BIRTH ASPHYXIA and organs failure

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BIRTH ASPHYXIAand organs failure

• BY
• SUPPAWAT BOONKASIDECHA MD.
• NEONATAL DIVISION
• DEPARTMENT OF PEDIATRICS

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BIRTH ASPHYXIA

• ?????????
• ???? Perinatal ?????????????????????? O 2
  ?????????
• 90 Intrauterine and perinatal
• 10 Post natal
• ?????? O2 ???? Perinatal ??????????????
  ??????????????????????????
• Cerebral palsy ??????? Asphyxia ??? 90
  ( Nelson KB, Clin. Perinatal 1989 )

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• Definition Perinatal asphyxia
  ??????????
• 1. ???????? O2 ( hypoxemia )
• 2. CO2 ??? ( hypercapnia )
• 3. ????????????????????? pH, HCO3, Base
  deficit Intrauterine asphyxia
• HR. ???????????????????
• Late deceleration
• Fetal scalp blood pH at 1 ???? lt 7.19

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Apgar score and asphyxia
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INCIDENCE
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???????????????????? Asphyxia
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Pathophysiology
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?????????????????????
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??????????????????
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Hypoxic ischemic encephalopathy(HIE)

• ???????????????????????????????????O2
  ??????????????
• Mild hyperalertness irritability
• Moros and DTR
• mild hypotonia
• rare apnea or seizure
• recover in 48 72 hrs

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HIE

• Moderate
• hypotonia DTR
• apnea seizure
• hypoactive after 72 hrs
• abnormal sucking swallowing
• recover in 1 week

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HIE

• Severe
• hypoactive to coma
• hypo or hyperventilation
• apnea ,early refractory seizure
• severe hypotonia
• severe neurological deficit

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MANAGEMENT OF
POST ASPHYXIAL SYNDROME
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AIM OF MANAGEMENT
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• ????????????????
• I Supportive care -
• Temp Vital and neuro signs
• RR keep paO2 60 90, pCO2 30-35
• Reoxygenation and reperfusion theory
• BP and circulation
• MAP ?????? GA ( in 1st day to 1st wks )
• Metabolic management
• Fluid management restrict fluid ?????
  Oliguria IWL U/O Extrarenal loss

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????????? HIE
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PROGNOSIS
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(No Transcript)
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EEG
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Cranial U/S or CT Brain
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Heart failure

• ??????????????????????????????????????????????????
  ???????????
• ?????? ?????? ??????? ???????????
• ???????????????????????
• ????? ??????????????????????
• Ductus arteriosus dependentcyanotic heart dz-
• AS PS PA Coarctation

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?????????????????

• ????????????????????????????
• ????????? ?????????????
• Cardiomegaly hepatomegaly
• Hyperactive precordium
• Crepitation or rhonchi
• hypotension

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????????????

• Supportive care -
• Vital signs I/O BW
• Oxygen therapy except Ductus arteriosus
  dependent
• maintain BP and circulation
• Metabolic management
• Fluid management restrict fluid salt and
  diuretics if clinical heart failure indicated

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????????????

• ?????????????????????
• Medications
• - inotropic drugs dopamine dobutamine
• - sedative drugs MO
• systemic venous capacitance
• blood volume to lung
• LA pressure

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Acute renal failure

• ??????????????????????????????????????????????????
  ???
• ???????? ?????????????????waste product BUN / Cr
  
• oliguria and polyuria
• Associated with perinatal hypoxia and hypovolemia
• Hemmorhage sepsis shock and nephrotoxic drugs
• Congenital anomalies
• Prerenal , renal , post renal causes

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Fractional excretion of Na

• Renal Fn cant assess by urine flow rate alone
• FeNa UNa x plasma Cr /Plasma Na x UCrx100
• The best discrimination parenchymal injury and
  hypoperfusion
• If FeNa lt 1 indicate hypoperfusion
• If FeNa gt 2.5 indicated renal injury

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????????????

• ????????????????????????????????????????????????
• Total fluid ISL U/O extrarenal loss
• ISL term 30 cc / kg / day
• ISL preterm 50-70 cc / kg / day
• ?????????????????????????????????? ??????????
  ??????urine
• ???????????????? ???????????? ????
  ???????????????????????????????????????????????
  ????metabolic acidosis
• Adequate nutrition and proper protein intake

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Acute respiratory failure

• To support or improve pulmonary gas exchange
• Alter pressure volume relation
• reverse hypoxemia and acute respiratory
  acidosis
• reverse atelectasis and improve lung function
• lung and airway healing eg. post op
• To reduce respiratory distress or work of
  breathing

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Clinical objectives

• Decrease myocardial oxygen demand
• Reduce intracranial pressure (ICP)
• Stabilize chest wall, e. g. flail chest

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Type of mechanical ventilators

• Positive pressure ventilators
• Pressure-cycled
• Volume-cycled
• Time-cycled
• Flow-cycled
• High frequency ventilators High frequency Flow
  interrupters, High frequency Jet and High
  frequency
• Oscillator

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Oxygen Concentration

• Set FiO2 high initially to ensure PaO2 gt 60 mm Hg
  
• Use lowest FiO2 to maintain SaO2 gt 90
• FiO2lt 50 probably safe

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Tidal Volume

• Use lower VT (4 to 7 ml/kg) to avoid volutrauma
  to the lung (minimal or gentle ventilation )
• Higher VT 10 to 15 ml/kg to prevent atelectasis
  but risks volutrauma
• Permissive hypercapnia

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Ventilator Rate

• IMV - rate usually set high initially and then
  weaned as tolerated
• CMV - backup rate should be 4 breaths less than
  patients rate
• No rate set with pressure support

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PEEP and CPAP

• PEEP prevents atelectasis at end of expiration
  and FRC
• CPAP similar except positive pressure continuous
  during inspiration

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PEEP

• Recruitment of atelectatic alveoli
• Reduction of intrapulmonary shunt by
  redistribution of lung edema from alveoli to
  interstitial space
• Permit use of lower FiO2
• PEEP does not prevent ARDS

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PEEP Recruitment of atelectatic alveoli
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PEEP

• PEEP can drop cardiac output by
• Venacava compression
• Alveolar distension compresses alveolar vessels
  increasing PVR and RV afterload
• LV compliance decreased by increased juxtacardiac
  pressure from lungs

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Modes of Positive Pressure ventilation An
Overview

• Controlled mandatory ventilation
• Required heavy sedation
• Use primarily in OR
• Assist control ventilation
• More comfortable but difficult to waen
• Intermittent mandatory ventilation (IMV)
• Comfortable and allows weaning
• Pressure support (PSV)

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Assist-control mechanical ventilation AC)

• Ventilator delivers volume or pressure after
  patient triggers
• every breath trigger.
• No spontaneous breaths allowed
• Back up rate setting when patient trigger rate
  lower than setting rate.

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Intermittent mandatory ventilation (IMV)

• Patient receives periodic positive pressure
  breaths from ventilator at a set TV or pressure
• Spontaneous breaths allowed in between machine
  breaths
• Asynchronized ventilation

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Synchronized Intermittent mandatory
ventilation (SIMV)

• Patient receives periodic positive pressure
  breaths from ventilator at a set TV or pressure
  (window time frame)
• Spontaneous breaths allowed in between machine
  breaths
• Synchronized ventilation

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(No Transcript)
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Flow cycled Assist-control (Flow cycled AC)

• Alter time-cycled to flow - cycled
• Total synchronized both inspired and expired
  phases

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High frequency ventilators

• High frequency Flow interrupters
• High frequency Jet and
• High frequency Oscillator active both inspired
  andexpired phases

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High frequency ventilators

• respiratory rate gt 120 /min (2 Hz )in neonate or
• respiratory rate gt 150 /min (2.5 Hz ) FDA
  definition
• Tidal volume lt dead space volume
• Minute ventilation tidal volume2 x rate

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High frequency ventilators

• Decrease BPD at 36 wks postconceptional age
• In RDS and air leak syndrome rescue treatment
• when compared to CMV ( multicenter trial )
  Cochrane
• Decrease ECMO treatment in RDS and rescue Rx

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Advantages

• Uniform lung function
• Improve ventilation at lower barotrauma and
  volumtrauma
• CO2 elimination depend on tidal volume gt
  frequency
• Oxygenation depend on lung volume Paw (MAP )

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Disadvantages

• may increase incidence of inadvertent peep to
  overinflation( due to short Te )
• Then Ti should lt 50 ( Sensor Medics ) Alexander
  et al
• Hemodynamic compromise
• But Goodman et al found that no significant
  difference

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conclusions

• Clinician must not to be sediced by exciting
  preliminary evidence.
• Early HFOV and new modes study would have
  advantages over conventionalBut these were not
  confirmed by meta-analysis study.
• Proved efficacious in appropiated design study
• Long term F/U fpr adverse outcome.

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• THANK YOU