspiratedpneumonia,alveolussurfaceactivesubstancedecreasemetabolismacidosis,hypoglycemia,hypocalcemia,ADHsecreteincreasedigestivesystemstressulcer，NEC(necrotizingenterocolitis),liverfunctionallesionskinsubcutaneousfatnecrosishematologicalsystemDIC(disseminatedintravascularcoagulation])第二十四頁，共五十六頁，編輯于2023年，星期三四laboratoryexamination

1.takebloodoutofintrauterineapneababy’sscalpbyamnioscopeorfetusouteropofcervixuteritomeasureitspH-howtorescuethebaby.

2.afterbirth,bloodgas,bloodsugar,electrolyte,bloodureanitrogenandcreatinine,type-BultrasonicorCTscandevelopmently,

第二十五頁，共五十六頁，編輯于2023年，星期三五Treatment

1.theresuscitationshouldbecarriedoutbypediatricianco-operatedwithobstetrician

2.shouldbefamiliaritywiththebaby’sdeliveryhistory,anddothefullprepareforskillandoperation,apparatusanddevicebeforehand;

第二十六頁，共五十六頁，編輯于2023年，星期三(一)ABCDEresuscitationprogram

A(airway)：B(breathing)C(Circulation)D(drug)E(evaluation)ABCisthemostimportant,andAisbasic,Bisthekeypoint.第二十七頁，共五十六頁，編輯于2023年，星期三(二)resuscitationprocedure

1．Thefirstresuscitationstep

⑴keepbodywarmextremeinfra-redraytable;⑵usewarmanddrytoweltomopthebaby;⑶arrangeposturepadtheshoulderfor2-3cm⑷suckthemucosaoutofthebaby’smouth,noseandpharyng(<10seconds)rightafterbirth;⑸tactilestimulusifthebabystillhasnobreathafterabovemanagement,couldflapthesoletwiceandrubitsback。Above5stepsshouldbefinishedwithin30secondsafterbirth.第二十八頁，共五十六頁，編輯于2023年，星期三Thefirstresuscitationstepkeepwarmwipedrytactilestimulusclearairway

completewithin30secondafterbirthcorrectposture

第二十九頁，共五十六頁，編輯于2023年，星期三

2.ventilatingresuscitationprocedure

⑴ifthebabyhasalreadynormalbreathandheartrate＞100pem,theskinisred,justobservehim.⑵ifhehasnobreath,oronlygaspandheartrate＜100pem,shouldsupplypressurizedoxygenwiththeresuscitatorrightaway,ifheartrateis80一100pemandspontaneouslybreathingoccurafter15-30seconds,couldcontinueabovestepforsometime,thenobservehim.第三十頁，共五十六頁，編輯于2023年，星期三⑶iftheheartratecan’tincreaseor＜80pem.Shouldcarryoutpressingheartfromout-chestfor30seconds,ifnorespond,shouldgive1：10000adrenalin0.1-0.3ml／kgbythewayofveinandtrachea.⑷iftheheartstill＜100pem,couldgivethemedicinetocorrectacidosisandexpansefluid.⑸ifthemotherwasgivennarcotic6hrsbeforebirth,couldgavethebabynaloxone0.1mg／kgbythewayofveinandtrachea.第三十一頁，共五十六頁，編輯于2023年，星期三

3.resuscitationtechnique

⑴resuscitatorsupplypressurizingoxygenventilatingrate30-40rimes,press:relaxis1：1.5,iflastfor>2mins,shouldinsertagastrictube,⑵pressingheartoutchestthelowerl/3ofthebreastbone,120pem,everypressing3times,shouldsupplypressurizeoxygenonce.Pressaboutl一2cmdept,thefingershouldn’tleftthepressinglocation；第三十二頁，共五十六頁，編輯于2023年，星期三雙拇指并排或重疊于患兒胸骨體下1/3處，其他手指繞胸廓托在背后Thewayofthumbs右手中、食指指端垂直壓胸骨下1/3處，左手托患兒背部Thewayofdoublefingers第三十三頁，共五十六頁，編輯于2023年，星期三

⑶oraltracheacannula

intubationandsusctiononceshouldbefinishedwithin20secondsifthebabyhasoneofthefollows

①meconiumropinessorthereisgranulesofmeconiumhypolarynx②thebabysufferfromsevereasphyxiaandneedartificialventilatingforalongtime;③theresultispoorusingresuscitaing;④thebabyheartrateis80-100pemanddoesn’tincreasetofollows；⑤suspectdiagnosisofdiaphragmatichernia.第三十四頁，共五十六頁，編輯于2023年，星期三anatomiclandmarkforputinlaryngoscopetrachealintubation第三十五頁，共五十六頁，編輯于2023年，星期三

4.medicineassistingresuscitation

⑴alkalitherapy⑵adrenalintherapy⑶vasoactiveagenttherapydopamine3-5ug/kg.min⑷Heparinetherapy20-30u/kg.d,H,tid⑸

naloxoneanti-morphinumandinhibitionofHIE.第三十六頁，共五十六頁，編輯于2023年，星期三5．Observeandmonitorpostresuscitation

bodytemperature,breath,heartrate.Bloodpressure,urinaryvolume,skincolor,andsymptomofnervoussystem;noticeacid-baseimbalance,electrolytedisturbances,abnormityofurinationanddefecation,infectionandfeedingetc.第三十七頁，共五十六頁，編輯于2023年，星期三出生是否足月？是否羊水清？是否有呼吸和哭聲？是否肌張力好？保溫擺正體位，通暢氣道擦干,刺激,重新擺正體位評價心率、呼吸和膚色常壓給氧常規(guī)護理保溫必要時通暢氣道擦干觀察護理是正常呼吸心率>100及膚色紅潤否紫紺膚色紅潤2006NRP流程圖HarrisAPetal.JPediatr1986;109:117ReddyVKetal.ClinPediatr1999;38:87TothBetal.ArchGynObst2002;266:105第三