ASSESSMENT OF CRITICALLY ILL NEWBORN

1
Debora Shinta Liana, dr., SpA
FK UNDANA
12016
 Introduction
2

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
3

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
 Critical Illness Alarm Sign
4

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

 Maternal and obstetric condition
5
associated with critically ill newborn

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

 Differential Diagnosis of Criticall Illness Newborn
6

Respiratory Diseases

Cardiac Diseases

Neurologic Diseases

Miscellaneous Diseases
7 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)
 PENYEBAB GANGGUAN NAFAS BBL
8

SSP  HIE
Paru  MAS, RDS,TTNB, Pneumonia, Pneumothorax
Jantung Kelainan Jantung Bawaan
 Metabolik Hipoglikemia, Asidosis
Lain2asfiksia, hypothermia, Hernia diafragmatika, TEF
9 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 2
Frekuensi nafas <60x/mnt 60-8-x/mnt >80x/mnt
Retraksi Tidak ada Retraksi ringan Retraksi berat
Sianosis Tidak ada Sianosis hilang Sianosis
10 dengan menetap
pemberian O2 walaupun diberi
O2
Suara nafas Suara nafas di Suara nafas di Tidak ada suara
kedua paru kedua paru nafas di kedua
baik menurun paru
Merintih Tidak merintih Dapat didengar Dapat didengar
dengan stetoskop tanpa alat
bantu
11 EVALUASI SKOR DOWNE

Total Diagnosis

< 3 Gawat napas ringan

4-5 Gawat napas sedang

>6 Gawat napas berat.

12 PEMERIKSAAN PENUNJANG

1. Thorax X-ray
2. Blood gas analysis
3. Complete blood count
4. Blood glucose
5. Blood culture
 HYALIN MEMBRANE DISEASE (HMD)/
RESPIRATORY DISTRESS SYNDROME (RDS)
13
14 Hyaline Membrane Disease
(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.
15 CLINICAL MANIFESTATION

 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
16 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
17 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.
18
 TRANSCIENT TACHYPNEA OF THE NEWBORN
19
(TTNB)
 Transient Tachypnea of the Newborn (TTNB)
20

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)
21 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.
22
 MECONIUM ASPIRATION SYNDROME
23
(MAS)
24 MECONIUM ASPIRATION SYNDROME (MAS)
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
25 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).
26 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.
27
28
AIR LEAK SYNDROME
29 AIR LEAK SYNDROME

 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
30 Risk Factors
 Spontaneous 0.5%
 Ventilatory support 15-20%
 CPAP 5%
 Meconium staining / aspiration
 Surfactant therapy
 Vigorous resuscitation (bag ventilation)
 Visu
al 31
32
APNEA OF THE NEWBORN
33 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).
34 RISK FACTORS OF APNEA

Hypothermia Cardiac disease

Hypoglycemia Lung disease
Anemia Gastro intestinal reflux
Hypovolemia Airway obstruction
Aspiration
Infection, meningitis
NEC / Distension
Neurological disordorder
35 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

 PATENT DUCTUS ARTERIOSUS
36
(PDA)
 Patent Ductus Arteriosus (PDA)
37

 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
 HEMODYNAMICS OF PDA
38
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  O2 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
 HIPOXIC ISCHEMIC ENCEPHALOPATHY
40
(HIE)
41 HIPOXIC ISCHEMIC ENCEPHALOPATHY (HIE)
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
42 Risk Factors that Predispose to Perinatal Asphyxia

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 Hyperalert Lethargic Stuporous, coma
Muscle tone Normal Hypotonic Flaccid
Posture Normal Flexion Decerebrate
Tendon reflexes/clonus Hyperactive Hyperactive Absent
Myoclonus Present Present Absent
Moro reflex Strong Weak Absent
Pupils Mydriasis Miosis Unequal, poor light reflex
Seizures None Common Decerebration
Electroencephalographic Normal Low voltage changing Burst suppression to
to seizure activity isoelectric
Duration <24 hr if 24 hr to 14 days Days to weeks
progresses;
otherwise,
may remain
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%)
 Gastrointestinal (29%)
 Pulmonary (26%)
 Others ( Hepatic, Hematologic,
Metabolic)
44
Differential Diagnoses that Mimic HIE

 Sedation and/or analgesia

 Sepsis and/or meningitis
 Viral encephalitis
 Congenital malformations
 Neuromuscular disease
 Birth trauma
 Metabolic disease

45
46 Tools to Assess A Critically Ill Newborn

1. Integrated Management of Chilhood Illness

2. ( WHO-UNICEF)

2. Illness severity Score in Neonate

Clinical Risk Index for Babies

Clinical Risk Index for Babies
(CRIB)
(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
 The Clinical Risk Index for Babies (CRIB) Score
47 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 Mortality

0–5 8%
6 – 10 38 %
11 – 15 70 – 16 %
> 16 85.– 90 %

Cited from: Courcy-Wheeler RH, Wolfe CD, Fitzgerald A, Spencer M, Goodman JD, Gamsu HR.
Use of the CRIB (Critical Risk Index for Babies)
score in prediction of neonatal mortality and morbidity. Arch Dis Child 1995; 73: F32-6.
49 2. Illness severity Score in Neonate

Score for Neonatal Acute Physiology (SNAP)

Based on 28 data collected during 24 hours of life (

Difficult)

SNAP II ( 6 variable )

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

SNAPPE II
 SNAP II and SNAPPE II
50 Variable Result Point
Mean Blood Pressure 20 – 29mmHg 9
< 20 mmhG 19
The lowest temperature 35 – 35,6oC 8
< 35 oC 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 < 3rd 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 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.
52

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