Cyanosis in newborn

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CYANOSISBy

P.Padma Priyanka

Contents Introduction

Factors affecting detection of cyanosis

Etiology

Types

Cardiac vs pulmonary

Approach

Conclusion

Introduction Cyanosis is the bluish discoloration of the skin and

mucous membranes due to increased concentration of

reduced hemoglobin to about >5g/100 mL in the

cutaneous veins

Desaturation of arterial blood

Increased extraction of oxygen by peripheral tissue in

the presence of normal arterial saturation

Detected –lips,fingernails,oral mucous

membranes,conjuctiva and tip of tongue

Factors affecting detection of

cyanosis in newborn

Hemoglobin concentration

Fetal hemoglobin

Skin pigmentation

Hemoglobin

concentration

The arterial oxygen saturation level at which cyanosis is detectable at different total hemoglobin concentrations is illustrated above. The

solid red portion of each bar represents 3 gm/dL reduced hemoglobin.

Fetal hemoglobin

The oxygen-dissociation curve of human blood and the effects of changes in the H+ ion concentration, Pco2 temperature and level of

2, 3-diposphoglycerate (2,3-DPG) are depicted above. For fetal hemoglobin, the normal curve (a) is shifted to the left (b).

Skin pigmentation Less apparent in the skin of babies with darker

pigmentation.

Examination should include the nail beds, tongue,

and mucous membranes, which are less affected by

pigmentation.

Cyanosis

Pulmonary

Central CNS depression

Local

Ventilation-perfusion mismatch

Alveolar hypoventilation

Diffuse impairment

Cardiac

Increased pulmonary vascularity

Decreased pulmonary vascularity

Hemoglobi-nopathies

Ventilation/perfusion mismatch

Airway disease: transient tachypnea of the newborn

(TTN), respiratory distress syndrome (RDS),

pneumonia, aspiration (meconium, blood, amniotic

fluid), atelectasis, diaphragmatic hernia, pulmonary

hypoplasia, pulmonary hemorrhage, CCAM

Extrinsic compression of the lungs: pneumothorax,

pleural effusion, hemothorax,

Alveolar hypoventilation CNS depression: asphyxia, maternal sedation,

intraventricular hemorrhage, seizure, meningitis,

encephalitis

Airway obstruction: choanal atresia, laryngomalacia,

Pierre Robin syndrome

Neuromuscular disease: phrenic nerve inury, neonatal

myasthenia gravis

Diffusion impairment Pulmonary edema: left-sided obstructive cardiac

disease, cardiomyopathy

Pulmonary fibrosis

Congenital lymphangiectasia

Cardiac causes Decreased pulmonary blood flow-

Tetralogy of Fallot

Tricuspid valve anomaly

Pulmonary valve atresia

Critical valvular pulmonary steanosis

Increased pulmonary blood flow-

Transposition of great arteries

Truncus arteriosus

Total anomalous pulmonary venous connection

Cardiac causes- "five Ts" of cyanotic CHD: Transposition of the great arteries Tetralogy of Fallot Truncus arteriosus Total anomalous pulmonary venous connection Tricuspid valve abnormalities.

A sixth "T" is often added for "tons" of other diseases, such as double outlet right ventricle, pulmonary atresia, multiple variations of single ventricle, hypoplastic left heart syndrome, or anomalous systemic venous connection (left superior vena cava connected to the left atrium).

Hemoglobinopathies Hereditary < exposure to toxic substances

>15%- cyanosis

>70% -lethal

Remain chocolate brown-even with full oxygenation or

long exposure to room air

Central cyanosis

Inadequate alveolar ventilation

CNS depression

Inadequate ventilatory drive

Obstruction

Structural changes

Muscle weakness

Desaturated blood bypassing alveolar units

Intracardiac R-L

Intrapulmonary shunt

Pulmonary hypertension with R-L shunt

Peripheral cyanosis

Peripheral cyanosis, involves a bluish discoloration of the

skin but sparing of the mucus membranes & tongue. In this

type, a normal PaO2 value is detected

Increased oxygen extraction due to sluggish movement

through the capillaries leads to increased deoxygenated

blood on the venous side

Vasomotor instability,vasoconstriction caused by cold, low

cardiac output, venous obstruction, elevated venous

pressure and polycythemia

Acrocyanosis Bluish discoloration of fingers seen in neonates and infants

due to vasoconstriction as a result of transient hypothermia

No clinical significance unless associated with circulatory shock

Circum-oral cyanosis Healthy child with fair skin due to sluggish blood flow

with vasoconstriction

No clinical significance unless associated with low

cardiac output

Cardiac vs Pulmonary Hyperoxiatest-

Response of arterial PaO2 to 100%oxygen inhalation

Result in PaO2 Disease

>100mm Hg Lung disease

Large pulmonary blood flow

(TAPVR)

<100mm Hg Massive intra-pulmonary shunt

with normal heart

<10-30mm Hg increase

(<100)

Intra-cardiac right to left shunt

Approach to cyanotic neonate

Antenatal history

Fetal ultrasound scans- congenital heart disease,

diaphragmatic hernia and congenital cystic

adenomatoid malformation (CCAM).

Family history of CHD

Physical examination Vitals

R/o choanal atresia

Respiratory system

Cardiovascular system

Abdomen

Neurological disorders

Vitals Vital signs-

signs of respiratory distress such as tachypnea,

retractions, nasal flaring & grunting usually indicate a

respiratory problem

congenital heart disease is often accompanied by absent

or effortless tachypnea.

Sepsis often has the following findings: peripheral

cyanosis, HR, RR, BP, / temp

R/o choanal atresia

Cyanosis decreases during crying

Confirmed by failure to pass a soft No. 5F to 8F

catheter through each nostril

Respiratory system Inspiratory stridor-

upper airway obstruction

Chest-

Asymmetric chest movement combined with severe

distress-

alarming sign for tension pneumothorax, diaphragmatic

hernia

Transillumination of the chest-

Pneumothorax

Cardiovascular system A systolic murmur audible in most forms of cyanotic

CHD (exception: d-TGA with intact ventricular septum &

no pulmonary stenosis).

Respirations often are unlabored unless there is

pulmonary congestion or complicated by the

development of heart failure or acidosis, which will

affect the respiratory pattern

Per abdomen Scaphoid abdomen-congenital diaphragmatic hernia

Neurological disorders Observe for apnea and periodic breathing, which may

be related to immaturity of the nervous system.

Seizures can cause cyanosis if the infant fails to

breathe during the episodes.

Investigations • CBC

• Serum glucose

• ABG

Chest X-ray films,ECG

Arterial PaO2 in preductal and postductal arteries

Hyperoxitest

CBC & diff :

or WBC sepsis

hematocrit > 65% polycythemia

Serum glucose: to detect hypoglycemia

Arterial Blood Gases (ABGs):

Arterial PO2: to confirm central cyanosis SaO2 not as good an indicator due to fetal Hb affinity for O2 (left-shift)

PaCO2: may indicate pulmonary or CNS disorders, heart failure

pH: sepsis, circulatory shock, severe hypoxemia

Methemoglobinemia: SaO2, normal PaO2, chocolate-brown blood

X-ray -Increased pulmonary

vascularity RVH on ECG

D-TGA

TAPVR with obstruction

DORV with subpulmonary VSD

PPHN

LVH/BVH on ECG

Persistent truncus arteriosus

Single ventricle

TGA and VSD

Polysplenia syndrome

X-ray -Decreased pulmonary

vascularity RVH on ECG

TOF

DORV with PS

Asplenia syndrome

RBBB on ECG

Ebstein’s anomaly

LVH on ECG

Pulmonary atresia

Tricuspid atresia

BVH on ECG

TGA and PS

Persistent truncus arteriosus

Single ventricle and PS

Total Anomalous Pulmonary Venous

Return

Snowman

Tetralogy of Fallot

Boot shape

Transposition of Great

Arteries

Egg on a string

Arterial PaO2 in preductal and

postductal arteries Right upper body-radial,brachial,temporal

Umbilical artery line

PaO2 should be compared

Right radial-umbilical artery=>10-15 mm Hg

Differential cyanosis In severe R-L ductal shunt

Pink-upper and cyanosed-lower

Causes

PPHN

Severe AS

Interrupted aortic arch

Coarctation of aorta

Initial management Monitor Airway, breathing, circulation (ABCs)

with respiratory compromise, establish an airway &

provide supportive therapy (e.g., oxygen, mechanical

ventilation)

Monitor Vital signs

Establish vascular access for sampling blood &

administering medicatons(if needed)

umbilical vessels convenient for placement of intravenous

& intra-arterial catheters

If sepsis is suspected or another specific cause is not

identified, start on broad spectrum antibiotics (e.g.,

ampicillin and gentamycin) after obtaining a CBC,

urinalysis, blood & urine cultures (if possible). Left

untreated, sepsis may lead to pulmonary disease & left

ventricular dysfunction.

Secure a separate intravenous catheter to provide

fluids for resuscitation and ensure accessibility of

intubation equipment should they be required.

Prostaglandin E1 infusion Prostaglandin E1

For cyanotic CHD/duct dependent cardiac defect

Infusion of prostaglandin E1 at a dose of 0.05-

0.1mcg/kg/min intravenously

Increase PaO2,increase systemic blood

pressure,improved pH-tapered 0.01mcg/kg/min

No effect-increased upto 0.4mcg/kg/min

Side effects-apnea(12%),fever(14%),flushing(10%)

Less common side effects-

tachy/bradycardia,hypotension,cardiac arrest

Cyanosis

Pulmonary

Central CNS depression

Local

Ventilation-perfusion mismatch

Alveolar hypoventilation

Diffuse impairment

Cardiac

Increased pulmonary vascularity

Decreased pulmonary vascularity

Hemoglobi-nopathies

System Causes Clinical findings

CNS depression Perinatal asphyxia

Heavy maternal sedation

Intra uterine fetal distress

• Shallow irregular respiration

• Poor muscle tone

• Cyanosis disappears when

patient is stimulated or O2

given

Pulmonary disease Parenchyma

Pneumothorax or pleural

effusion

Diaphragmatic hernia

PPHN

• Tachypnea, respiratory

distress with retraction and

expiratory grunt

• Crackles or decreased

breath sounds

• X-ray findings

• Improve/abolish with oxygen

inhalation

Cardiac disease Cyanotic CHD with R-L shunt • Tachypnea without

retractions

• lack of crackles/abnormal

breath sounds

• Continuous murmur(PDA)

• X-ray findings

• Little/no increase with O2

Conclusion Central cyanosis in a newborn is an abnormal finding and

one must consider all of the possible etiologies with a complete history, physical examination and relevant investigations.

Remember to think about the various mechanisms causing cyanosis and go through each systematically until you have your diagnosis.

Prompt management should be undertaken while you are trying to figure out your diagnosis.

For ductal dependent lesion, start prostaglandin E1 and early referral

Thank You

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