Asphyxia of the newborn

Asphyxia of the newborn - terminal state due to the violation of gas exchange, characterized by a lack of breathing or its sharp weakening (irregular or shallow breathing) with stored or suppressed cardiac activity.

In a healthy newborn, regular breathing should be established no later than 60 seconds after birth, and after 5 minutes should be 40-60 per 1 minute.

The volume of each inspiration (respiratory volume) is equal to an average of 30 ml, the minute volume of respiration fluctuates within 500-1200 ml. Oxygen tension in capillary blood is 8.0-1067 kPa, pCO2 is 4.0-6.0 kPa.

Lack of breathing during transition from intrauterine to extrauterine existence. leads to acute oxygen deficiency - a violation of the supply of oxygen to tissues and the release of carbon dioxide from the body. This causes the need for emergency resuscitation, and further intensive therapy to eliminate posthypoxic effects and metabolic disorders in the early neonatal period.


Directly to asphyxia of newborns lead:



- Intratinal hypoxia in healthy women, which most often occurs in cases of abnormal fetal metabolism caused by an acute uterine-placental circulatory disorder (cord embossing around body parts, premature detachment of the normally located placenta, rupture of the uterus, weakness of labor, etc.);

- Some medications given to women in labor during the second stage of labor may lead to a depression of respiration in newborns (promedol, fluorotane, ether, Relanium, seduksen)

- Birth trauma (intra-cranial hemorrhage);

- Infringement of patency of respiratory tracts as a result of aspiration of amniotic fluid, meconium, blood;

- Intrauterine congenital lung aplasia, tracheoesophageal fistula, diaphragmatic hernia, atresia of the hoan, intrapulmonary hemorrhage.

In most cases, asphyxia of newborns in pregnant women from high-risk groups occurs as a result of chronic fetal hypoxia and has a common pathogenesis with it. During fights or attempts, there is a further progressive decrease in uteroplacental blood circulation, which, against the background of chronic chronic hypoxia, increases oxygen deficiency of the fetus, depletes its energy resources and is the immediate cause of asphyxiation of newborns.

In this case, acute intrapartum hypoxia, layered chronic fetal hypoxia, passes into asphyxia of the newborn and is accompanied by severe metabolic disorders in the postresuscitation period, which dictates the need for intensive therapy aimed at normalizing pulmonary respiration, cardiovascular, nervous system and metabolic processes.

Resuscitative measures and intensive therapy of newborns from high-risk groups should be strictly differentiated taking into account the features of the course of pregnancy and childbirth, the degree of hypoxia transferred, the compensatory-adaptive mechanisms and the reserve capabilities of the fetus.

Asphyxia of the newborn, as a rule, is an extension of fetal hypoxia. The system for assessing the state of the newborn was developed and proposed by Virginia Apgar in 1953 and in 1965 this system was proposed by the WHO team for all countries.

Apgar score for evaluation of the newborn's condition



Clinical sign

Score in points

0

1

2

Palpitation

is missing

less than 100 in 1 min

more than 100 in 1 min

Breathing

is missing

not regular

normal, cry

Muscular tone

is missing

easy bending of hands and feet

active movement

Reflex excitability

is missing

grimace

sneezing, coughing

Skin color

overall pallor

pink trunk, cyanosis of hands and feet

The volume of resuscitation in newborns depends on the severity of asphyxia. An Apgar score of 7 or less indicates that the newborn is in asphyxiated state.

With mild asphyxia, the score is 6-7 points, the average is 4-5 points and the severe degree of asphyxia is 1-3 points. However, in most cases, the Apgar score of 4 points and below indicates a serious condition of the child.

The Apgar score is scored twice - at the 1st and 5th minutes after birth, regardless of the gestational age and body weight of the child. In preterm infants, in addition to assessing the general condition on the Apgar scale, the severity of respiratory disorders is assessed on the Silverman-Andersen scale. During the resuscitation of newborns, it is important to take into account the dynamics of disappearance of the main signs of asphyxia. If, after 5 minutes, the condition of a newborn born in a state of asphyxia improves and the Apgar score increases to 8 points or higher, the child has a chance to be healthy.

The timely resuscitation of newborns born in asphyxia includes activities aimed at:

- Restoration of airway patency;

- Oxygenation of the body;

- Stimulation of vital vital functions - pulmonary respiration and cardiac activity.

The amount of care for a newborn depends on his condition, vital signs, absence or presence of miconia in the amniotic fluid.

In cases where the amniotic fluid in the amniotic fluid, the child is placed under a radiant heat source and dried by a dry diaper. Sucking out the contents of the mouth and nasal passages, providing maximum airway patency. In cases when spontaneous breathing does not appear, tactile stimulation is carried out by stimulation of the skin along the vertebra, soles, light strokes on the heel.

If labor is carried out with amniotic mycelial water, immediately after the birth of the head, the contents of the upper respiratory tract are suctioned. Under the radiant heat source, the trachea is intubated and the contents of the tracheohronchial tree are aspirated directly through the intubation tube. These activities must be performed in the first 20 seconds after birth. After this, the first assessment of the state of the child on the quality of breathing, heart rate, skin color is done.

The Apgar score for determining the volume of resuscitation is not applied, because it is too late - the first assessment at the end of the first minute of life. Assessment on this scale at 1 and 5 minutes serves to determine the effectiveness of resuscitation.

If spontaneous breathing is present, evaluate the heart activity of the newborn. In the absence of respiration proceed to the artificial ventilation of the lungs with 90-100% oxygen through the bag and mask.

The effectiveness of ventilation is determined by the movement of the baby's thorax and auscultatory.

After 15-30 seconds of artificial ventilation, another assessment of the child's condition is made and the heart rate (HR) is determined.

At a heart rate exceeding 100 per minute and the presence of spontaneous breathing, stop stopping the artificial ventilation (TTTVL) and assess the skin color. In the absence of spontaneous breathing - continue TTTVL before it appears. If the heart rate is less than 100 per 1 minute, TTTVL is carried out regardless of the presence of spontaneous breathing. With heart rate, which is from 60 to 100 per minute and continues to grow, TTTVL continues. In the case of an exacerbation of heart rate within 80 per minute against TTTVL, a closed cardiac massage begins, pressing on the lower third of the sternum (it is located below the conditional line between the nipples). It is important not to press the xiphoid process to prevent liver rupture.

Control of heart rate is carried out in 10-15 seconds, while its frequency will be more than 100 per minute and spontaneous breathing will not take place. In this situation, they make a last evaluation of the child's condition - assess the color of the skin. An indicator of the effectiveness of ventilation and circulation is the pink shade of the skin of the newborn.

Acrocyanosis, characteristic in the first hours after birth, develops as a vascular reaction to changes in the temperature of the environment and does not indicate hypoxia. A sign of hypoxia in a child is a common cyanosis. In such cases, the newborn requires an increased concentration of oxygen in the mixture for inspiration. This is ensured by the supply of a free jet from the oxygen hose. If the end of the hose is located at a distance of 1.0-1.5 cm from the nasal passages, the oxygen content in the air on inhalation will be approximately 80%.

The disappearance of cyanosis indicates the elimination of hypoxia. Tang gradually away from the nasal passages. Preservation of pink skin color when removing the hose by 5 cm indicates that there is no need for an increased concentration of oxygen.

In the delivery room at the resuscitation of newborns use epinephrine, funds that normalize bcc, sodium bicarbonate and an antagonist of anesthetic agents.

Adrenaline is prescribed in cases of asystole and with the preservation of heart rate within 80 per minute after 15-30 seconds of artificial ventilation of the lungs with 100% oxygen. Adrenaline is administered intravenously or endotracheally in the form of a solution of 1: 10000 sodium chloride at a rate of 0.1-0.3 ml /kg of the newborn. With an endotracheal injection, a 1: 10000 solution is further diluted 1: 1 with an isotonic solution. If there is no effect, the injection is repeated every 5 minutes (manipulation is continued for no more than 30 minutes).

Of the drugs normalizing bcc, 5% albumin solution and saline are used. It is believed that all children who need intensive care have a city of hypovolemia. Clinical manifestations of the hypovolemic state are pallor of the skin, a weak pulse with a sufficient heart rate, a decrease in blood pressure. In the case of metabolic acidosis, 4.2% sodium bicarbonate solution is slowly introduced at a rate of 4 ml /kg.

In severe anesthetic depression, the introduction of antagonists of narcotic drugs - naloxen 0.1 mg /kg or bemegrid 0.1 mg /kg.

After the resuscitation, the newborn is transferred to the Intensive Care Unit for further treatment.

Children born in asphyxia, in the intensive care unit, continue to take measures for the further restoration of vital functions (cardiac activity and respiration), the elimination of major pathophysiological disorders caused by asphyxia, in particular metabolic and electrolyte disorders, microcirculation and brain disorders. Differentiated asyndrome intensive therapy is determined by the clinical state of newborns.

Monitoring of the child's condition during the intensive care is carried out by careful clinical observation, monitor and laboratory examination. At the same time pay attention to the frequency and rhythm of breathing, the auscultation of the lungs, palpitations, the level of arterial pressure, the color of the skin, the neurological status.

Monitored EEG indices, reoelektroentsefalogramy, ECG, ultrasound examination of the brain.

In addition to a general blood test, laboratory monitoring includes assessment of water-electrolyte metabolism, acid-base state, hematocrit and blood glucose. The results of clinical and laboratory studies and a list of drugs introduced by the dynamics of body weight and diuresis are noted in the letter of resuscitation and intensive care.

In the first days of life, a regime of kuveza is created with the supply of moistened oxygen to it and the observance of rest for the newborn. All manipulations are advisable to be carried out in a kuveze.

A significant help in the fight against respiratory distress syndrome is provided by vibration massage, which regulates the contractile and temperature regimes.

According to the indications with prevailing syndrome of respiratory disorders and moderately expressed violation of hemolytic dysfunction under the control of echoencephalography, hyperbaric oxygenations are used in the KB-02 pressure chamber at an oxygen pressure of 0.3 atm for 1-2 hours.

In order to normalize the contractile activity of the myocardium, the reduction of venous return and pulmonary hypertension, the elimination of volemic disorders and hyperhydration, cardiac glycosides are administered. Indications for their use are symptoms of congestion of a small circle of blood circulation in combination with paroxysmal tachycardia (congestion in the lungs, cyanosis, dyspnea, edematous syndrome). Most often, 005% solution of strophanthin or 006% solution of Korglikona 002 ml is administered intravenously together with 10% glucose solution (10 ml).

In the absence of the effect of the use of cardiac glycosides intravenously, glucagon is injected with an infusion rate of 5-7 ml /year.

Glycosides should be used in conjunction with drugs that improve the metabolic processes in the heart muscle: 10 mg /kg of cocarboxylase intramuscularly, cytochrome C - 025% solution 1 ml, ATP - 0.5 ml intramuscularly, ascorbic acid 5% solution 1 ml.

To restore vascular tone, prednisolone (1 mg /kg) or hydrocortisone (5 mg /kg) is used. With arterial hypotension, dopamine (10 mg /kg /hv) is administered on a 10% glucose solution.

With bradycardia, 005-0.1 ml of a 0.1% solution of atropine sulfate is intravenously administered. If the bradycardia does not disappear, the injection of the drug can be repeated in combination with adrenaline.

When right ventricular failure is introduced, eufillin 2.4% solution (0.1 ml /kg).

One of the most important tasks of intensive care units is the early rehabilitation of children with hypoxic injuries to the central nervous system. Activities carried out for this purpose, aimed at combating brain edema, hemorrhagic syndrome, as well as correction of metabolic and hemodynamic disorders.

To combat hypertension syndrome, 25% magnesium sulfate solution (0.5 ml /kg) is administered.

Children who have undergone moderate and severe asphyxia in childbirth are prescribed osmodiuretics and sedatives. Dehydration therapy includes intravenous administration of sorbitol 10% (10ml /kg), albumin 5% (10ml /kg) or mannitol 0.5-1.0 dry substance per 1 kg of body weight in 10 ml of 5% glucose solution, rheopolyglucin or gemodez ( 10ml /kg). If necessary, these drugs should be combined with sedatives and anticonvulsants (sodium oxybutyrate 75-100 mg /kg).

The introduction of 20% glucose solution (10ml /kg), 2.4% solution of euphyllin (0.1 ml /kg), cocarboxylase (10 mg /kg), 5% solution of ascorbic acid (0.5 ml /kg), essential ( 1ml /kg). The appointment of haemostatic agents (1% solution of dicinone in 0.5 ml, 1% solution of vicasol in 0.2-0.3 ml, 10% calcium gluconate solution, 0.5 ml /kg) is indicated.

Infusion therapy is performed at a slow rate (8 drops /min) under the control of diuresis, acid-base state, hematocrit and body mass dynamics. After the end of the infusion therapy, saluretics are introduced (lasix 1 mg /kg). The total amount of injected liquid should not exceed 50ml /kg. Assign drugs that improve brain metabolism (ATP, B vitamins, glutamic acid).

As a result of the transferred asphyxia, most newborns develop hypoxic encephalopathy.

In the clinical picture of hypoxic encephalopathy, is isolated.

- Syndrome of increased nervous excitatory excitability;

- Syndrome of oppression of CNS functions;

- Convulsive syndrome;

- Hypertensive syndrome;

- Locomotor disorders.

When hypoxic encephalopathy is dominated by symptoms of increased neural reflex excitability. With hyperexcitability syndrome, sodium oxybutyrate (100 mg /kg) or seduxen, Relanium (0.1 ml /kg) or droperidol (0.5 mg /kg) is injected intravenously, per os - 0003 times per day.

With moderate encephalopathy, symptoms of oppression of the nervous system predominate, followed by the development of hypertensionnano-hydrocephalic and convulsive syndromes.

Focal neurological symptoms with hypoxic encephalopathy are slightly pronounced, which significantly differs it from the birth trauma and can be used in differential diagnosis between these two forms of neurological damage in newborns.

Taking into account the manifestations of disorders of central hemo-and liquorodynamics, in the first days of life of newborns after asphyxia in labor, the therapeutic complex includes dehydration therapy, agents that improve metabolic processes in the brain (cerebrolysin, B vitamins, cocarboxylase, ATP, glucose, essential, preparations of g-aminobutyric acid, glutamic acid).

With a marked increase in intracranial pressure, which is determined by echolocation, a spinal puncture is indicated. At the same time, 3-5 ml of cerebrospinal fluid is evacuated. It is advisable to prescribe vasoactive drugs, such as Cavinton. The latter selectively enhances blood circulation, improves microcirculation and brain metabolism. In addition to cerebrovascular, Cavinton also has a nootropic effect. Enter it intravenously at the rate of 1 mg /kg of body weight.

All children who survived asphyxia in childbirth, go through a phased treatment, dispensary observation pediatrician and neurologist. For the correct organization of rehabilitation of these children, the time of onset of asphyxia (intra-, antenatal), its severity and duration, the severity of hypoxic encephalopathy, the prevailing neurological syndromes, and the therapeutic measures that were conducted, should be recorded in the newborn's exchange card.

At the stage of rehabilitation continue treatment with cavinton, followed by its replacement with nootropic drugs:

- Piracetam 20% solution 200 mg /kg three times a day, treatment course from 2-3 weeks to 2-6 months

- Aminolone - 0125 (1/4 tablets) twice a day inside or 1% solution of 1 teaspoon three times, treatment course - 6-8 weeks;

- Pyriditol (encephabol) - 1 ml of syrup twice or thrice a day 15-30 minutes after feeding. The course of treatment is one month;

- Glutamic acid by 005-01 two to three times a day for 15-30 minutes before meals;

- Cerebrolysin - 0.5-1ml intramuscularly to 20-30 injections per course of treatment.

Newborns should be under the dispensary supervision of children's psychoneurologists.