英新生儿窒息与新法复苏.ppt

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1、Neonatal Asphyxia and its New Concept on Resuscitation Chongmin XuDep.Newnates Union HospitalNew Wordspregnant woman invalidApgar score umbilical cordprimary apnea asynersisHIE(hypoxic-ischemic encephalopathy)ICH(intracranial hemorrhage)MOD(multiple organs function damage)hypercapnia hypoxemia Neona

2、tal 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

3、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.Asphyxia could cause not only HIE,but also MOD,and is the one of the important causes of death,dysnoesia and inv

4、alid(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 millio

5、n neonates suffer from dysnoesia,cerebral palsy and other deformity caused by it too.Delivery factorsPlacenta factorFetal factorumbilical cord factorPregnant woman Asphyxial etiopatho-genisistoo older or youngRespiratory disease cardiac diseasesevere severe anaemiaSmoking&Smoking&drug druggestationa

6、l hypertensionPregnant woman factor polycyesisdiabetesplacenta praeviaplacental abruptioninfarctusageing Placenta factorshort cordknot of umbilical cordumbilical hang downumbilical cord circle neckUmbilical factor胎儿因素prematurelarge for date infantintrauterine infectionrespiratory tract obstructionco

7、ngenital cardiopathy congenital abnormality foetus factorsucking fetal head forceps aid deliver breech presentation unsuitably use drugs in labor labor extension&precipitate labor cephalopelvic disproportion deliver factorPathophysiologyv Switch of respiration&circulation from fetus to newborn are b

8、locked v Breath alterv biochemistry&metabolism alter in blood 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 functionalit

9、yNormal fetus transform to neonate in respiration&circulation Blocked switch of respiration&circulation from fetus to newborn Asphyxia Respiration ceases or inhibit alveolar ectasia Hypoxia,acidosisSas secretes Sas secretes activity pulmonary fluid removes Fetal circulation reopendurative PHT reopen

10、durative PHTConstitution hypoxia,ischemia and acidosis acidosisInconvertible damage of organs damage of organspulmonary vascular resistance Hypoxia-ischemia alter in difference organs as asphyxia缺 缺O O2 2PH PHPaO PaO2 2PaCO PaCO2 2 潜水反射 潜水反射血液再分配 血液再分配无氧酵解 无氧酵解低血糖 低血糖儿茶酚胺 儿茶酚胺血钙 血钙心纳素 心纳素抗利尿激素 抗利尿激素

11、细胞膜 细胞膜钠泵 钠泵钙泵 钙泵钙离子内流 钙离子内流高血糖 高血糖肠 肠血钠 血钠NEC NEC肾 肾肾 肾V V血栓 血栓肾功能衰竭 肾功能衰竭肾上腺 肾上腺脑 脑缺 缺O2 O2加重 加重压力被动 压力被动性脑血流 性脑血流体循环压 体循环压体循环压 体循环压颅内出血 颅内出血HIE HIE脑血流灌注 脑血流灌注大脑半 大脑半球血流 球血流矢状旁 矢状旁区及其 区及其下白质 下白质受损 受损PVL PVL心脏 心脏肺 肺A A压 压心功能受损 心功能受损 心衰 心衰休克 休克PFC PFC缺 缺O2 O2加重 加重血液高凝 血液高凝DIC DIC Breath alter 1Prima

12、ry 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

13、,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)blood gas PaCO2，PH&PaO2mixed acidosis Glucose metabolic disordercatecholamine&glucagon release earlyblood sug

14、ar normal or then glycogen depletion,blood sugar Hyperbilirubinemia Bilirubin combine with albumin、the vigor of liver enzymeunconjugated bilirubin Hyponatremiaatrial natriuretic peptide,ADH is parasecretiondiluted hyponatremia Hypocalcemiacalcium channel open、calcium pump dysfunction calcium influx

15、Blood biochemistry and metabolism alteration三 Clinical situation(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)Apgar score A simple cli

16、nical 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.physical signScore denom score0 1 2 1 min.5&10 min.Skin co

17、lorcyanose/paleBody red,limbs cyanoseRed all over03 severe asphyxia47 mild asphyxia810 normalJudge PrognosisH.R.(time/min)no 100Reaction after stimulate sole or intubatenoSome actioneg.frownCry,sneezemuscular tension laxitasLimbs flex a littleLimbs activerespirationnoslow,irregularnormal,cry loudlyA

18、sphyxia diagnostic code AAP(美国儿科学会)&ACOG(妇产科学会)1996 Blood in arteria umbillicalis shows severe shows severe metabolism or mixed acidosis,pHpH77 ApgarApgar score is 003 points,and 3 points,and persistence time5min.5min.Nervous system manifestation,such as such as convulsion、coma or muscular tension l

19、ow etc.MODMOD Committee on Fetus and Newborn,American Academy of Pediatrics,and Committee on Fetus and Newborn,American Academy of Pediatrics,and Committee on Obstetric Practice,American College of Obstetricians and Committee on Obstetric Practice,American College of Obstetricians and Gynecologists.

20、Use and abuse of the Gynecologists.Use and abuse of the Apgar Apgar score.Pediatrics,1996,98(1):141-142 score.Pediatrics,1996,98(1):141-142 MOD 1.cardiovascular system(CVS)mild case may presence conducting system and cardiac muscle damaged;severe case presence cardiac shock(CS),heart failure and per

21、sistent 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.3.Kidney acute renal failure(ARF,oliguria,proteinuria,Blood urea nitrogen and creatinine in

22、crease);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 aggra

23、tate.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 mitr

24、al 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 fu

25、nctional lesionskin subcutaneous fat necrosishematological system DIC(disseminated intravascular coagulation)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,blo

26、od sugar,electrolyte,blood urea nitrogen and creatinine,type-B ultrasonic or CT scan developmently,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 operati

27、on,apparatus and device beforehand;(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.(二)resuscitation procedure 1The first resuscitation step keep body warm extreme infra-red ray table;use warm and dry

28、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(10 seconds)right after birth;tactile stimulus if the baby still has no breath after above management,could flap the sole twice and rub its back。Above 5 steps should be finished w

29、ithin 30 seconds after birth.The first resuscitation stepkeep warmwipe drytactile stimulusclear airway complete within 30 second after birthcorrect posture 2.ventilating resuscitation procedure if the baby has already normal breath and heart rate 100 pem,the skin is red,just observe him.if he has no

30、 breath,or only gasp and heart rate 100 pem,should supply pressurized oxygen with the resuscitator right away,if heart rate is 80一100 pem and spontaneously breathing occur after 15-30 seconds,could continue above step for some time,then observe him.if the heart rate cant increase or 80 pem.Should ca

31、rry out pressing heart from out-chest for 30 seconds,if no respond,should give 1：10000 adrenalin 0.1-0.3ml kg by the way of vein and trachea.if the heart still 100 pem,could give the medicine to correct acidosis and expanse fluid.if the mother was given narcotic 6 hrs before birth,could gave the bab

32、y naloxone 0.1mg kg by the way of vein and trachea.3.resuscitation technique resuscitator supply pressurizing oxygen ventilating rate 30-40 rimes,press:relax is 1：1.5,if last for 2 mins,should insert a gastric tube,pressing heart out chest the lower l/3 of the breast bone,120 pem,every pressing 3 ti

33、mes,should supply pressurize oxygen once.Press about l 一2 cm dept,the finger shouldnt left the pressing location；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 1/3 1/3处，其他手指 处，其他手指绕胸廓托在背后 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、食指指端垂直压胸骨下 骨下 1/3 1/3处，左手托患儿背部 处，左手托患儿背部The way of double fingersThe way of double fi

34、ngers 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

35、resuscitaing;the baby heart rate is 80-100 pem and doesnt increase to follows；suspect diagnosis of diaphragmatic hernia.anatomic landmark for put in laryngoscopetracheal intubation 4.medicine assisting resuscitation alkali therapy adrenalin therapy vasoactive agent therapy dopamine 3-5ug/kg.min Hepa

36、rine therapy 20-30u/kg.d,H,tid naloxone anti-morphinum and inhibition of HIE.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 an

37、d defecation,infection and feeding etc.出生是否足月？是否羊水清？是否有呼吸和哭声？是否肌张力好？保温 摆正体位，通畅气道 擦干,刺激,重新摆正体位评价心率、呼吸和肤色常压给氧常规护理 保温 必要时通畅气道 擦干观察护理是正常呼吸心率 100 及 肤色红润否紫绀肤色红润2006 NRP 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正压人工呼吸 正压人工呼吸 胸外按压给

38、肾上腺素 和/或 扩容复苏后护理 呼吸暂停 HR 100 及 皮肤红润HR 60HR 60*在某些步骤可考虑气管插管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

39、循环往复，至完成复苏遵循六、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.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.thank you listening！