Approach to the Cyanotic Infant
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Transcript Approach to the Cyanotic Infant
Approach to the Cyanotic Infant
Billie Parsley
Goals
Recognition of a cyanotic infant
What to do in any setting from ICU to rural
community pediatric practice
What questions to ask
What to look for
What imaging to order
What test to order
Case
39 week male born at home in uncomplicated
vaginal delivery
Presented at ACH ED 24 hours old due to temp of
35.1 rectal
Sats in 50s, HR 100, RR 80, BP 76/59
Cyanotic on general appearance
What is cyanosis?
Cyanosis is a bluish discoloration of the tissue that results
when the absolute level of reduced hemoglobin (when
not combined with oxygen) in the capillary bed exceeds
3 g/dL. The appearance of cyanosis depends upon the
total amount of reduced hemoglobin rather than the
ratio of reduced to oxygenated hemoglobin.
Cyanosis
Two mechanisms result in cyanosis:
Peripheral cyanosis
Normal systemic arterial oxygen saturation and increased
tissue oxygen extraction that leads to a widened systemic
arteriovenous oxygen difference of >60% (normal 40%)
resulting in an increased concentration of reduced
hemoglobin on the venous side of the capillary bed.
Central cyanosis caused by systemic arterial oxygen
desaturation
Don’t confuse central cyanosis with acrocyanosis!!!!
Acrocyanosis-common physical finding in newborns as a
result of peripheral vasoconstriction
Cyanosis
Best indicator is the tongue-due to free of
pigmentation and has rich vascular supply.
Also seen in lips, nails, earlobes, mucous
membranes
Cyanosis
Depends on multiple
factors
Hemoglobin
Fetal hemoglobin
Skin Pigment
Factors affecting the
hemoglobin dissociation
curve
Cause
Alveolar hypoventilation
Nml response is hypercarbia but can also cause hypoxemia
Ventilation Perfusion mismatch
Nml is for areas with decreased ventilation to have decreased
blood flow, but alterations in this cause hypoxemia
Diffusion Impairment
Oxygen molecules must diffuse from alveoli to pulmonary
capillary to oxygenate hemoglobin
Right to Left Shunt
Systemic venous blood bypasses ventilated alveoli and returns to
the left heart without being oxygenated
Disturbed Hemoglobin
Decreased oxygen affinity
History
Pregnancy
Maternal Diabetes-associated with cyanotic heart dz.
Polyhydramnios-associated with fetal airway, esophageal,
neurologic abnormalities
Oligohydramnios-associated with renal defects and
pulmonary hypoplasia
Drug Use during pregnancy
Maternal Serology
US results
Previous complications with pregnancy (stillborn/multiple
spontaneous abortions)
Medication Use during pregnancy
History
Perinatal/Peripartum
Gestational Age
Prolonged/Premature Rupture of Membranes
What/How treatment given for illness during pregnancy
(GBS)
Maternal fever
Birth Trauma
Neonatal polycythemia
Hypoglycemia
Meconium Staining-associated with Meconium Aspiration
syndrome and P-HTN
Hospital course post delivery
History
HPI
Fever
Exposure
Trauma
Well water
Seizure
Poor Feeding
Decreased urine output
Medications
Different Temperatures between extremities
Cough/Congestion
Rashes Changes in skin
“birth marks”
Abnormal breathing-pauses in breathing
Weight loss or gain
Edema
History
Diet
What (could mom be taking in meds that get into
breastmilk)
How long does it take?
Perspiration with feeds
Coughing/Gagging/Gurgling with feeds
Medications
Family History
Hemoglobinopathies
Congenital Cardiac Abnormalities
Cystic Fibrosis
Neuromusclar Disorders
Physical Exam
*The presence and degree of respiratory distress are very important
factors in differentiating your 2 main causes of Cyanosis-Cardiac vs.
Respiratory
General exam: Comfort, WOB, LOC, Color,
Head: Fontanel, Shape of Head, eccymosis, lacerations, Pupils, nose
shape and location, shape of chin and size, mouth size, moisture, cleft
palate,
Neck: size of vessels, abnormal masses
Abdomen: HSM, ascities,
Skin: Rashes, birthmarks , mottled, slate gray color associated with
methemolglobinemia
Limb abnormalities
Physical Exam
Respiratory Exam
Respiratory Rate (newborn nml 40-60)
Low RR-alveolar hypoventilation
Tachypnea-Cardiac or Pulmonary cause
Regularity of RR
apnea events
Grunting (prevents end expiratory alveolar collapse)
Nasal flare (reduces nasal resistance)
Stridor
Tracheal Deviation
Chest wall movement
Retractions
Accessory muscle use
Auscultation
Physical Exam
Cardiac Exam-not as severe respiratory distress
Heart Rate
Pulses
Perfusion
Auscultation
Four Extremity Blood Pressure
Pre/Post Ductal oxygen Saturation
Point of Maximal Impulse
Labs
ABG-for arterial oxygenation
Painful and can cause increasing agitation
Methemoglobinemia oxygen saturation will be low but measured PO2
will be normal
Elevated arterial PCO2 suggest pulmonary cause
Metabolic acidosis indicates poor perfusion-possible due to poor
cardiac output or oxygen delivery or shock.
CBC
Can show high hgb/hct in polycythemia
I/T ratio
Blood glucose
Blood Culture
Imaging
Trauma
Airway
Situs of heart, stomach, liver-any abnormalities in
location point towards cardiac disease
Heart size and shape
Lung fields
Vascular Markings
Decreased vascular markings can be seen in cyanotic
cardiac lesions and pulmonary hypertension
Other Test
Hyperoxia testing—Right radial artery PaO2
(preductal) measured on RA and after 10 minutes
on 100%FiO2
if right radial arterial PaO2 on 100% FiO2 is less
than 150mmHg, severe congenital heart disease is
likely. The infant is presumed to have ductal
dependant congenital heart disease and the low
PaO2 is attributed to the obligatory mixing of
oxygenated with deoxygenated blood within the
circulatory system.
Other Test
Echo
Transposition
Tetralogy of Fallot
Truncus arteriosus
Total anomalous pulmonary venous Return
Tricuspid
“Tons” of others
EKG
Managment
ABCs
Access-venous and arterial if possible
Ventilation as needed
Cautious fluid resuscitation
Antibiotics
Prostaglandin Infusion
Prostaglandin
Goal is to prevent closure of the PDA if this is where
mixing is occurring.
Improvement normally seen within 1-2 hours
Side effects: APNEA and peripheral vasodilatation
with hypotension
Case Review
Mom GBS + treated with oral clindamycin
Baby with severe Pulmonary HTN with near
systemic pressures
By 48 hours of life on ECMO on way to Edmonton