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ASSESSMENT OF CRITICALLY ILL NEWBORN

Debora Shinta Liana, dr., SpA

FK UNDANA

12016

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Introduction
Introduction

37 % of under five death occur in the neonatal periode

It is important to improve neonatal quality of care

Assessment is primary and essential

The critically ill neonate is a challenging

Several illness severity scores Critical Risk Index for the

Babies (CRIB) and Score Neonatal Acute Physiology

(SNAP) widely used

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Definition
Definition

A critical illness acutely impairs one or more

vital organ system such that there is a high

probability of imminent or life threatening

deterioration in the newborn condition

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Critical Illness Alarm Sign
Critical Illness Alarm Sign

Hany Aly.Pediatrics in Review. 2004;25:201-8

Maternal and obstetric condition associated with critically ill newborn
Maternal and obstetric condition
associated with critically ill newborn
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Hany Aly.Pediatrics in Review. 2004;25:201-8

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Differential Diagnosis of Criticall Illness Newborn
Differential Diagnosis of Criticall Illness Newborn

Respiratory Diseases

Cardiac Diseases

Neurologic Diseases

Miscellaneous Diseases

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Tanda bahaya Gawat Nafas pada bayi baru lahir

Sianosis Sesak nafas merintih Kesulitan bernafas (gasping) Retraksi dada yang berat

Takipnea (RR>60x/mnt) Perfusi buruk (schock)

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PENYEBAB GANGGUAN NAFAS BBL

SSP HIE

Paru MAS, RDS,TTNB, Pneumonia, Pneumothorax Jantung Kelainan Jantung Bawaan

Metabolik Hipoglikemia, Asidosis

Lain2asfiksia, hypothermia, Hernia diafragmatika, TEF

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PENDEKATAN DIAGNOSIS

Riwayat persalinan :

Umur Kehamilan, Pemberian Steroid Saat Hamil,

Asfiksia, Ketuban Pecah Prematur, ketuban mekoneal

pemeriksaan fisik

hipothermi, Status Neurologi,Hepatomegali, Sianosis,

perubahan suara nafas, hiperinflasi

DOWNE SCORE

PEMERIKSAAN SCORE 0 1 Frekuensi nafas Retraksi Sianosis <60x/mnt 60-8-x/mnt Tidak ada Tidak ada Retraksi ringan
PEMERIKSAAN
SCORE
0
1
Frekuensi nafas
Retraksi
Sianosis
<60x/mnt
60-8-x/mnt
Tidak ada
Tidak ada
Retraksi ringan
10
Sianosis hilang
dengan
pemberian O2
Suara nafas
Suara nafas di
Suara nafas di
kedua paru
baik
Tidak merintih
kedua paru
menurun
Merintih
Dapat didengar
dengan stetoskop

2

>80x/mnt

Retraksi berat Sianosis menetap

walaupun diberi

O2

Tidak ada suara

nafas di kedua paru

Dapat didengar tanpa alat

bantu

EVALUASI SKOR DOWNE 11 Total Diagnosis < 3 Gawat napas ringan 4-5 Gawat napas sedang >
EVALUASI SKOR DOWNE
11
Total
Diagnosis
<
3
Gawat napas ringan
4-5
Gawat napas sedang
> 6
Gawat napas berat.
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PEMERIKSAAN PENUNJANG

1. Thorax X-ray 2.Blood gas analysis 3.Complete blood count 4.Blood glucose 5.Blood culture

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HYALIN MEMBRANE DISEASE (HMD)/ RESPIRATORY DISTRESS SYNDROME (RDS)

Hyaline Membrane Disease 14 (Respiratory Distress Syndrome)  Hyaline membrane disease (HMD) is also called respiratory
Hyaline Membrane Disease
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(Respiratory Distress Syndrome)
Hyaline membrane disease (HMD) is also called
respiratory distress syndrome (RDS).
This condition usually occurs in a preterm neonate.
Premature lungs are surfactant deficient
HMD occurs in about 25% of neonates born at 32 weeks
gestation. The incidence increases with increasing
prematurity.
CLINICAL MANIFESTATION 15  Increasing tachypnea (> 60/min)  Chest retractions  Cyanosis on room air
CLINICAL MANIFESTATION
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Increasing tachypnea (> 60/min)
Chest retractions
Cyanosis on room air that persists or progresses
over the first 24-48 hours of life.
Decreased air entry
Grunting
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Risk Factors of HMD

INCREASED RISK

Prematurity

Male sex

Neonate of diabetic mother

DECREASED RISK

Chronic intrauterine stress PRoM Maternal hypertension Narcotic use IUGR or Small for Gestational Age (SGA)

Corticosteroids Prenatal

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INVESTIGATIONS FOR HMD (RDS)
INVESTIGATIONS FOR HMD (RDS)

LABORATORY STUDIES:

Blood gases: hypoxia, hypercarbia, acidosis.

CBC and blood culture are required to rule out infection.

Serum glucose levels are usually low.

CHEST X-RAY:

Reveals ground glass appearance with air bronchograms.

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TRANSCIENT TACHYPNEA OF THE NEWBORN

(TTNB)

Transient Tachypnea of the Newborn (TTNB) 20 A benign disease of near-term or term neonates who
Transient Tachypnea of the Newborn (TTNB)
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A benign disease of near-term or term neonates who have
respiratory distress shortly after delivery that resolves within
3-5 days.
RISK FACTORS
Cesarean section without labor
Macrosomia
Male sex
Prolonged labor
Excessive maternal sedation
Low Apgar score (< 7 at 1 minute)
Transient Tachypnea of the Newborn (TTNB) 20 A benign disease of near-term or term neonates who
21 Clinical Presentation of TTNB  The neonate is usually near-term or term, and shortly after
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Clinical Presentation of TTNB
The neonate is usually near-term or term, and shortly
after delivery has tachypnea (>80 breaths/minute).
The neonate may also have grunting, nasal flaring, rib
retractions, and cyanosis.
The disease usually does not last longer than 72 hours.
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MECONIUM ASPIRATION SYNDROME

(MAS)

MECONIUM ASPIRATION SYNDROME (MAS) 24 The respiratory distress secondary to meconium aspiration by the fetus in
MECONIUM ASPIRATION SYNDROME (MAS)
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The respiratory distress secondary to meconium aspiration by
the fetus in utero or by the neonate during labor and delivery.
RISK FACTORS:
Post-term pregnancy
Maternal hypertension
Abnormal fetal heart rate
Biophysical profile  6
Pre-eclampsia
Maternal diabetes mellitus
SGA
Chorioamnionitis
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CLINICAL PRESENTATIONS

Meconium staining of amniotic fluid before birth. Meconium staining of neonate after birth. Respiratory distress leading to increased anteroposterior diameter of the chest. Persistent pulmonary hypertension of the newborn (PPHN).

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INVESTIGATIONS FOR MAS
INVESTIGATIONS FOR MAS

LABORATORY STUDIES:

Blood gases: hypoxia, hypercarbia, acidosis.

CBC and blood culture are required to rule out infection.

CHEST X-RAY:

findings include patchy infiltrates, coarse streaking of both lung fields, hyperinflation of the lung and flattening of the diaphragm.

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AIR LEAK SYNDROME

AIR LEAK SYNDROME 29  Overdistension of alveolar sacs or terminal airways  disruption of airway
AIR LEAK SYNDROME
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Overdistension of alveolar sacs or terminal airways 
disruption of airway integrity  dissection of air into
surrounding spaces.
Most commonly seen in neonates with lung disease who are
on ventilatory support, but can also occur spontaneously.
The air leaks syndromes : pneumomediastinum,
pneumothorax, pulmonary interstitial emphysema and
pneumopericardium
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Risk Factors

  • Spontaneous 0.5%

  • Ventilatory support 15-20%

  • CPAP 5%

  • Meconium staining / aspiration

  • Surfactant therapy

  • Vigorous resuscitation (bag ventilation)

Visu al 31
Visu
al 31
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APNEA OF THE NEWBORN

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APNEA

Definition

Cessation of respiration accompanied by bradycardia and/or

cyanosis for more than 20 seconds.

Incidence

50-60% of preterm neonates have evidence of apnea (35% with

central apnea, 5-10% with obstructive apnea, and 15-20% with mixed

apnea).

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RISK FACTORS OF APNEA

Hypothermia Hypoglycemia Anemia Hypovolemia Aspiration NEC / Distension

Cardiac disease Lung disease Gastro intestinal reflux Airway obstruction Infection, meningitis Neurological disordorder

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INVESTIGATIONS

  • Monitoring at-risk neonates less than 32 weeks gestational age.

  • Evaluate for a possible underlying cause.

  • Laboratory studies should include a CBC, blood gas analysis, serum glucose, electrolyte, and calcium levels.

  • Radiologic studies if chest disease is suspected

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PATENT DUCTUS ARTERIOSUS (PDA)

       37
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Patent Ductus Arteriosus (PDA)

Patent ductus arterious is an abnormal persistence of the fetal connection between the aorta and the pulmonary artery.

Full-term neonates:

Functional closure often occurs in the first day

Anatomic closure in 3 month

Preterm neonates:

May persist longer in neonates with primary respiratory disease and fluid overload

More preterm neonates and low birth weight

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HEMODYNAMICS OF PDA

Shunting of blood from the aorta to the pulmonary artery Increased pulmonary venous return to the left ventricle

Flooded lung

Pulmonary edema

Left sided heart failure

SHUNT:

Systolic murmur

The classic continuous murmur is not common in the neonate.

CIRCULATION:

Hyperactive apex

Bounding peripheral pulses

Wide pulse pressure

CLINICAL PRESENTATIONS 39  Deterioration in respiratory condition with  O 2 requirement  Symptoms and
CLINICAL PRESENTATIONS
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Deterioration in respiratory condition with  O 2 requirement
Symptoms and signs of congestive heart failure:
Rapid respiration
Growth failure
Feeding difficulties
Chest X-ray :
heart with left ventricular and left atrial enlargement, a dilated ascending
aorta, and a prominent pulmonary artery
Lungs : increased pulmonary vascularity with increased blood flow to the
lungs. They will appear plethoric and edematous.
ECG will reveal left axis deviation.
Echocardiography shows size of Ductus and direction of flow
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HIPOXIC ISCHEMIC ENCEPHALOPATHY

(HIE)

HIPOXIC ISCHEMIC ENCEPHALOPATHY (HIE) 41 Definition a term that used in evaluating a term infant at
HIPOXIC ISCHEMIC ENCEPHALOPATHY (HIE)
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Definition
a term that used in evaluating a term infant at risk for brain injury in
perinatal period, as a result of perinatal asphyxia condition
Asphyxia is reserved to describe a neonate with all the following
conditions (AAP):
1.
Profound metabolic / mixed acidosis
(pH < 7.0)
2.
Apgar score of <3 (> 5 minutes)
3.
Neonatal neurologic manifestations
4.
Multi-system organ dysfunction
Risk Factors that Predispose to Perinatal Asphyxia 42 Antepartum Conditions Intrapartum Conditions Postpartum Conditions Perinatal Asphyxia
Risk Factors that Predispose to Perinatal Asphyxia
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Antepartum Conditions
Intrapartum Conditions
Postpartum Conditions
Perinatal Asphyxia
Hypoxic-Ischemis Encephalopathy in Term Infants 43 SIGNS STAGE 1 STAGE 2 STAGE 3 Level of consciousness
Hypoxic-Ischemis Encephalopathy in Term Infants
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SIGNS
STAGE 1
STAGE 2
STAGE 3
Level of consciousness
Muscle tone
Posture
Hyperalert
Lethargic
Normal
Hypotonic
Normal
Flexion
Stuporous, coma
Flaccid
Decerebrate
Tendon reflexes/clonus
Hyperactive
Hyperactive
Absent
Myoclonus
Moro reflex
Pupils
Seizures
Electroencephalographic
Present
Strong
Mydriasis
None
Normal
Duration
<24 hr if
progresses;
otherwise,
may remain
Present
Weak
Miosis
Common
Low voltage changing
to seizure activity
24 hr to 14 days
Absent
Absent
Unequal, poor light reflex
Decerebration
Burst suppression to
isoelectric
Days to weeks
normal
Outcome
Good
Variable
Death, severe deficits
Modified from Sarnat HB, Sarnat MS : Neonatal encephalopathy following fetal distress:
A clinical and electroencephalographic study. Arch Neurol 1976;33:696-705.
Multi-Organ Involvement caused by perinatal asphyxia  CNS (72%)  Renal (52%)  Cardiac (29%) 
Multi-Organ Involvement
caused by perinatal asphyxia
CNS (72%)
Renal (52%)
Cardiac (29%)
Gastrointestinal (29%)
Pulmonary (26%)
Others ( Hepatic, Hematologic,
Metabolic)
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Differential Diagnoses that Mimic HIE  Sedation and/or analgesia  Sepsis and/or meningitis  Viral encephalitis
Differential Diagnoses that Mimic HIE
Sedation and/or analgesia
Sepsis and/or meningitis
Viral encephalitis
Congenital malformations
Neuromuscular disease
Birth trauma
Metabolic disease
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Tools to Assess A Critically Ill Newborn 46 1. Integrated Management of Chilhood Illness 2. (
Tools to Assess A Critically Ill Newborn
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1.
Integrated Management of Chilhood Illness
2.
( WHO-UNICEF)
2.
Illness severity Score in Neonate
Clinical Risk Index for Babies
(CRIB)
Clinical Risk Index for Babies
(CRIB II) 2003  score add by
birth weight, maximum base
deficits in the first 12 hours
Predict mortality for Infant
and admission temperature
born < 32 weeks GA
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The Clinical Risk Index for Babies (CRIB) Score

Parameter

Result

Point

Birth Weight

>1350 g

0

 

851 1350 g

1

 

701 850 g

4

 

≤ 700 g

7

Gestational Age (weeks)

>24 weeks

0

 

≤ 24 weeks

1

Congenital Malformation

No

0

 

Not life- threatening

1

 

Life threatening

3

Maximum Base Excess

> - 7,0 mmol/L

0

 

-7,0 s.d. 9,9 mmol/L

1

 

-10 s.d. 14,9

2

 

- 15 mmol/L

3

Minimum FiO2

≤ 0,40

0

 

0,41 0,60

2

 

0,61 0,90

3

 

0,91 1,00

4

Maximum FiO2

≤ 0,40

0

 

0,41 0,80

1

 

0,81 0,90

3

 

0,91 1,00

5

Cited from: Fowlie PW, Gould CR, Tarrow-Mordi WO. Measurement properties of the clinical risk index for babies reliability, validity beyond the first 12 hours, and responsiveness over 7 days. Crit Care Med 1998;26:163-8

48 Neonatal mortality prediction with CRIB score CRIB Score 0 – 5 Mortality 8 % 6
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Neonatal mortality prediction with CRIB score
CRIB Score
0 – 5
Mortality
8 %
6 – 10
11 – 15
> 16
38 %
70 – 16 %
85.– 90 %
Use of the CRIB (Critical Risk Index for Babies)

Cited from: Courcy-Wheeler RH, Wolfe CD, Fitzgerald A, Spencer M, Goodman JD, Gamsu HR.

score in prediction of neonatal mortality and morbidity. Arch Dis Child 1995; 73: F32-6.

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2. Illness severity Score in Neonate
2.
Illness severity Score in Neonate

Score for Neonatal Acute Physiology (SNAP)

49 2. Illness severity Score in Neonate Score for Neonatal Acute Physiology (SNAP) Based on 28

Based on 28 data collected during 24 hours of life ( Difficult)

49 2. Illness severity Score in Neonate Score for Neonatal Acute Physiology (SNAP) Based on 28

SNAP II

( 6 variable )

49 2. Illness severity Score in Neonate Score for Neonatal Acute Physiology (SNAP) Based on 28

Add ( Birth weight, SGA, Apgar Score in 5 minute)SNAPPE II

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SNAP II and SNAPPE II

Variable

 

Result

Point

Mean Blood Pressure

20

29mmHg

9

 

< 20 mmhG

19

The lowest temperature

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35,6 o C

8

 

< 35 o C

15

PO2/FiO2 ratio

1,0 2,49

5

 

0,3 0,99

16

 

<0,3

28

Lowest PH serum

7,10 7,19

7

 

<7,10

16

Convulsion

recurrent

5

Urine production

0,1 0,9 ml/kg/hour

5

 

<0,1 ml/kg/hour

18

Birth weight

750 999 g

10

 

<750 g

17

Small for gestational age

< 3 rd percentile

12

Apgar score minute - 5

<7

18

Cited from: Richardson DK, Corcoran JD, Escobar GJ, Lee SK. SNAP-II and SNAPPE II:

simplified newborn illness severity and mortality risk scores. J Pediatr 2001;138:92-100

51 SUMMARY  Assessment of critically ill newborn is quite challenging  Newborn infants need a
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SUMMARY
Assessment of critically ill newborn is quite challenging
Newborn infants need a transitional period
Symptoms and signs may vary and not appear in the first
days of life
Vulnerable newborns need to be continously monitored
Good communication between doctor and parents
should be maintained.
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THANK YOU