Approach to Cyanotic Neonate in NICVD.pptx

Ward case

1. A CYANOTIC NEONATE Dr. Muhammad Asif Khan Post Fellow Pediatric Cardiology NICVD Karachi.

2. Objectives: To identify a cyanotic neonate and differentiate cardiac causes from non cardiac causes. Know how to investigate When and how to refer

3. Case scenario 1 A 2 days old baby weighing 3 kg was found cyanosed by the nurse in the postnatal ward. He was delivered via normal vaginal delivery at term gestation. His APGAR score was 8 at 1 min and 10 at 5 min .

4. Clinical Exam: No dysmorphic features. His lips, tongue and extremities were cyanosed. CRT 2sec. Vitals: HR. 140 b/m, RR. 50 br/m , Temp: 99.4 F. O2 sats: 45 % No signs of respiratory distress

5. Initial approach…. Give oxygen I/V access and start fluids Check RBS Order ABGs, CXR, send septic workup

6. RBS 80 mg/dl CXR. Normal ABG. PH 7.2, PCO2 30, PO2 40, HCO3 16,O2% 40. on room air .

7. Hyperoxia test done After giving 10 liters oxygen via head box for 10 minutes. O2 sats: 50% ABG. PH 7.3, PCO2 30, PO2 70, HCO3 18, O2% 50 .

8. Management

9. Oxygen should be administered for severe hypoxia. Oxygen may help lower pulmonary vascular resistance and increase PBF, resulting in increased systemic arterial oxygen saturation. Correction of acidosis Treatment of hypoglycemia Treat infection

10. Role of PG E1. Indications : Cyanotic newborn suspected to have duct dependent lesion Echo proven duct dependent lesion Dose : 0.01 – 0.2 mcg / kg /minute I.V infusion Side effects: Apnea, hypotension, seizures

11. ECG. Rate 160, Sinus rhythm, Right axis, upright T wave in V1 {RVH} ECHO: S.D.D, AV concordance VA discordance. Intact ventricular septum. Small restricted PFO, tiny PDA. Complete transposition of great vessels Oxygen saturations improved to 65% due to prostaglandin infusion.

12. Balloon Atrial s eptostomy Before surgery, a balloon atrial septostomy (i.e., the Rashkind procedure) are often carried out to establish Right to left shunt .

13. Case scenario 2. A 10 hours old baby weighing 2kg referred from gyanae ward with respiratory distress and bluish discoloration. He was delivered via normal vaginal delivery at term gestation. His APGAR score was 5 at 1 min and 6 at 5 min and 8 at 10 min.

14. Clinical Exam: No dysmorphic features. He was in severe respiratory distress. CRT 2sec. Vitals: HR. 180 b/m, RR. 70 br /m, Temp: 100 F. O2 sats: 55 %

15. Initial approach…. Give oxygen I/V access and start fluids Check RBS Order ABGs, CXR, send septic workup

16. RBS 80 mg/dl CXR. Normal ABG. PH 7.2, PCO2 40, PO2 50, HCO3 16, O2 % 55 . on room air

17. Hyperoxia test done: After giving 10 litres oxygen via head box via head box. O2 sats: 85% ABG. PH 7.3, PCO2 40, PO2 100 , HCO3 18, O2 % 90.

18. ECG. Rate 180, Sinus rhythm, Right axis, ECHO: S.S, Levocardia , AV and VA concordance, PFO with right to left shunt, PDA with right to left shunt. PG across tricuspid valve 50 mmHg. Final Diagnosis. PPHN

19. Therapeutic Goals Arterial blood gas values pH 7.45 -7.55 PaO2 50-100 torr PaCO2 25-40 torr Maintain Systemic blood pressure Treatment Ensure adequate oxygen carrying capacity. Maintain hematocrit greater than 40% Medication Tolazine ( Priscoline )- Dopamine or Dobutamine to maintain systemic blood pressure and to increase CO Nitric Oxide (NO),Potent pulmonary vasodilator PGE1 also may be given

20. Alkalizing agents -sodium bicarbonate Antifailure treatment Mechanical ventilation Hyperventilation ECMO Extra corporeal membrane oxygenation Form of cardiorespiratorys upport that allows the lungs to rest ECMO has increased survival rate significantly 20

21. Approach ?

22. Approach Confirm central c y an o s is Pulse oximetry (preductal and po s t du c tal) Clinical e v alua tion Blood gas analysis

23. CARDIAC VS NON CARDIAC

24. Cardiac Tachypnea, no/less distress Crepts -, Cyanosis variable/uniform No/ minimal response to oxygen , Usually after 24 hours Respiratory Tachypnea with distress Tachycardiac Crepts +, Cyanosis mild/uniform response to oxygen Usually at birth with in 24 hours

25. WHAT ELSE TO DO?

26. Hyperoxia Test Infant on Room Air, get ABG Infant on 100% oxygen, get ABG PaO 2 unchanged = fixed shunt = CCHD Max PaO 2 <100 = CCHD Max PaO 2 >200 = No CCHD

27. INTERPRETATION OF ABGs

28. Cardiac ABG Low PH Normal or low PaCO 2. PaO2 < 100 mmHg/ Rise < 10 – 30mm Hg M etabolic acidosis predominantly

29. Non Cardiac ABG Low PH Elevated PaCO 2. PaO2 >250 mmHg after hyperoxia test. Respiratory acidosis predominantly

30. THANK YOU