课件：英新生儿窒息与新法复苏.ppt

,Neonatal Asphyxia and its New Concept on Resuscitation,Chongmin Xu Dep.Newnates Union Hospital,New Words pregnant woman invalid Apgar score umbilical cord primary apnea asynersis HIE ( hypoxic-ischemic encephalopathy) ICH (intracranial hemorrhage) MOD (multiple organs function damage) hypercapnia hypoxemia,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.,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.,Delivery factors,Placenta factor,Fetal factor,umbilical cord factor,Pregnant woman,Asphyxial etiopatho-genisis,too older or young,Respiratory disease,cardiac disease,severe anaemia,Smoking & drug,gestational hypertension,Pregnant woman factor,polycyesis,diabetes,placenta praevia,placental abruption,infarctus,ageing,short cord,knot of umbilical cord,umbilical hang down,umbilical cord circle neck,胎儿因素,premature,large for date infant,intrauterine infection,respiratory tract obstruction,congenital cardiopathy,congenital abnormality,foetus factor,sucking fetal head,forceps aid deliver,breech presentation,unsuitably use drugs in labor,labor extension & precipitate labor,cephalopelvic disproportion,deliver factor,Pathophysiology,Switch of respiration & circulation from fetus to newborn are blocked Breath alter 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 functionality,Normal fetus transform to neonate in respiration & circulation,Blocked switch of respiration & circulation from fetus to newborn,Asphyxia Respiration ceases or inhibit,alveolar ectasia ,Hypoxia, acidosis,Sas secretesactivity,pulmonary fluid removes ,Fetal circulation reopendurative PHT,Constitution hypoxia, ischemia and acidosis,Inconvertible damage of organs,pulmonary vascular resistance,Hypoxia-ischemia alter in difference organs as asphyxia,缺O2,PH,PaO2,PaCO2,潜水反射 血液再分配,无氧酵解,低血糖,儿茶酚胺,血钙,心纳素,抗利尿激素,细胞膜,钠泵,钙泵,钙离子内流,高血糖,肠,血钠,NEC,肾,肾V血栓 肾功能衰竭,肾上腺,脑,缺O2 加重,压力被动 性脑血流,体循环压,体循环压,颅内出血,HIE,脑血流灌注,大脑半 球血流,矢状旁 区及其 下白质 受损PVL,心脏,肺A压,心功能受损,心衰,休克,PFC,缺O2 加重,血液高凝,DIC,Breath alter 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 ),blood gas PaCO2，PH & PaO2mixed acidosis Glucose metabolic disorder catecholamine & glucagon release earlyblood sugar normal or then glycogen depletion, blood sugar Hyperbilirubinemia Bilirubin combine with albumin、the vigor of liver enzymeunconjugated bilirubin Hyponatremia atrial natriuretic peptide, ADH is parasecretiondiluted hyponatremia Hypocalcemia calcium channel open、calcium pump dysfunction calcium influx ,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 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.,Asphyxia diagnostic code AAP(美国儿科学会) & ACOG(妇产科学会)1996,Blood in arteria umbillicalis shows severe metabolism or mixed acidosis, pH7 Apgar score is 03 points, and persistence time5min. Nervous system manifestation, such as convulsion、coma or muscular tension low etc. MOD,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 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 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.,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.,Systems damaged by Asphyxia in perinatal period damage central nervous system hypoxic-ischemic encephalopathy, intracranial hemorrhage, encephaledema urinary system glomerular filtration rate and/or tubular reabsorption function damage, renal tubular necrosis, renal failure cardiovascular system mitral insufficiency, myocardiolysis, cardia failure，shock respiratory system pulmonary hypertension, meconium aspirated pneumonia, alveolus surface active substance decrease metabolism acidosis, hypoglycemia, hypocalcemia, ADH secrete increase digestive system stress ulcer，NEC (necrotizing enterocolitis), liver functional lesion skin subcutaneous fat necrosis hematological 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, blood 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 operation, 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 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 within 30 seconds after birth.,The first resuscitation step,keep warm,wipe dry,tactile stimulus,clear airway,complete within 30 second after birth,correct posture,2. ventilating resuscitation procedure if the baby has already normal breath and heart rate100 pem, the skin is red, just observe him. if he has no 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 carry out pressing heart from out-chest for 30 seconds, if no respond, should give 1：10000 adrenalin 0.1-0.3mlkg 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 baby naloxone 0.1mgkg 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 times, should supply pressurize oxygen once. Press about l一2 cm dept, the finger shouldnt left the pressing location；, 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.,anatomic landmark for put in laryngoscope,tracheal intubation,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.,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.,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;109:117 Reddy VK et al. Clin Pediatr 1999;38:87 Toth 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,给肾上腺素 和/或 扩容,复苏后护理,呼吸暂停 HR 100,持续性紫绀,有效通气 HR 100 及 皮肤红润,HR 60,HR 60,H