Cyanosis in newborns: Difference between revisions

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*With high [[hemoglobin]] [[concentrations]] (normal relative [[polycythemia]],14-20 g/dl) seen in normal [[infants]], [[cyanosis]] becomes apparent at higher [[PaO2]] ([[partial pressure]] of [[oxygen]]) compared to the setting of severe [[anemia]], whereas a far lower [[PaO2]] leads to clinically recognizable [[cyanosis]] due to very low [[hemoglobin]] [[concentration]]. Therefore, [[cyanosis]] depends on the [[concentration]] of [[Deoxygenation|deoxygenated]] [[hemoglobin]] and not merely [[oxygen saturation]]. As an example, a [[neonate]] with a [[hemoglobin]] [[concentration]] of 24 g/dl exhibits [[signs]] of [[central cyanosis]] at 88% [[arterial]] [[saturation]] (SaO2) while [[cyanosis]] isn't clinically obvious in an [[anemic]] [[infant]] until SaO2 falls to about 62%.<ref name="pmid19727322">{{cite journal| author=Steinhorn RH| title=Evaluation and management of the cyanotic neonate. | journal=Clin Pediatr Emerg Med | year= 2008 | volume= 9 | issue= 3 | pages= 169-175 | pmid=19727322 | doi=10.1016/j.cpem.2008.06.006 | pmc=2598396 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19727322  }} </ref><ref name="pmid3332361">{{cite journal| author=Lees MH, King DH| title=Cyanosis in the newborn. | journal=Pediatr Rev | year= 1987 | volume= 9 | issue= 2 | pages= 36-42 | pmid=3332361 | doi=10.1542/pir.9-2-36 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3332361  }} </ref>
*With high [[hemoglobin]] [[concentrations]] (normal relative [[polycythemia]],14-20 g/dl) seen in normal [[infants]], [[cyanosis]] becomes apparent at higher [[PaO2]] ([[partial pressure]] of [[oxygen]]) compared to the setting of severe [[anemia]], whereas a far lower [[PaO2]] leads to clinically recognizable [[cyanosis]] due to very low [[hemoglobin]] [[concentration]]. Therefore, [[cyanosis]] depends on the [[concentration]] of [[Deoxygenation|deoxygenated]] [[hemoglobin]] and not merely [[oxygen saturation]]. As an example, a [[neonate]] with a [[hemoglobin]] [[concentration]] of 24 g/dl exhibits [[signs]] of [[central cyanosis]] at 88% [[arterial]] [[saturation]] (SaO2) while [[cyanosis]] isn't clinically obvious in an [[anemic]] [[infant]] until SaO2 falls to about 62%.<ref name="pmid19727322">{{cite journal| author=Steinhorn RH| title=Evaluation and management of the cyanotic neonate. | journal=Clin Pediatr Emerg Med | year= 2008 | volume= 9 | issue= 3 | pages= 169-175 | pmid=19727322 | doi=10.1016/j.cpem.2008.06.006 | pmc=2598396 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19727322  }} </ref><ref name="pmid3332361">{{cite journal| author=Lees MH, King DH| title=Cyanosis in the newborn. | journal=Pediatr Rev | year= 1987 | volume= 9 | issue= 2 | pages= 36-42 | pmid=3332361 | doi=10.1542/pir.9-2-36 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3332361  }} </ref>
*[[Oxygen]] binding capacities differ between [[fetal]] and [[adult hemoglobin]]. If a [[newborn]] has mostly adult [[hemoglobin]], [[cyanosis]] would be observed at an elevated [[PaO2]] of 42-53 mmHg which is comparable to SaO2 of 75%-85% as opposed to the predominantly [[fetal hemoglobin]] ([[PaO2]] of 32-42 mmHg); [[infants]] have varied proportions of [[adult]] and [[fetal hemoglobin]]. Therefore, a major reduction in [[PaO2]] would have set in before [[cyanosis]] becomes apparent in a [[newborn]] with elevated [[fetal hemoglobin]], a setting that shifts the [[oxygen-hemoglobin dissociation curve]] to the left.<ref name="pmid3332361">{{cite journal| author=Lees MH, King DH| title=Cyanosis in the newborn. | journal=Pediatr Rev | year= 1987 | volume= 9 | issue= 2 | pages= 36-42 | pmid=3332361 | doi=10.1542/pir.9-2-36 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3332361  }} </ref>
*[[Oxygen]] binding capacities differ between [[fetal]] and [[adult hemoglobin]]. If a [[newborn]] has mostly adult [[hemoglobin]], [[cyanosis]] would be observed at an elevated [[PaO2]] of 42-53 mmHg which is comparable to SaO2 of 75%-85% as opposed to the predominantly [[fetal hemoglobin]] ([[PaO2]] of 32-42 mmHg); [[infants]] have varied proportions of [[adult]] and [[fetal hemoglobin]]. Therefore, a major reduction in [[PaO2]] would have set in before [[cyanosis]] becomes apparent in a [[newborn]] with elevated [[fetal hemoglobin]], a setting that shifts the [[oxygen-hemoglobin dissociation curve]] to the left.<ref name="pmid3332361">{{cite journal| author=Lees MH, King DH| title=Cyanosis in the newborn. | journal=Pediatr Rev | year= 1987 | volume= 9 | issue= 2 | pages= 36-42 | pmid=3332361 | doi=10.1542/pir.9-2-36 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3332361  }} </ref>
*Several changes occur in the [[newborn]] from the first [[breath]]. Blood flow [[resistance]] decreases within the [[pulmonary vasculature]] as a result of a rise in [[oxygen]] tension; this increase in [[oxygen]] tension and [[pulmonary circulation]] causes functional closure of the [[patent ductus arteriosus (PDA)]]. Raised left [[atrial]] pressures closes the [[foramen ovale]]. The events resulting in the closures of those [[shunts]] invariably abolishes the right-to-left shunts of the precedent [[fetal circulation]]. The first breath also causes a net [[absorption]] of the [[fluid]] from the [[lungs]], causing its expansion and successfully initiates the [[gaseous]] exchange. Furthermore, removal of the low-[[pressure]] [[placental]] bed causes a rise in [[blood]] flow [[resistance]] of the [[systemic]] [[vasculature]]. These are the traditional [[physiological]] changes observed within the normal [[neonate]] after [[birth]].<ref name="pmid19727322">{{cite journal| author=Steinhorn RH| title=Evaluation and management of the cyanotic neonate. | journal=Clin Pediatr Emerg Med | year= 2008 | volume= 9 | issue= 3 | pages= 169-175 | pmid=19727322 | doi=10.1016/j.cpem.2008.06.006 | pmc=2598396 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19727322  }} </ref>
*Several changes occur in the [[newborn]] from the first [[breath]]. [[Blood flow]] [[resistance]] decreases within the [[pulmonary vasculature]] as a result of a rise in [[oxygen]] tension; this increase in [[oxygen]] tension and [[pulmonary circulation]] causes functional closure of the [[patent ductus arteriosus (PDA)]]. Raised left [[atrial]] pressures closes the [[foramen ovale]]. The events resulting in the closures of these [[shunts]] invariably abolishes the right-to-left shunts of the precedent [[fetal circulation]]. The first breath also [[causes]] a net [[absorption]] of the [[fluid]] from the [[lungs]], causing its expansion and successfully initiates the [[gaseous]] [[Exchange interaction|exchange]]. Furthermore, removal of the low-[[pressure]] [[placental]] bed causes a rise in [[blood]] flow [[resistance]] of the [[systemic]] [[vasculature]]. These are the traditional [[physiological]] changes observed in a normal [[neonate]] after [[birth]].<ref name="pmid19727322">{{cite journal| author=Steinhorn RH| title=Evaluation and management of the cyanotic neonate. | journal=Clin Pediatr Emerg Med | year= 2008 | volume= 9 | issue= 3 | pages= 169-175 | pmid=19727322 | doi=10.1016/j.cpem.2008.06.006 | pmc=2598396 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19727322  }} </ref>
*Deviations from these may result in [[pathological]] [[conditions]] requiring immediate [[interventions]]; [[infants]], especially those born prematurely would require medical assistance for this phenomenal transition.<ref name="pmid25870083">{{cite journal| author=Hooper SB, olglase GR, Roehr CC| title=Cardiopulmonary changes with aeration of the newborn lung. | journal=Paediatr Respir Rev | year= 2015 | volume= 16 | issue= 3 | pages= 147-50 | pmid=25870083 | doi=10.1016/j.prrv.2015.03.003 | pmc=4526381 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25870083  }} </ref>
*Deviations from these may result in [[pathological]] [[conditions]] requiring immediate [[interventions]]; [[infants]], especially those born prematurely would require medical assistance for this phenomenal transition.<ref name="pmid25870083">{{cite journal| author=Hooper SB, olglase GR, Roehr CC| title=Cardiopulmonary changes with aeration of the newborn lung. | journal=Paediatr Respir Rev | year= 2015 | volume= 16 | issue= 3 | pages= 147-50 | pmid=25870083 | doi=10.1016/j.prrv.2015.03.003 | pmc=4526381 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25870083  }} </ref>
*In [[peripheral cyanosis]], there's normal SaO2 with a rise in [[oxygen]] uptake by tissues leading to a wide arteriovenous difference within the [[venous]] aspect of the [[capillaries]]. [[Vasoconstriction]] could be a cause. This kind of [[cyanosis]] is seen majorly at the [[extremities]].
*In [[peripheral cyanosis]], there's normal SaO2 with a rise in [[oxygen]] uptake by the [[tissues]] leading to a wide arteriovenous difference within the [[venous]] aspect of the [[capillaries]]. [[Vasoconstriction]] could be a [[Causes|cause]]. This kind of [[cyanosis]] is seen majorly at the [[extremities]].


==Causes==
==Causes==

Revision as of 21:46, 20 January 2021

Cyanosis in newborns Microchapters

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Epidemiology and Demographics

Risk factors

Natural History, Complications, and Prognosis

Diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Ifeoma Anaya, M.D.[3]

Synonyms and keywords: Acrocyanosis; central cyanosis

Overview

Cyanosis is derived from the word kuaneos which is Greek for dark blue. It is categorized into two major types: peripheral and central cyanosis. Cyanosis is observed with an increase in the absolute concentration of deoxygenated hemoglobin to a level of 3-5g/dl. A structured way of grouping the common causes of cyanosis in newborns is by using the ABC which stands for Airway, Breathing, and Circulation. Persistent pulmonary hypertension of the newborn and congenital heart diseases (CHD) are the common causes of newborn cyanosis. Common risk factors in the development of cyanosis in newborns are evident in the pregnancy and labor period. Prompt recognition, and administration of treatment modalities, with appropriate referral to the ideal hospital setting equipped to manage the diagnosis, can improve the prognosis. The primary symptom is the bluish/dark colored lips, mucous membrane, and/or hands and feet. Patients can have breathing difficulties which can be seen as nasal flaring and chest retractions. Findings from exam include lethargy, conjunctival injection, features of shock, and tachypnea. Laboratory findings include a complete blood count, and differentials showing packed cell volume (PCV) suggesting polycythemia, and white cell count (septicemia). ECG is used seldomly however, it may aid in the diagnosis of arrhythmias and dextrocardia. X-rays can show pulmonary causes such as pulmonary hypoplasia and increased lung vascular markings in pulmonary edema, and bronchopneumonia. Echocardiography can be used when the diagnosis is equivocal or when physical exam findings and/or failed hyperoxia test suggests the presence of congenital heart disease. There are other imaging techniques used as adjuncts to making diagnoses. The immediate priority is to optimize the neonate, especially in severe cyanosis. Surgery is employed for more definitive treatment. The preventive measures that can be adopted include pre-conceptual counseling for expectant mothers especially women who are above the age of 35 years, routine prenatal and postnatal care for early detection of congenital anomalies, and adequate preparedness for its management during pregnancy, labor, and delivery.

Historical Perspective

Classification

Pathophysiology

Causes

  • A structured way of grouping the common causes of cyanosis in newborns is by using the ABC which stands for Airway, Breathing, and Circulation.
 
 
 
 
 
Causes of cyanosis in newborns
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Airway
 
 
Breathing
 
 
Circulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cystic hygroma
Hemangioma
Choanal atresia
Micrognathia
Laryngomalacia
• Tracheal stenosis
Vascular rings
Vocal cord paralysis
• Pierre Robin sequence
 
 
Phrenic nerve palsy
Congenital diaphragmatic hernia
• Perinatal asphyxia
• Pulmonary hypoplasia
• Inborn errors of metabolism
Central nervous system and muscle congenital anomalies
Neonatal sepsis
• Neonatal botulism
Congenital cystic adenomatoid malformation
Pneumonia
 
 
Congenital heart diseases
Tetralogy of Fallot (TOF)
Tricuspid atresia
Pulmonary atresia
Pulmonary stenosis
Ebstein's anomaly
Transposition of great arteries (TGA)
Hypoplastic left heart syndrome
Atrioventricular canal defect
Total anomalous pulmonary venous return (TAPVR)
Anemia
Methemoglobinemia
Polycythemia
• Persistent pulmonary hypertension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Epidemiology and Demographics

Age

Gender

  • No documented evidence of gender predilection.

Race

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Boot-shaped heart in Tetralogy of Fallot. [1]

Echocardiography or Ultrasound

CT scan

  • Used as an adjunct to further define cardiac and other anatomical anomalies in preparation for definitive management.

MRI

  • Used as an adjunct to further define cardiac and other anatomical anomalies in preparation for definitive management.

Other Imaging Findings

Other Diagnostic Studies

  • Pre-ductal and post-ductal PaO2 measurements

Treatment

Medical Therapy

Surgery

Prevention

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Steinhorn RH (2008). "Evaluation and management of the cyanotic neonate". Clin Pediatr Emerg Med. 9 (3): 169–175. doi:10.1016/j.cpem.2008.06.006. PMC 2598396. PMID 19727322.
  2. Izraelit A, Ten V, Krishnamurthy G, Ratner V (2011). "Neonatal cyanosis: diagnostic and management challenges". ISRN Pediatr. 2011: 175931. doi:10.5402/2011/175931. PMC 3317242. PMID 22482063.
  3. 3.0 3.1 Lees MH, King DH (1987). "Cyanosis in the newborn". Pediatr Rev. 9 (2): 36–42. doi:10.1542/pir.9-2-36. PMID 3332361.
  4. Hooper SB, olglase GR, Roehr CC (2015). "Cardiopulmonary changes with aeration of the newborn lung". Paediatr Respir Rev. 16 (3): 147–50. doi:10.1016/j.prrv.2015.03.003. PMC 4526381. PMID 25870083.
  5. https://pediatriccare.solutions.aap.org/chapter.aspx?sectionid=108722941&bookid=1626
  6. 6.0 6.1 6.2 6.3 6.4 "StatPearls". 2020. PMID 29763177.