英新生儿窒息与新法复苏幻灯片.ppt

英新生儿窒息与新法复苏第1页，共56页，编辑于2022年，星期二Neonatal Asphyxia and its New Concept on Resuscitation Chongmin XuDep.Newnates Union Hospital第2页，共56页，编辑于2022年，星期二New Wordspregnant woman invalidApgar score umbilical cordprimary apnea asynersisHIE(hypoxic-ischemic encephalopathy)ICH(intracranial hemorrhage)MOD(multiple organs function damage)hypercapnia hypoxemia第3页，共56页，编辑于2022年，星期二 Neonatal asphyxia is a kind of gas exchange disorder,that could cause hypoxemia,hypercapnia and metabolism acidosis,which is accounted on that newborn has no auto respiration or only has irregular,intermittent and feeble respiration at birth,or present respiratory depression after birth.Its incidence is about 5%occupied the viable birth,and can cause 20%death in toltal newnatal death.The nature of asphyxia itself is hypoxia.Usually we adopt Apgar score to judge the degree of asphyxiation.第4页，共56页，编辑于2022年，星期二 Asphyxia could cause not only HIE,but also MOD,and is the one of the important causes of death,dysnoesia and invalid(cerebral palsy)in newborns all over the world.Neonatal mortality is about 19.0(2005)in our country.The first three death causes are premature birth&low birth weight,asphyxia and pneumonia.There are 1 million newborn death caused by neonatal asphyxia(total 4 million yearly-2005.WHO),and 1 million neonates suffer from dysnoesia,cerebral palsy and other deformity caused by it too.第5页，共56页，编辑于2022年，星期二Delivery factorsPlacenta factorFetal factorumbilical cord factorPregnant woman Asphyxial etiopatho-genisis第6页，共56页，编辑于2022年，星期二too older or youngRespiratory diseasecardiac diseasesevere severe anaemiaSmoking&Smoking&drugdruggestational hypertensionPregnant woman factor polycyesisdiabetes第7页，共56页，编辑于2022年，星期二placenta praeviaplacental abruptioninfarctusageing Placenta factorfactor第8页，共56页，编辑于2022年，星期二short cordknot of umbilical cordumbilical hang downumbilical cord circle neckUmbilical factor第9页，共56页，编辑于2022年，星期二胎儿因素胎儿因素prematurelarge for date infantintrauterine infectionrespiratory tract obstructioncongenital cardiopathy congenital abnormality foetus factor第10页，共56页，编辑于2022年，星期二sucking fetal head forceps aid deliver breech presentation unsuitably use drugs in labor labor extension&precipitate labor cephalopelvic disproportion deliver factor第11页，共56页，编辑于2022年，星期二PathophysiologyvSwitch of respiration&circulation from fetus to newborn are blocked vBreath altervbiochemistry&metabolism alter in blood 第12页，共56页，编辑于2022年，星期二 fetal pulmonary fluid is removed from lungs surface active substance(SAS)secretes functional residual capacity of alveolus set up pulmonary circulation resistancegenetal circulation resistance arterial duct&ovale foramen shut functionalityNormal fetus transform to neonate in respiration&circulation 第13页，共56页，编辑于2022年，星期二Blocked switch of respiration&circulation from fetus to newborn Asphyxia Respiration ceases or inhibit alveolar ectasia Hypoxia,acidosisSas secretesSas secretesactivity pulmonary fluid removes Fetal circulation reopendurative PHT reopendurative PHTConstitution hypoxia,ischemia and acidosisacidosisInconvertible damage of organsdamage of organspulmonary vascular resistance 第14页，共56页，编辑于2022年，星期二Hypoxia-ischemia alter in difference organs as asphyxia缺缺缺缺OO2 2PHPHPaOPaO2 2PaCOPaCO2 2 潜水反射潜水反射潜水反射潜水反射血液再分配血液再分配血液再分配血液再分配无氧酵解无氧酵解无氧酵解无氧酵解低血糖低血糖低血糖低血糖儿茶酚胺儿茶酚胺儿茶酚胺儿茶酚胺血钙血钙血钙血钙心纳素心纳素心纳素心纳素抗利尿激素抗利尿激素抗利尿激素抗利尿激素细胞膜细胞膜细胞膜细胞膜钠泵钠泵钠泵钠泵钙泵钙泵钙泵钙泵钙离子内流钙离子内流钙离子内流钙离子内流高血糖高血糖高血糖高血糖肠肠肠肠血钠血钠血钠血钠NECNEC肾肾肾肾肾肾肾肾V V血栓血栓血栓血栓肾功能衰竭肾功能衰竭肾功能衰竭肾功能衰竭肾上腺肾上腺肾上腺肾上腺脑脑脑脑缺缺缺缺O2O2加重加重加重加重压力被动压力被动压力被动压力被动性脑血流性脑血流性脑血流性脑血流体循环压体循环压体循环压体循环压体循环压体循环压体循环压体循环压颅内出血颅内出血颅内出血颅内出血HIEHIE脑血流灌注脑血流灌注脑血流灌注脑血流灌注大脑半大脑半大脑半大脑半球血流球血流球血流球血流矢状旁矢状旁矢状旁矢状旁区及其区及其区及其区及其下白质下白质下白质下白质受损受损受损受损PVLPVL心脏心脏心脏心脏肺肺肺肺A A压压压压心功能受损心功能受损心功能受损心功能受损心衰心衰心衰心衰休克休克休克休克PFCPFC缺缺缺缺O2O2加重加重加重加重血液高凝血液高凝血液高凝血液高凝DICDIC第15页，共56页，编辑于2022年，星期二 Breath alterBreath alter 1 1Primary apnea When hypoxia,the baby may breath deeply and quickly at first l-2 mins,if no management in time,it may occur breath inhibition and reflective heart rate decreasing in a short time.2Secondary apnea If the hypoxia persistence,the baby may occur gasping respiration,heart rate continue step down,the BP begin to descend,muscular tension lost,the baby is pale and respiratory movement asynersis,he may occur a deep gasp at last and then enter the secondary apnea.(need positive pressure)第16页，共56页，编辑于2022年，星期二第17页，共56页，编辑于2022年，星期二blood gas PaCO2，PH&PaO2mixed acidosis Glucose metabolic disordercatecholamine&glucagon release earlyblood sugar normal or then then glycogen depletion,blood sugarHyperbilirubinemia Bilirubin combine with albumin、the vigor of liver enzymeunconjugated bilirubin Hyponatremiaatrial natriuretic peptide,ADH is parasecretiondiluted hyponatremiaHypocalcemiacalcium channel open、calcium pump dysfunction calcium influx Blood biochemistry and metabolism alteration第18页，共56页，编辑于2022年，星期二三三 Clinical situation(一一)intrauterine asphyxia 1.early stage the fetal heart rate and fetal movement increase;2.advanced stage fetal movement decrease or disappear,fetal heart rate slow down,amniotic fluid was polluted by meconium.(二二)Apgar score A simple clinical evaluation way to determine the degree of asphyxia in baby just borned.0-3 score is severe asphyxia,while 4-7 scores,mild asphyxia.1 min score after birth can judge degree of asphyxia,5 mins score is helpful ro judge the baby prognosis.第19页，共56页，编辑于2022年，星期二physical signScore denomscore0121 min.5&10 min.Skin colorcyanose/paleBody red,limbs cyanoseRed all over03 severe asphyxia47 mild asphyxia810 normalJudge PrognosisH.R.(time/min)no100Reaction after stimulate sole or intubatenoSome actioneg.frownCry,sneezemuscular tensionlaxitasLimbs flex a littleLimbs activerespirationnoslow,irregularnormal,cry loudly第20页，共56页，编辑于2022年，星期二Asphyxia diagnostic code AAP(AAP(美国儿科学会美国儿科学会)&ACOG()&ACOG(妇产科学会妇产科学会)1996)1996Blood in arteria umbillicalis shows severe shows severe metabolism or mixed acidosis,pHpH7 7 Apgar Apgar score is 0 03 points,and 3 points,and persistence time5min.5min.Nervous system manifestation,such as such as such as such as convulsion、coma or muscular tension low etc.MODMOD Committee on Fetus and Newborn,American Academy of Pediatrics,and Committee on Obstetric Committee on Fetus and Newborn,American Academy of Pediatrics,and Committee on Obstetric Practice,American College of Obstetricians and Gynecologists.Use and abuse of the Apgar Practice,American College of Obstetricians and Gynecologists.Use and abuse of the Apgar score.Pediatrics,1996,98(1):141-142score.Pediatrics,1996,98(1):141-142 第21页，共56页，编辑于2022年，星期二 MOD 1.cardiovascular system(CVS)mild case may presence conducting system and cardiac muscle damaged;severe case presence cardiac shock(CS),heart failure and persistent fetal circulation.2.respiratory system(RS)Aspiration of amniotic fluid or meconium syndrome,pneumorrhagia and persistent pulmonary hypertension,LBWI may presence hyaline membrane disease and apnea etc.第22页，共56页，编辑于2022年，星期二3.Kidney acute renal failure(ARF,oliguria,proteinuria,Blood urea nitrogen and creatinine increase);thrombosis of renal vein(gross hematuria).4.central nervous system(C.N.S)HIE(hypoxic-ischemic encephalopathy)and ICH(intracranial hemorrhage)5.Metabolism acidosis,hypoglycemia and electrolyte disturbances；6.gastrointestinal tract(GIT)stress ulcer NEC(necrotizing enterocolitis),jaundice aggratate.第23页，共56页，编辑于2022年，星期二 Systems damaged by Asphyxia in perinatal period damagecentral nervous system hypoxic-ischemic encephalopathy,intracranial hemorrhage,encephaledema urinary system glomerular filtration rate and/or tubular reabsorption function damage,renal tubular necrosis,renal failurecardiovascular system mitral insufficiency,myocardiolysis,cardia failure，shockrespiratory system pulmonary hypertension,meconium aspirated pneumonia,alveolus surface active substance decreasemetabolism acidosis,hypoglycemia,hypocalcemia,ADH secrete increasedigestive system stress ulcer，NEC(necrotizing enterocolitis),liver functional lesionskin subcutaneous fat necrosishematological system DIC(disseminated intravascular coagulation)第24页，共56页，编辑于2022年，星期二四四 laboratory examination 1.take blood out of intrauterine apnea babys scalp by amnioscope or fetus outerop of cervix uteri to measure its pH-how to rescue the baby.2.after birth,blood gas,blood sugar,electrolyte,blood urea nitrogen and creatinine,type-B ultrasonic or CT scan developmently,第25页，共56页，编辑于2022年，星期二五五 Treatment 1.the resuscitation should be carried out by pediatrician co-operated with obstetrician 2.should be familiarity with the babys delivery history,and do the full prepare for skill and operation,apparatus and device beforehand;第26页，共56页，编辑于2022年，星期二(一一)ABCDE resuscitation program A (air way)：B (breathing)C (Circulation)D (drug)E (evaluation)ABC is the most important,and A is basic,B is the key point.第27页，共56页，编辑于2022年，星期二(二二)resuscitation procedure 1The first resuscitation step keep body warm extreme infra-red ray table;use warm and dry towel to mop the baby;arrange posture pad the shoulder for 2-3 cm suck the mucosa out of the babys mouth,nose and pharyng(2 mins,should insert a gastric tube,pressing heart out chest the lower l/3 of the breast bone,120 pem,every pressing 3 times,should supply pressurize oxygen once.Press about l一2 cm dept,the finger shouldnt left the pressing location；第32页，共56页，编辑于2022年，星期二双拇指并排或重叠于患儿双拇指并排或重叠于患儿双拇指并排或重叠于患儿双拇指并排或重叠于患儿胸骨体下胸骨体下胸骨体下胸骨体下 1/3 1/3处，其他手指处，其他手指处，其他手指处，其他手指绕胸廓托在背后绕胸廓托在背后绕胸廓托在背后绕胸廓托在背后The way of thumbs右手中、食指指端垂直压胸右手中、食指指端垂直压胸右手中、食指指端垂直压胸右手中、食指指端垂直压胸骨下骨下骨下骨下 1/3 1/3处，左手托患儿背部处，左手托患儿背部处，左手托患儿背部处，左手托患儿背部The way of double fingers第33页，共56页，编辑于2022年，星期二 oral trachea cannula intubation and susction once should be finished within 20 seconds if the baby has one of the follows meconium ropiness or there is granules of meconium hypolarynx the baby suffer from severe asphyxia and need artificial ventilating for a long time;the result is poor using resuscitaing;the baby heart rate is 80-100 pem and doesnt increase to follows；suspect diagnosis of diaphragmatic hernia.第34页，共56页，编辑于2022年，星期二anatomic landmark for put in laryngoscopetracheal intubation第35页，共56页，编辑于2022年，星期二 4.medicine assisting resuscitation alkali therapy adrenalin therapy vasoactive agent therapy dopamine 3-5ug/kg.min Heparine therapy 20-30u/kg.d,H,tid naloxone anti-morphinum and inhibition of HIE.第36页，共56页，编辑于2022年，星期二5Observe and monitor post resuscitation body temperature,breath,heart rate.Blood pressure,urinary volume,skin color,and symptom of nervous system;notice acid-base imbalance,electrolyte disturbances,abnormity of urination and defecation,infection and feeding etc.第37页，共56页，编辑于2022年，星期二出生出生是否足月？是否足月？是否羊水清？是否羊水清？是否有呼吸和哭声？是否有呼吸和哭声？是否肌张力好？是否肌张力好？保温保温 摆正体位，摆正体位，通畅气道通畅气道 擦干擦干,刺激刺激,重新摆正体位重新摆正体位评价心率、呼吸和肤色评价心率、呼吸和肤色常压给氧常压给氧常规护理常规护理 保温保温 必要时通畅气道必要时通畅气道 擦干擦干观察护理观察护理是是正常呼吸正常呼吸心率心率 100 及及 肤色红润肤色红润否否紫绀紫绀肤色红润肤色红润2006 NRP 流程图流程图Harris AP et al.J Pediatr 1986;109:117Reddy VK et al.Clin Pediatr 1999;38:87Toth B et al.Arch Gyn Obst 2002;266:105第38页，共56页，编辑于2022年，星期二正压人工呼吸正压人工呼吸 正压人工呼吸正压人工呼吸 胸外按压胸外按压给肾上腺素给肾上腺素 和和/或或 扩容扩容复苏后护理复苏后护理 呼吸暂停呼吸暂停 HR 100 及及 皮肤红润皮肤红润HR 60HR 60*在某些步骤可考虑气管插管在某些步骤可考虑气管插管第39页，共56页，编辑于2022年，星期二第40页，共56页，编辑于2022年，星期二第41页，共56页，编辑于2022年，星期二第42页，共56页，编辑于2022年，星期二第43页，共56页，编辑于2022年，星期二第44页，共56页，编辑于2022年，星期二第45页，共56页，编辑于2022年，星期二第46页，共56页，编辑于2022年，星期二第47页，共56页，编辑于2022年，星期二第48页，共56页，编辑于2022年，星期二Announcements Seize every minute and second，obstetrics and pediatric operate together Excute the ABCDE procedure strictly Respiratory heart rate and skin colour are the tree big physical sign to judge the asphyxia and resusitation 循环往复，至完成复苏循环往复，至完成复苏循环往复，至完成复苏循环往复，至完成复苏遵循遵循第49页，共56页，编辑于2022年，星期二第50页，共56页，编辑于2022年，星期二第51页，共56页，编辑于2022年，星期二第52页，共56页，编辑于2022年，星期二六、六、preventing 1、antepartum body check periodicly,avoid premature and operation delivery.2、waiting for delivery fetal heart monitor and discovery early intrauterine distress.3、intrapartum suck the mucosa out of the babys mouth,nose and pharyng(10 seconds)right after birth,get ready for all of resuscitation.第53页，共56页，编辑于2022年，星期二七七 prognosis the poor prognosis include:chronic intrauterine hypoxia,congenital abnormity,severe asphyxia without management in time or unsuitable management,Apgar score is low after 20 mins of birth;nervous system persistence for 2 weeks.第54页，共56页，编辑于2022年，星期二 thank you listening！第55页，共56页，编辑于2022年，星期二第56页，共56页，编辑于2022年，星期二