APPROACH TO

CYANOSIS IN
NEWBORN

SPEAKER - Dr. SOUTRIK

CHAIRPERSON -
INTRODUCTION
Cyanosis, derived from the Greek word kuaneos
meaning dark blue
Refers to bluish discoloration of the skin,
nailbeds, or mucous membranes
Cyanosis can be central or peripheral
PERIPHERAL CYANOSIS
Cyanosis limited to the extremities is referred to as
acrocyanosis or peripheral cyanosis , spares the mucus
membranes & tongue.
Relatively common in young infants , PHYSIOLOGIC
finding
Increased O2 extraction due to sluggish movement
through the capillaries increased deoxygenated blood
on the venous side
PaO2 value is NORMAL.
Vasomotor instability, vasoconstriction caused by cold,
low cardiac output and polycythemia can all cause slow
movement through the capillaries
CENTRAL CYANOSIS
Central cyanosis is a bluish discoloration of the whole
body, mostly evident in the mucous membranes and
tongue ; observed when deoxygenated hemoglobin is
> 3g/dL in arterial blood or > 5g/dL (>3.1mmol/L) in
capillary blood.
Associated with low PaO2 (ABG) and low SaO2
(oximetry)
Cyanosis is dependent on the absolute concentration
of deoxy Hb, not on the ratio of oxy Hb/deoxy Hb
In polycythemia, cyanosis is detectable at a higher
value of SaO2, whereas in anemia, the reverse is true
CAUSES OF CYANOSIS IN
NEWBORN
RESPIRATORY CAUSES
Upper Airway obstruction: Choanal Atresia,
Laryngomalacia, Pierre Robin Syndrome ,
Obstructive Apnea
Airway disease/ VQ mismatch: TTNB, RDS,
Pneumonia, Aspiration (Meconium, Blood,
Amniotic Fluid), Atelectasis, Pulmonary
Hypoplasia, Pulmonary Hemorrhage, CCAM
Extrinsic compression of the lungs:
Pneumothorax, Pleural Effusion, Hemothorax ,
 CARDIAC CAUSES
Right-to-left shunt / congenital cyanotic HD
Decreased PBF Tricuspid Atresia , PA , PS , TOF ,
Ebsteins Anomaly
Parallel circulation/Inadequate mixing TGA
Complete intracardiac mixing Truncus Arteriosus ,
TAPVC , Complex Single Ventricles
Eissenmenger syndrome
Intrapulmonary shunting AV malformation
PPHN
Shock
 CNS CAUSES
CNS depression: Apnea , Asphyxia, Maternal
Sedation, Intraventricular Hemorrhage, Seizure,
Meningitis, Encephalitis
Neuromuscular disease: Phrenic Nerve Inury,
Neonatal Myasthenia Gravis
OXYGEN CARRYING CAPACITY
Methemoglobinemia
Anemia
Polycythemia
 PERIPHERAL CYANOSIS
Sepsis
Shock Of Any Cause
Polycythemia
Hypothermia
Hypoglycemia
 Initial Assessment of infants with cyanosis should include:
History
Physical Examination
Pulse Oximetry (Pre- And Post-ductal)
ABG
CXR
CBC With Differential Count
Blood Glucose , Calcium , Electrolytes
Blood Culture/Sepsis Screen
ECG And Echocardiogram
 MATERNAL HISTORY
Diabetes
TTNB
RDS
Hypoglycaemia
TGA
Use of opiates
Respiratory depression
Pregnancy-induced HTN
IUGR
Polycythaemia
Hypoglycaemia
Polyhydramnios
TEF
CDH
Delivery of previous sibling with RDS
RDS
Surfactant protein B deficiency or ATP-binding cassette, sub-family A mutations
Oligohydramnios
Pulmonary hypoplasia
 PROM,Fever,GBS+
Sepsis/pneumonia
Anaesthesia/analgesia
Respiratory depression
Apnea
Meconium
Perinatal asphyxia
MAS

Preterm labour
RDS
Caesarean section without labour
TTNB , RDS
PPHN
Breech delivery (trauma)
Erb's palsy with phrenic nerve palsy.
Physical examination
Cyanosis can develop immediately or several hours after birth.

Immediate: Onset hours after birth:

TTNB Cyanotic CHD
RDS Aspiration
Pneumothorax Or Air Tracheo-oesophageal
Leak Fistula
MAS Pneumonia
CDH
CCAM
PPHN
0-7 days 7-28 days >28 days
TGA Truncus arteriosus TOF like physiology

PS +IVS TAPVC Truncus Arteriosus

HLHS TGA+VSD TGA+ASD
Severe Ebstein TOF
Anomaly
TAPVC (obstructed)
PPHN
Respiratory examination
Tachypnea with Respiratory Distress indicate
Pulmonary Cause
Tachypnea without respiratory distress likely CVS
cause
The respiratory rate may even be normal in
infants with cyanotic heart disease and
Methemoglobinemia.
Apnea and then cyanosis may be due to SEPSIS,
ASPHYXIA, OR SEIZURES.
 Tachypnea with distress
Crepitations +
Cyanosis mild/uniform
Responsive to oxygen
Improves with crying
Immediate onset

Tachypnea, no/ less distress

Creptitations -
Cyanosis variable/ uniform
No/ minimal response to O2
Worsens with crying
Usually after 24 hrs

RESPIRATORY CARDIAC
 INSPECTION tachypnea +
Apnea asphyxia , prematurity , sepsis , obstruction ,
convulsion
Supraclavicular, Submandibular, Suprasternal Retractions
Upper Airway Obstruction
Bilateral choanal atresia generally gives rise to significant
retractions at birth, but the cyanosis is relieved by crying
(oral airway)
Intercostal and Subcostal Retractions Parenchymal Lung
Disease
PALPATION movement of chest wall unequal in
pneumothorax, pleural effusion, hemothorax , CDH
Mediastinal shifting collapse , CDH , pneumothorax ,
effusion
 PERCUSSION tympanitic in CDH , dull in
pneumonia , effusion and hyperresonant in
pneumothorax
AUSCULTATION
Stridor Laryngotracheomalacia , Subglottic
stenosis , Pierre-Robin syndrome
Absent/poor aeration of one side of chest -
Pneumothorax , Pleural effusion, Atelectasis,
CDH.
Adventitious sounds crepitations in
pneumonia , MAS , aspiration
Cardiovascular examination
PALPATION parasternal heave , epigastric
pulsation
AUSCULTATION : Nature of S2 (loud/single)
A single S2 is generally indicative of:
Severe PS , PA , TGA
S2 is loud and narrowly split in pulmonary HTN
Look for Murmurs
Shock tachycardia
 ABDOMINAL EXAMINATION
Scaphoid in CDH
Hepatomegaly can co-exist with pulmonary
congestion in TAPVC
CNS EXAMINATION
Hypotonia with CNS depression HIE , Sepsis ,
Metabolic disorders
Convulsions
Phrenic nerve paresis associated with Erb's palsy
following traumatic vaginal delivery
Pulse oximetry
Pulse oximetry is a non-invasive diagnostic test
used for detecting the percentage of
haemoglobin (Hb) that is saturated with oxygen
Pre-ductal & Post-ductal PaO2 or SaO2
measurements
SaO2 is measured (right hand & right or left leg) ;
significant if > 10-15 % difference
Preductal artery (right radial) PaO2 10 15 mmHg
> post ductal artery (lower limb) PaO2 R L
DUCTAL shunt (differential cyanosis)
Hyperoxia test
Administer 100 % oxygen for > 10 min
Measure PaO2 by ABG
If PaO2 > 150 respiratory cause
If PaO2 < 100 Cardiac cause / PPHN
If PaO2 between 100 150 : equivocal
 Low pH
Elevated PaCO2
PaO2 >250 mm Hg after hyperoxia test (Passed Hyperoxia Test)
Respiratory acidosis predominantly

Low pH
Normal or low PaCO2
PaO2< 100 mm Hg/ Rise <10-30 mm Hg (Failed Hyperoxia Test)
Metabolic acidosis predominantly

RESPIRATORY CARDIAC
Hyperoxia Hyperventilation Test
Administer 100% O2
Hyperventilate (face mask or ET tube) FIO2
> 0.7
PPHN = PaO2 > 100 mmHg (Pulmonary
vasodilation, decreases right to left shunt
at atrial or ductal level)
CHD = PaO2 little change (< 100 mmHg)


CXR
The location of stomach, liver, and heart should be
ascertained to rule out dextrocardia and situs inversus
Cardiomegaly is present in Ebstein's anomaly, infants of
diabetic mothers (hyperinsulinaemia) ,cardiomyopathy
(infections, metabolic disorders, or asphyxia) and
congestive cardiac failure
'Egg on end' appearance of transposition of the great vessel
'Snowman' sign of total anomalous pulmonary venous
return
Boot-shaped heart of tetralogy of Fallot
Oligaemic Lung Fields indicate pulmonary stenosis or
pulmonary atresia with inadequate ductal shunting
 Hyperinflated lung fields are seen occasionally in
lobar emphysema or cystic lesions of lungs.
The prevalence of spontaneous air leaks giving rise
to pneumothorax and pneumomediastinum
TTNB : lung fields may appear hazy with normal lung
volume and fluid in the horizontal fissure
RDS: reticular granular pattern and air bronchograms
MAS : fluffy infiltrates, patchy areas of atelectasis,
and areas of hyperinflation
CDH: bowel gas shadow in thorax
Cystic adenomatoid malformation: multi-cystic air-
filled lesion
Blood investigations
CBC with differential count - to rule out Polycythaemia,
Anaemia, Neutropenia, Leukopenia, Abnormal I:T ratio,
and Thrombocytopenia as signs of SEPSIS.
Calcium and Magnesium Levels -- Hypocalcaemia and
hypomagnesaemia are both associated with CNS
irritability and seizures.
Metabolic screening of urine and drug screening of
urine/meconium should be performed as clinically
indicated
Methemoglobinemia: SaO2, normal PaO2, chocolate-
brown blood
 ARTERIAL BLOOD GASES (ABGs):
Arterial PO2: to confirm central cyanosis SaO2
not as good an indicator due to fetal Hb
affinity for O2 (left-shift)
o PaCO2: may indicate Pulmonary or CNS
disorders, Heart Failure
o pH: Sepsis, Circulatory Shock, Severe
Hypoxemia
THANK YOU