Neonat Engl

PERINATAL ASPHYXIA Dr.LORN TRY Patrich,Pediatrician.DHM

Dr.LORN TRY Patrich,pediatrician,DHM

DEFINITION  Perinatal asphyxia as 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. – A failure of function of at least two organs (include lung, heart, liver, brain, kidneys, and hematological) consistent with the effects of acute asphyxia. Dr.LORN TRY Patrich,pediatrician,DHM

RISK FACTOR            

Hypertensive disease of pregnancy or preeclampsia. Intrauterine growth restriction Placental abruption Fetal anemia (eg rhesus incompatible) Post maturity Malpresentation cord compression transplacental anaesthetic or narcotic administration severe meconium aspiration congenital cardiac or pulmonary anomalies birth trauma intrauterine pneumonia Dr.LORN TRY Patrich,pediatrician,DHM

D’APGAR SCORE

 D’apgar Scoreis based on 5 vital signs : – – – – –

Heart rate Respiratory effort Present or absence of central or peripheral cyanosis Muscle tone Response to stimulation

 Each vital signs is given a score 0 or 1 or 2. A vital sign score of 2 is normal.A score 1 mildly abnormal .A score 0 is severity abnormal.  Normally D’apgare score is of 7 to 10: – –

4 – 6 Moderate depression 0-3 severely depress vital signs and great risk of dying unless actively resuscitated. Dr.LORN TRY Patrich,pediatrician,DHM

CLINICAL DIAGNOSIS  At delivery – Abnormal fetal heart rate – Meconium staining of the liquor

 At birth – Apgar score < 7 at 5 minutes – Acidosis pH< 7

 Post natal – Hypoxic ischemic encephalopathy – Multiorgan system dysfonctionnement (Liver, Kedney, heart, brain) Dr.LORN TRY Patrich,pediatrician,DHM

INTERVENTION 

Principle: – – – – – – – –

Correct of hypoglycemia Correction of acidosis Treatment of seizures Temperature: Maintain core temperature 36-37 o- 37o . Respiratory status : Meconium aspiration, oxygene Cardiac status : Cardiac ECHO Fluid therapy and renal impairment:electrolytes and creatinine should be performed. Gastro-intesinal-feeding: Brest milk is preferred.

Dr.LORN TRY Patrich,pediatrician,DHM

PREDICTION OF OUTCOME 

During resuscitation a) Apgar scores – Although the 1 and 5 minutes Apgar scores, are poor predictors of neonatal. – Apgars score 0-3 at 20 minutes ,59% of survivors died before 1 year, and 57 % of the survivors had cerebral palsy. b) Time to spontaneous respirations • The overall risk of death or handicap was 72% in the pooled seri of infants with > 30 minutes to substained spontaneous resppiration Dr.LORN TRY Patrich,pediatrician,DHM

PREDICTION OF OUTCOME(Count)  Clinical assessment of encephalopathy the overall risk of death or severe handicap in a pooled serie of infant was: – Grade 1 : HIE 1.6% – Grade 2 : HIE 24% – Grade 3 : HIE 78%  Grade of HIE – Grade 1 : Mild encephalopathy with infant hyperalert, and over sensitive to stimulation EEG is normal,tarchycardia,dilated pupils. – Grade 2 : moderate encephalopathy with the infant displaying lethargy, hypotonie. EEG abnormal , 70% of infants will have seizure, small pupils. – Grade 3 : Severe encephalopathy with a stuporous absent reflexes .The infant may have seizures and has abnormal EEG with decreased background activity Dr.LORN TRY Patrich,pediatrician,DHM

NEONATAL HYPOGLYCEMIA Dr.LORN TRY Patrich,Pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM

DEFINITION  Glycemia < 1.1 mmol/l(1mmol/l=180mg/l) in growth retarded and preterm; < 1.7 mmol/l in term baby : – In at risk asymptomatic term or near term baby ( 36 weeks ) BGL should be maintained about 1.5 mmol/l – In preterm babies ( < 35 weeks) or sick term babies BGL should be maintained about 2.5 mmol/l.

Dr.LORN TRY Patrich,pediatrician,DHM

RISKS FACTORS     

Infants of diabetic mothers Growth restricted babies Preterm babies Macrosomie babies (may have hyperinsulinism) Sick babies including these with: – – – –

Pernatal asphyxia Rhesus diseas Sepsis Polycythaemia Dr.LORN TRY Patrich,pediatrician,DHM

CLINICAL DIAGNOSIS    

Irritability Apnea and cyanosis Hypotonia and poor feeding Convulsions

Dr.LORN TRY Patrich,pediatrician,DHM

PREVENTION and TREATMENT  Prevention at risk infant – – – – –

Infant of all diabetic mothers Small for gestational age infants Wasted “babies”( < 3rd centil) Preterm babies (< 37 weeks ) Macrosomies baby

Need attention paid to early establishement of breast feeding .

Dr.LORN TRY Patrich,pediatrician,DHM

WHEN SHOULD ACTIVE INTERVENTION BE STARTED?  Glycemia =1.5-2mmol/l – Admit to NICU – Continue breast, complements or tube feeds – Commence IV 10% dextrose if BSL not maintained about 2 mmol/l  Glycemia = 1 – 1.5 mmol/l – Admit to NICU – Continue IV 10% dextrosee at 60-90mls/kg/day to maintain normal blood glucose.

Dr.LORN TRY Patrich,pediatrician,DHM

WHEN SHOULD ACTIVE INTERVENTION BE STARTED?(Counti)  Glycemia < 1 mmol/l – Admit to NICU urgently – Give IV bolus of 10% dextrose at 2.5mls/kg – Ensure BSL has increased to > 1.5 mmol/l – Contious IV 10% dextrose at 60-90 mls/Kg/day to maintain normal blood glucose.  Persistent severe hypoglycemia: We should interpretation of hormone levels and take some blood for : Insulin, Cortisol, Growth hormone. The treatment : – Increase volume by 30 ml/kg/day. – Increase the glucose concentration to 12.5% – If still persisting.Start a glucagon infusion Dr.LORN TRY Patrich,pediatrician,DHM

RESUSCITATION Dr.LORN TRY Patrich,pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM

INTRODUCTION  Approximately 1-10% of in hospital delivered newborns require resuscitation. The aim of resuscitation is to prevent neonatal death and adverse long term neurodevelopmental sequelae associated with asphyxia.  Substantial physiologic changes occur in the transition from fetal to extra uterine life including: – Changes from fluid-filled to air filled alveolar sacs – Reduction in pulmonary vascular bed pressure – Reduction of intra and extra cardiac shunting – Establishment of adequate lung volume – Surfactant production Dr.LORN TRY Patrich,pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM

PREPARATION  Personnel – At least two trained people are required for adequate resuscitation involving ventilation and cardiac compression.  Check equipment – Resuscitation equipment should be checked daily after each usage. – When use is anticipated at birth recheck equipment, including : Oxygen supply, laryngoscope, bag and mask circuit and endotracheal tubs.  Communication: with anesthetic and obstetric staff regarding maternal condition and therapie, fetal condition  Environment: Prevention of heat loss, dry infant,warm towels. Dr.LORN TRY Patrich,pediatrician,DHM

ASSESSMENT  Evaluation begins immediately after birth and continues throughout the resuscitation process until vitals signs have normalized: – Respiration : the newly infant should establish regular respirations in order to maintain 30 100 bpm. – Color: A central pink color in room air

Dr.LORN TRY Patrich,pediatrician,DHM

MANAGEMENT  Stimulation: Most infants respond to stimulation with movement of extremities.  Airway : The head should in a neutral.  Breathing: Attend to adequate inflation and ventilation before oxygenation .Few infants require immediate intubation .The majority of infants can be managed with bag and mask ventilation.  Circulation: The majority of infants establishment of adequate ventilation will restore circulation. Begin chest compressions(3:1) for either: – Absent HR or HR < 60 for 30 seconds Dr.LORN TRY Patrich,pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM

Dr.LORN TRY Patrich,pediatrician,DHM

MEDICATION Route of delivery : Umbilical venous catheter Adrenaline : For HR < 60 for > 30 Sec despite compression Naloxone : 0.1 ml/kg of 0,4 mg/ml solution and contraindication infant of narcotic dependant mothers.  Bicarbonate : Currently there is insufficient evidence for routine use.  Stopping resuscitations : If the infant has not responded with a spontaneous circulation by 15 minutes of age.   

Dr.LORN TRY Patrich,pediatrician,DHM

Newborn Life Support

Dry & cover A © RC (UK)

B

Airway & Breathing

C

CC

D D Dr.LORN TRY Patrich,pediatrician,DHM

NLS Resus 31