Approach to the Cyanotic Infant
Billie Parsley
Goals
 Recognition of a cyanotic infant
 What to do in any setting from ICU to rural
community pediatric practice
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What questions to ask
What to look for
What imaging to order
What test to order
Case
 39 week male born at home in uncomplicated
vaginal delivery
 Presented at ACH ED 24 hours old due to temp of
35.1 rectal
 Sats in 50s, HR 100, RR 80, BP 76/59
 Cyanotic on general appearance
What is cyanosis?
Cyanosis is a bluish discoloration of the tissue that results
when the absolute level of reduced hemoglobin (when
not combined with oxygen) in the capillary bed exceeds
3 g/dL. The appearance of cyanosis depends upon the
total amount of reduced hemoglobin rather than the
ratio of reduced to oxygenated hemoglobin.
Cyanosis
 Two mechanisms result in cyanosis:
 Peripheral cyanosis
 Normal systemic arterial oxygen saturation and increased
tissue oxygen extraction that leads to a widened systemic
arteriovenous oxygen difference of >60% (normal 40%)
resulting in an increased concentration of reduced
hemoglobin on the venous side of the capillary bed.
 Central cyanosis caused by systemic arterial oxygen
desaturation
 Don’t confuse central cyanosis with acrocyanosis!!!!
 Acrocyanosis-common physical finding in newborns as a
result of peripheral vasoconstriction
Cyanosis
 Best indicator is the tongue-due to free of
pigmentation and has rich vascular supply.
 Also seen in lips, nails, earlobes, mucous
membranes
Cyanosis
 Depends on multiple
factors
 Hemoglobin
 Fetal hemoglobin
 Skin Pigment
 Factors affecting the
hemoglobin dissociation
curve
Cause
 Alveolar hypoventilation
 Nml response is hypercarbia but can also cause hypoxemia
 Ventilation Perfusion mismatch
 Nml is for areas with decreased ventilation to have decreased
blood flow, but alterations in this cause hypoxemia
 Diffusion Impairment
 Oxygen molecules must diffuse from alveoli to pulmonary
capillary to oxygenate hemoglobin
 Right to Left Shunt
 Systemic venous blood bypasses ventilated alveoli and returns to
the left heart without being oxygenated
 Disturbed Hemoglobin
 Decreased oxygen affinity
History
 Pregnancy
 Maternal Diabetes-associated with cyanotic heart dz.
 Polyhydramnios-associated with fetal airway, esophageal,
neurologic abnormalities
 Oligohydramnios-associated with renal defects and
pulmonary hypoplasia
 Drug Use during pregnancy
 Maternal Serology
 US results
 Previous complications with pregnancy (stillborn/multiple
spontaneous abortions)
 Medication Use during pregnancy
History
 Perinatal/Peripartum
 Gestational Age
 Prolonged/Premature Rupture of Membranes
 What/How treatment given for illness during pregnancy
(GBS)
 Maternal fever
 Birth Trauma
 Neonatal polycythemia
 Hypoglycemia
 Meconium Staining-associated with Meconium Aspiration
syndrome and P-HTN
 Hospital course post delivery
History
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HPI
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Fever
Exposure
Trauma
Well water
Seizure
Poor Feeding
Decreased urine output
Medications
Different Temperatures between extremities
Cough/Congestion
Rashes Changes in skin
“birth marks”
Abnormal breathing-pauses in breathing
Weight loss or gain
Edema
History
 Diet
 What (could mom be taking in meds that get into
breastmilk)
 How long does it take?
 Perspiration with feeds
 Coughing/Gagging/Gurgling with feeds
 Medications
 Family History
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Hemoglobinopathies
Congenital Cardiac Abnormalities
Cystic Fibrosis
Neuromusclar Disorders
Physical Exam
 *The presence and degree of respiratory distress are very important
factors in differentiating your 2 main causes of Cyanosis-Cardiac vs.
Respiratory
 General exam: Comfort, WOB, LOC, Color,
 Head: Fontanel, Shape of Head, eccymosis, lacerations, Pupils, nose
shape and location, shape of chin and size, mouth size, moisture, cleft
palate,
 Neck: size of vessels, abnormal masses
 Abdomen: HSM, ascities,
 Skin: Rashes, birthmarks , mottled, slate gray color associated with
methemolglobinemia
 Limb abnormalities
Physical Exam
 Respiratory Exam
 Respiratory Rate (newborn nml 40-60)
 Low RR-alveolar hypoventilation
 Tachypnea-Cardiac or Pulmonary cause
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Regularity of RR
apnea events
Grunting (prevents end expiratory alveolar collapse)
Nasal flare (reduces nasal resistance)
Stridor
Tracheal Deviation
Chest wall movement
Retractions
Accessory muscle use
Auscultation
Physical Exam
 Cardiac Exam-not as severe respiratory distress
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Heart Rate
Pulses
Perfusion
Auscultation
Four Extremity Blood Pressure
Pre/Post Ductal oxygen Saturation
Point of Maximal Impulse
Labs
 ABG-for arterial oxygenation
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Painful and can cause increasing agitation
Methemoglobinemia oxygen saturation will be low but measured PO2
will be normal
Elevated arterial PCO2 suggest pulmonary cause
Metabolic acidosis indicates poor perfusion-possible due to poor
cardiac output or oxygen delivery or shock.
 CBC
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Can show high hgb/hct in polycythemia
I/T ratio
 Blood glucose
 Blood Culture
Imaging
 Trauma
 Airway
 Situs of heart, stomach, liver-any abnormalities in
location point towards cardiac disease
 Heart size and shape
 Lung fields
 Vascular Markings
 Decreased vascular markings can be seen in cyanotic
cardiac lesions and pulmonary hypertension
Other Test
 Hyperoxia testing—Right radial artery PaO2
(preductal) measured on RA and after 10 minutes
on 100%FiO2
 if right radial arterial PaO2 on 100% FiO2 is less
than 150mmHg, severe congenital heart disease is
likely. The infant is presumed to have ductal
dependant congenital heart disease and the low
PaO2 is attributed to the obligatory mixing of
oxygenated with deoxygenated blood within the
circulatory system.
Other Test
 Echo
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Transposition
Tetralogy of Fallot
Truncus arteriosus
Total anomalous pulmonary venous Return
Tricuspid
“Tons” of others
 EKG
Managment
 ABCs
 Access-venous and arterial if possible
 Ventilation as needed
 Cautious fluid resuscitation
 Antibiotics
 Prostaglandin Infusion
Prostaglandin
 Goal is to prevent closure of the PDA if this is where
mixing is occurring.
 Improvement normally seen within 1-2 hours
 Side effects: APNEA and peripheral vasodilatation
with hypotension
Case Review
 Mom GBS + treated with oral clindamycin
 Baby with severe Pulmonary HTN with near
systemic pressures
 By 48 hours of life on ECMO on way to Edmonton