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Asphyxia of the Newborn
Dr,Xiaoping Luo
Professor and Chairman
Department of Pediatrics
Tongji Hospital
Tongji Medical College
The highest mortality that befalls the human
race in one day occurs on the day of birth.,.…,
……
It is said that the most important period of
the life of a human being is the time spent in
utero,The most trying ordeal a human being
sustains is the ordeal of birth.
Asphyxia Neonatorum,
Causation and Treatment
Professor of Obstetrics,Northwestern University Medical School
Jos,B,De Lee Published in Medicine (Detroit) 3:643-660,1897.
Definition of Perinatal Asphyxia
a condition in the neonate where there is the
following combination:
? An event or condition during the perinatal period that is
likely to severely reduce oxygen delivery and lead to acidosis;
AND
? A failure of function of at least two organs consistent with
the effects of acute asphyxia.
Hypoxemia,Hypercapnia,Mixed acidosis,Organic failure
Risk Factors-Maternal
? Systemic disease,diabetes,heart or renal
diseases,anemia,infectious diseases
? Obstetric Conditions,hypertensive disease of
pregnancy or pre-eclampsia,placental abruption
? Substance abuse,drug addiction,smoking
? Maternal age,>35,or <16,multiple pregnancy
Risk Factors-Fetal
? Premature,SGA,macrosomia
? Congenital malformation,nose and laryngo-
pharynx malformation,lung hypoplasia,
heart disease
? Amniotic fluid or meconium aspiration
? Intrauterine infection,Torch syndrome
Risk Factors-Intrapartum
? Umbilical cord,obstruction
? Obstetric procedures,forceps delivery,
breech extraction,vacuum extraction
? Medication,analgesic and oxytocic
medicine
Pathophysiology of Asphysia
? Respiratory Alteration:
primary hyperpnea,primary apnea,secondary apnea
? Hypoxic-ischemic Changes of Multi-organic system:
“diving reflex”,inter-organ shunting,organ failure
? Biochemical and metabolic Consequences:
acidosis,hyper- or hypoglycemia,hypocalcemia,
hyperbilirubinemia,hyperkalemia,hyponatremia
Clinical Manifestation of Asphysia
? Apgar Scoring System
Apgar Scoring System
Sign 0 Points 1 Point 2 Points
Activity
(muscle tone)
absent arms and
legs flexed
active
movement
Pulse
(heart rate)
absent below 100
bpm
above 100
bpm
Grimace
(reflex irritability)
no response grimace sneeze,cough,
pulls away
Appearance
(skin color)
blue-gray,
pale all over
normal,
/-extremities
normal over
entire body
Respiration absent slow,
irregular
good,crying
A
P
G
A
R
The Significance of Apgar Score
?Apgar 8~10,normal;
4~7,mild asphyxia;
0~3,severe asphyxia
?Assigned at 1,5,and 10 min,until score of 7 or more
?1’ score indicate the severity and guide for resuscitation
?5’ score and later is more predictive of prognosis
?Premature infants intend to have lower scores
Clinical Manifestation of Asphyxia
? Multiorgan System Dysfunction
? Renal compromise,oliguria and elevated creatinine
? Hypoxic cardiomyopathy (ECHO or ECG abnormality)
? Hypoxic ischemic encephalopathy (HIE)
? Pulmonary complications,respiratory distress (RDS),
persistent pulmonary hypertension (PPHN)
? Disseminated intravascular coagulation (DIC)
? Hepatic failure,hyperbilirubinemia
? Necrotising enterocolitis (NEC),stress ulcer
? Fluid overload,hyperkalemia,hypoglycemia,and acidosis
American Heart Association-American Academy of Pediatrics
Approach to Resuscitation
?Infant with an Apgar Score of 7 or more
? generally do not require resuscitation
? a brief period of oxygen blown over the face
? oxygen increases pulmonary blood flow
? avoid excessive suctioning of clear fluid
?Infant with an Apgar Score of 4 to 6
? stimulation
? administration of oxygen by face mask,or bag
? empty the stomach when using bag or mask ventilation
American Heart Association-American Academy of Pediatrics
Approach to Resuscitation
?Infant with an Apgar Score of 1 to 3
? usually require intubation and expansion of the lung
? bag and mask ventilation usually is adequate to sustain
? further steps depend on the response to ventilation
?Infant with an Apgar Score of 0
? no live born infant should be assigned a score of 0
? resuscitation should proceed as for a score of 1
? cardiac compression
Resuscitation – the ABCDE Protocol
?Air way
?Breathing
?Circulation
?Drugs
?Evaluation & Enviroment
Advanced
Life
Support (ALS)
The Neonatal
Resuscitation
Guidelines
Pediatrics,2000
Neonatal Resuscitation Medications
Medication Concentration
to Administer
Preparation Dosage &
Route
Rate & Precautions
Epinephrine 1:10,000 (0.1 mg/l) 1 ml 0.1-0.3 ml/kg IV or IT Give rapidly,may repeat every 5-10 minutes,
Volume
Expanders
whole blood,5%
albumin,saline,
Ringer's lactate
Varies 10 ml/kg IV Give over 5-10 minutes,Repeat
as needed.
Sodium
Bicarbonate
0.5 meq/ml (4.2%
solution)
20 ml or two 10
ml prefilled
syringes
2 meq/kg
(4 ml/kg) IV
Give slowly,over at least 2
minutes,may repeat every 10
minutes,Ventilate infant,
Narcan
(Naloxone)
0.4 mg/ml 1 ml 0.1 mg/kg
(0.25ml/kg) IV,
IM,SQ,IT
Give rapidly.
Calcium
Gluconate
100 mg/ml (10%
solution,0.465
mEq/ml)
10 ml 100 mg/kg
(1 ml/kg) IV
Give over 3-5 minutes,may
repeat every 15 min,Do not mix
with sodium bicarbonate in line,
Post-resuscitation Issues and More
?Continuing Care of the Newly Born Infant
supportive or ongoing care
monitoring
appropriate diagnostic evaluation
?Documentation of Resuscitation
?Continuing Care of the Family
?Ethics,Noninitiation of Resuscitation
Discontinuation of Resuscitation To save,or not to save
Advanced life support,
Your support!!
Thank you!
Asphyxia of the Newborn
Dr,Xiaoping Luo
Professor and Chairman
Department of Pediatrics
Tongji Hospital
Tongji Medical College
The highest mortality that befalls the human
race in one day occurs on the day of birth.,.…,
……
It is said that the most important period of
the life of a human being is the time spent in
utero,The most trying ordeal a human being
sustains is the ordeal of birth.
Asphyxia Neonatorum,
Causation and Treatment
Professor of Obstetrics,Northwestern University Medical School
Jos,B,De Lee Published in Medicine (Detroit) 3:643-660,1897.
Definition of Perinatal Asphyxia
a condition in the neonate where there is the
following combination:
? An event or condition during the perinatal period that is
likely to severely reduce oxygen delivery and lead to acidosis;
AND
? A failure of function of at least two organs consistent with
the effects of acute asphyxia.
Hypoxemia,Hypercapnia,Mixed acidosis,Organic failure
Risk Factors-Maternal
? Systemic disease,diabetes,heart or renal
diseases,anemia,infectious diseases
? Obstetric Conditions,hypertensive disease of
pregnancy or pre-eclampsia,placental abruption
? Substance abuse,drug addiction,smoking
? Maternal age,>35,or <16,multiple pregnancy
Risk Factors-Fetal
? Premature,SGA,macrosomia
? Congenital malformation,nose and laryngo-
pharynx malformation,lung hypoplasia,
heart disease
? Amniotic fluid or meconium aspiration
? Intrauterine infection,Torch syndrome
Risk Factors-Intrapartum
? Umbilical cord,obstruction
? Obstetric procedures,forceps delivery,
breech extraction,vacuum extraction
? Medication,analgesic and oxytocic
medicine
Pathophysiology of Asphysia
? Respiratory Alteration:
primary hyperpnea,primary apnea,secondary apnea
? Hypoxic-ischemic Changes of Multi-organic system:
“diving reflex”,inter-organ shunting,organ failure
? Biochemical and metabolic Consequences:
acidosis,hyper- or hypoglycemia,hypocalcemia,
hyperbilirubinemia,hyperkalemia,hyponatremia
Clinical Manifestation of Asphysia
? Apgar Scoring System
Apgar Scoring System
Sign 0 Points 1 Point 2 Points
Activity
(muscle tone)
absent arms and
legs flexed
active
movement
Pulse
(heart rate)
absent below 100
bpm
above 100
bpm
Grimace
(reflex irritability)
no response grimace sneeze,cough,
pulls away
Appearance
(skin color)
blue-gray,
pale all over
normal,
/-extremities
normal over
entire body
Respiration absent slow,
irregular
good,crying
A
P
G
A
R
The Significance of Apgar Score
?Apgar 8~10,normal;
4~7,mild asphyxia;
0~3,severe asphyxia
?Assigned at 1,5,and 10 min,until score of 7 or more
?1’ score indicate the severity and guide for resuscitation
?5’ score and later is more predictive of prognosis
?Premature infants intend to have lower scores
Clinical Manifestation of Asphyxia
? Multiorgan System Dysfunction
? Renal compromise,oliguria and elevated creatinine
? Hypoxic cardiomyopathy (ECHO or ECG abnormality)
? Hypoxic ischemic encephalopathy (HIE)
? Pulmonary complications,respiratory distress (RDS),
persistent pulmonary hypertension (PPHN)
? Disseminated intravascular coagulation (DIC)
? Hepatic failure,hyperbilirubinemia
? Necrotising enterocolitis (NEC),stress ulcer
? Fluid overload,hyperkalemia,hypoglycemia,and acidosis
American Heart Association-American Academy of Pediatrics
Approach to Resuscitation
?Infant with an Apgar Score of 7 or more
? generally do not require resuscitation
? a brief period of oxygen blown over the face
? oxygen increases pulmonary blood flow
? avoid excessive suctioning of clear fluid
?Infant with an Apgar Score of 4 to 6
? stimulation
? administration of oxygen by face mask,or bag
? empty the stomach when using bag or mask ventilation
American Heart Association-American Academy of Pediatrics
Approach to Resuscitation
?Infant with an Apgar Score of 1 to 3
? usually require intubation and expansion of the lung
? bag and mask ventilation usually is adequate to sustain
? further steps depend on the response to ventilation
?Infant with an Apgar Score of 0
? no live born infant should be assigned a score of 0
? resuscitation should proceed as for a score of 1
? cardiac compression
Resuscitation – the ABCDE Protocol
?Air way
?Breathing
?Circulation
?Drugs
?Evaluation & Enviroment
Advanced
Life
Support (ALS)
The Neonatal
Resuscitation
Guidelines
Pediatrics,2000
Neonatal Resuscitation Medications
Medication Concentration
to Administer
Preparation Dosage &
Route
Rate & Precautions
Epinephrine 1:10,000 (0.1 mg/l) 1 ml 0.1-0.3 ml/kg IV or IT Give rapidly,may repeat every 5-10 minutes,
Volume
Expanders
whole blood,5%
albumin,saline,
Ringer's lactate
Varies 10 ml/kg IV Give over 5-10 minutes,Repeat
as needed.
Sodium
Bicarbonate
0.5 meq/ml (4.2%
solution)
20 ml or two 10
ml prefilled
syringes
2 meq/kg
(4 ml/kg) IV
Give slowly,over at least 2
minutes,may repeat every 10
minutes,Ventilate infant,
Narcan
(Naloxone)
0.4 mg/ml 1 ml 0.1 mg/kg
(0.25ml/kg) IV,
IM,SQ,IT
Give rapidly.
Calcium
Gluconate
100 mg/ml (10%
solution,0.465
mEq/ml)
10 ml 100 mg/kg
(1 ml/kg) IV
Give over 3-5 minutes,may
repeat every 15 min,Do not mix
with sodium bicarbonate in line,
Post-resuscitation Issues and More
?Continuing Care of the Newly Born Infant
supportive or ongoing care
monitoring
appropriate diagnostic evaluation
?Documentation of Resuscitation
?Continuing Care of the Family
?Ethics,Noninitiation of Resuscitation
Discontinuation of Resuscitation To save,or not to save
Advanced life support,
Your support!!
Thank you!
