Cyanosis in newborns: Difference between revisions

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==Overview==
==Overview==
[[Cyanosis]] is coined from the word '''''kuaneos''''' which is greek for '''dark blue'''. It is classified into two major types: peripheral and [[central cyanosis]]. [[Cyanosis]] results when there is an increase in the absolute [[concentration]] of deoxygenated [[hemoglobin]] to a level of 3-5g/dl. A systematic way of classifying the common causes of [[cyanosis]] in [[newborns]] is by using the '''ABC''' which stands for '''''[[Airway]]''''', '''''[[Breathing]]''''', and '''''[[Circulation]]'''''. [[Congenital heart diseases]] (CHD) affecting 8-9 per 1000 live births and Persistent [[pulmonary hypertension]] of the [[newborn]] are the common causes of [[newborn]] [[cyanosis]]. In older kids, [[respiratory]] [[diseases]] tend to be more common. Common [[risk factors]] in the development of [[cyanosis]] in [[newborns]] are evident in the [[pregnancy]] and [[labor]] period. [[Complications]] and [[prognosis]] are dependent on the actual cause of the [[cyanosis]], prompt recognition, and administration of [[treatment]] modalities with appropriate referral to the ideal [[hospital]] setting equipped to manage the [[diagnosis]]. The primary [[symptom]] is the bluish/dark colored lips, [[mucous membrane]], and/or hands and feet. [[Breathing]] difficulties such as [[nasal]] flaring, chest retractions. [[Physical examination|Exam]] findings include lethargy, [[conjunctival injection]], features of [[shock]], [[tachypnea]]. [[Laboratory findings]] include a [[Complete blood count]] and differentials showing ↑Packed cell volume([[PCV increased|PCV]]) suggesting [[polycythemia]], ↑[[White blood cells|White cell]] count ([[Septicemia]]). Although seldom helpful, an [[ECG]] may aid in the [[diagnosis]] of [[arrhythmias]] and [[dextrocardia]]<nowiki/>s. [[X-rays]] can show [[pulmonary]] causes like [[pulmonary]] [[hypoplasia]] and increased [[lung]] [[vascular]] markings in [[pulmonary edema]], [[bronchopneumonia]]. [[Echocardiography]] is employed when [[physical exam]] findings and/or failed [[hyperoxia]] test suggests the presence of [[congenital heart disease]] or when the [[diagnosis]] is uncertain. Other imaging modalities are used as adjuncts in making diagnoses. The priority in the immediate term will be to optimize the [[neonate]], especially in severe [[cyanosis]]. [[Surgery]] is employed for more definitive treatment. The following [[Preventive care|preventive]] measures can be adopted; 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]].  
[[Cyanosis]] is coined from the word '''''kuaneos''''' which is greek for '''dark blue'''. It is classified into two major types: peripheral and [[central cyanosis]]. [[Cyanosis]] results when there is an increase in the absolute [[concentration]] of deoxygenated [[hemoglobin]] to a level of 3-5g/dl. A systematic way of classifying the common causes of [[cyanosis]] in [[newborns]] is by using the '''ABC''' which stands for '''''[[Airway]]''''', '''''[[Breathing]]''''', and '''''[[Circulation]]'''''. [[Congenital heart diseases]] (CHD) affecting 8-9 per 1000 live births and Persistent [[pulmonary hypertension]] of the [[newborn]] are the common causes of [[newborn]] [[cyanosis]]. In older kids, [[respiratory]] [[diseases]] tend to be more common. Common [[risk factors]] in the development of [[cyanosis]] in [[newborns]] are evident in the [[pregnancy]] and [[labor]] period. [[Complications]] and [[prognosis]] are dependent on the actual cause of the [[cyanosis]], prompt recognition, and administration of [[treatment]] modalities with appropriate referral to the ideal [[hospital]] setting equipped to manage the [[diagnosis]]. The primary [[symptom]] is the bluish/dark colored lips, [[mucous membrane]], and/or hands and feet. [[Breathing]] difficulties such as [[nasal]] flaring, chest retractions. [[Physical examination|Exam]] findings include lethargy, [[conjunctival injection]], features of [[shock]], [[tachypnea]]. [[Laboratory findings]] include a [[Complete blood count]] and differentials showing ↑Packed cell volume([[PCV increased|PCV]]) suggesting [[polycythemia]], ↑[[White blood cells|White cell]] count ([[Septicemia]]). Although seldom helpful, an [[ECG]] may aid in the [[diagnosis]] of [[arrhythmias]] and [[dextrocardia]]<nowiki/>s. [[X-rays]] can show [[pulmonary]] causes like [[pulmonary]] [[hypoplasia]] and increased [[lung]] [[vascular]] markings in [[pulmonary edema]], [[bronchopneumonia]]. [[Echocardiography]] is employed when [[physical exam]] findings and/or failed [[hyperoxia]] test suggests the presence of [[congenital heart disease]] or when the [[diagnosis]] is uncertain. Other imaging modalities are used as adjuncts in making diagnoses. The priority in the immediate term will be to optimize the [[neonate]], especially in severe [[cyanosis]]. [[Surgery]] is employed for more definitive treatment. The following [[Preventive care|preventive]] measures can be adopted; 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==
==Historical Perspective==
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===Laboratory Findings===
===Laboratory Findings===


*Complete blood count and differentials
*[[Complete blood count]] and differentials
**↑Packed cell volume(PCV)- Polycythemia
**↑Packed cell volume([[PCV increased|PCV]])- [[Polycythemia]]
**↑White cell count- Septicemia
**↑[[White blood cells|White cell]] count- [[Septicemia]]
*Complete metabolic panel- electrolyte derangements (metabolic acidosis)
*Complete metabolic panel- [[electrolyte imbalance]] ([[metabolic acidosis]])
*Serum glucose- hypo or hyperglycemia
*[[Serum glucose]]- hypo or [[hyperglycemia]]
*Hyperoxia Test- differentiates pulmonary from a cardiovascular cause. An increase in PaO2 to 100mmHg or more after administering 100% oxygen suggests a pulmonary etiology. Currently not necessary due to the wide availability of echocardiography.
*[[Hyperoxia]] Test- differentiates [[pulmonary]] from a [[cardiovascular]] cause. An increase in [[PaO2]] to 100mmHg or more after administering 100% [[oxygen]] suggests a [[pulmonary]] [[etiology]]. Currently not necessary due to the wide availability of [[echocardiography]].
*Arterial Blood Gases (ABGs)
*[[Arterial]] [[Blood]] [[Gases]] (ABGs)
**PaCO2, ↑ suggests hypoventilation of either CNS or pulmonary etiology, heart failure
**[[PaCO2]], ↑ suggests [[hypoventilation]] of either [[CNS Disease|CNS]] or [[pulmonary]] [[etiology]], [[heart failure]]
**PaO2, ↓ confirms cyanosis
**[[PaO2]], ↓ confirms [[cyanosis]]
**PH, a ↓ suggests hypoxemia, sepsis
**Ph, a ↓ suggests [[hypoxemia]], [[sepsis]]
**↔ PaO2, ↓SaO2, the color of blood described as 'chocolate-brown, Methemoglobinemia
**↔ [[PaO2]], ↓SaO2, the color of [[blood]] described as 'chocolate-brown, [[Methemoglobinemia]]


===Electrocardiogram===
===Electrocardiogram===


*It is seldom helpful however, an ECG may be helpful in the diagnosis of arrhythmias and dextrocardias. It detects abnormal axis deviations such as a left axis deviation seen in Tricuspid atresia due to left ventricular hypertrophy. It could give a normal reading in very serious heart defects like TGA. <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>
*It is seldom helpful however, an [[ECG]] may be helpful in the [[diagnosis]] of [[arrhythmias]] and [[dextrocardia]]. It detects abnormal axis deviations such as a [[left axis deviation]] seen in [[Tricuspid atresia]] due to [[left ventricular hypertrophy]]. It could give a normal reading in very serious heart defects like [[TGA]]. <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>


===X-ray===
===X-ray===


*Can identify:
*Can identify:
**Pulmonary causes like pulmonary hypoplasia
**[[Pulmonary]] causes like [[pulmonary]] [[hypoplasia]]
**Increased lung vascular markings in pulmonary edema, bronchopneumonia
**Increased [[lung]] [[vascular]] markings in [[pulmonary edema]], [[bronchopneumonia]]
**Decreased pulmonary markings in Pulmonary stenosis, pulmonary atresia, persistent pulmonary hypertension of newborns
**Decreased [[pulmonary]] markings in [[Pulmonary stenosis]], [[pulmonary atresia]], persistent [[pulmonary hypertension]] of [[newborns]]
**Location of abdominal contents in diaphragmatic hernia
**Location of [[abdominal]] contents in [[diaphragmatic hernia]]
**Raised hemidiaphragm compared with the opposite in phrenic nerve injury
**Raised [[hemidiaphragm]] compared with the opposite in [[phrenic nerve injury]]
**Cystic adenomatoid malformation
**[[Cystic]] adenomatoid [[malformation]]
*Can show characteristic cardiac features of some congenital heart diseases such as:
*Can show characteristic [[cardiac]] features of some [[congenital heart diseases]] such as:
**'Snowman' or 'Figure 8' in TAPVR
**'Snowman' or 'Figure 8' in TAPVR
**'Boot-shaped heart' in TOF
**'Boot-shaped heart' in TOF
**'Egg-on-string' in TGA
**'Egg-on-string' in [[TGA]]
**Cardiomegaly in Ebstein's anomaly
**[[Cardiomegaly]] in [[Ebstein's anomaly]]


[[File:Boot-shaped heart.jpg|thumb|300px|none| Boot-shaped heart in Tetralogy of Fallot. [https://medpix.nlm.nih.gov/search?allen=true&allt=true&alli=true&query=boot%20shaped%20heart]]]
[[File:Boot-shaped heart.jpg|thumb|300px|none| Boot-shaped heart in Tetralogy of Fallot. [https://medpix.nlm.nih.gov/search?allen=true&allt=true&alli=true&query=boot%20shaped%20heart]]]
Line 254: Line 254:
===Echocardiography or Ultrasound===
===Echocardiography or Ultrasound===


*It is employed when physical exam findings and/or failed hyperoxia test suggests the presence of congenital heart disease or when the diagnosis is uncertain.
*It is employed when [[physical exam]] findings and/or failed [[hyperoxia]] test suggests the presence of [[congenital heart disease]] or when the [[diagnosis]] is uncertain.
*Used with doppler to define the direction of shunts. <ref name="pmid29763177">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=29763177 | doi= | pmc= | url= }} </ref>
*Used with [[doppler]] to define the direction of [[shunts]]. <ref name="pmid29763177">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=29763177 | doi= | pmc= | url= }} </ref>


===CT scan===
===CT scan===


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


===MRI===
===MRI===


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


===Other Imaging Findings===
===Other Imaging Findings===


*Cardiac catheterization and angiography:
*[[Cardiac catheterization]] and [[angiography]]:
**Sometimes as an adjunct to further define cardiac anatomical anomalies in preparation for definitive management.
**Sometimes as an adjunct to further define [[cardiac]] and other [[anatomical]] anomalies in preparation for definitive management.


===Other Diagnostic Studies===
===Other Diagnostic Studies===


*Pre-ductal and post-ductal PaO2 measurements
*Pre-ductal and post-ductal [[PaO2]] measurements


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===


*The priority in the immediate term will be to optimize the neonate, especially in severe cyanosis. This includes:
*The priority in the immediate term will be to optimize the [[neonate]], especially in severe [[cyanosis]]. This includes:
**Establishing assisted ventilation in respiratory distress
**Establishing assisted [[ventilation]] in [[respiratory distress]]
**Keep infant in a radiant warmer
**Keep [[infant]] in a radiant warmer
**Seize all feeds by mouth and commence administration of intravenous fluids which can be via a peripheral line or central access through the umbilical vein
**Seize all feeds by mouth and commence administration of [[intravenous fluids]] which can be via a peripheral line or central access through the [[umbilical vein]]
**Glucose administration for hypoglycemic infants with close monitoring of serum glucose levels
**[[Glucose]] administration for [[hypoglycemic]] [[infants]] with close monitoring of [[serum glucose]] levels
**Consult should be sent to the Neonatologist
**Consult should be sent to the [[Neonatologist]]
**Oxygen administration should be done with caution. Care must be taken not to begin with very high concentrations of 100% due to damage to the lung tissue and pulmonary vessels
**[[Oxygen]] administration should be done with caution. Care must be taken not to begin with very high [[concentrations]] of 100% due to damage to the [[lung]] tissue and [[pulmonary vessels]]
**An infusion of Prostaglandin E1(PGE1) can be given to maintain ductal patency to allow for pulmonary blood flow in CHDs
**An infusion of [[Prostaglandin]] E1([[PGE1]]) can be given to maintain ductal patency to allow for [[pulmonary]] [[blood]] flow in CHDs
**Once the infant is optimized and a diagnosis is made, more definitive treatment can commence or be planned in stages.
**Once the [[infant]] is optimized and a [[diagnosis]] is made, more definitive [[treatment]] can commence or be planned in stages.
**If sepsis is suspected, adequate antibiotics are given after blood samples for culture and sensitivity, urine samples have been collected.
**If [[sepsis]] is suspected, adequate [[antibiotics]] are given after [[blood]] samples for [[Culture collection|culture]] and [[Sensitivity (tests)|sensitivity]], [[urine]] samples have been collected.


===Surgery===
===Surgery===


*This a treatment modality for diagnoses associated with anatomic deformities in CHDs or airway obstructions.
*This a [[treatment]] modality for diagnoses associated with [[anatomic]] [[deformities]] in CHDs or [[airway]] obstructions.
*Surgical treatment is tailored to the cause of the cyanosis that requires surgical intervention. An example is a Balloon Atrial Septostomy for acute TGA allowing for blood mixing. <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>
*[[Surgical]] [[treatment]] is tailored to the cause of the [[cyanosis]] that requires [[surgical]] intervention. An example is a Balloon Atrial Septostomy for acute [[TGA]] allowing for [[blood]] mixing. <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>
   
   
===Prevention===
===Prevention===


*Prevention of cyanosis in the neonatal period can be challenging as some of its causes would have been prevalent in-utero before the birth of the child while others occur during the actual labor and birthing process.
*[[Prevention]] of [[cyanosis]] in the [[neonatal]] period can be challenging as some of its [[causes]] would have been prevalent in-utero before the [[birth]] of the child while others occur during the actual [[labor]] and birthing process.
*The following preventive measures can be adopted:
*The following preventive measures can be adopted:
*Pre conceptual counseling for expectant mothers especially women who are above the age of 35 years.
*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.
*Routine [[prenatal]] and [[postnatal]] care for early detection of [[congenital anomalies]] and adequate preparedness for its management during [[pregnancy]], [[labor]], and [[delivery]].
*Early detection and management of gestational diabetes and pregnancy-induced hypertension.
*Early detection and management of [[gestational diabetes]] and [[pregnancy-induced hypertension]].
*Counsel parents of kids with congenital malformations on the risk of having another child with the same or similar deformities.
*Counsel parents of kids with [[congenital malformations]] on the risk of having another child with the same or similar [[deformities]].
*Prophylaxis against Respiratory syncytial virus(RSV).
*[[Prophylaxis]] against [[Respiratory syncytial virus]]([[Human respiratory syncytial virus|RSV]]).
*Follow up for polycythemia, excessive dehydration, and iron-deficiency anemia.<ref name="pmid29763177">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=29763177 | doi= | pmc= | url= }} </ref>
*Follow up for [[polycythemia]], excessive [[dehydration]], and [[iron-deficiency anemia]].<ref name="pmid29763177">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=29763177 | doi= | pmc= | url= }} </ref>


==References==
==References==

Revision as of 13:07, 25 October 2020

Cyanosis in newborns Microchapters

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differential Diagnosis

Epidemiology and Demographics

Risk factors

Natural History, Complications, and Prognosis

Diagnosis

Treatment

Prevention

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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 coined from the word kuaneos which is greek for dark blue. It is classified into two major types: peripheral and central cyanosis. Cyanosis results when there is an increase in the absolute concentration of deoxygenated hemoglobin to a level of 3-5g/dl. A systematic way of classifying the common causes of cyanosis in newborns is by using the ABC which stands for Airway, Breathing, and Circulation. Congenital heart diseases (CHD) affecting 8-9 per 1000 live births and Persistent pulmonary hypertension of the newborn are the common causes of newborn cyanosis. In older kids, respiratory diseases tend to be more common. Common risk factors in the development of cyanosis in newborns are evident in the pregnancy and labor period. Complications and prognosis are dependent on the actual cause of the cyanosis, prompt recognition, and administration of treatment modalities with appropriate referral to the ideal hospital setting equipped to manage the diagnosis. The primary symptom is the bluish/dark colored lips, mucous membrane, and/or hands and feet. Breathing difficulties such as nasal flaring, chest retractions. Exam findings include lethargy, conjunctival injection, features of shock, tachypnea. Laboratory findings include a Complete blood count and differentials showing ↑Packed cell volume(PCV) suggesting polycythemia, ↑White cell count (Septicemia). Although seldom helpful, an ECG may aid in the diagnosis of arrhythmias and dextrocardias. X-rays can show pulmonary causes like pulmonary hypoplasia and increased lung vascular markings in pulmonary edema, bronchopneumonia. Echocardiography is employed when physical exam findings and/or failed hyperoxia test suggests the presence of congenital heart disease or when the diagnosis is uncertain. Other imaging modalities are used as adjuncts in making diagnoses. The priority in the immediate term will be to optimize the neonate, especially in severe cyanosis. Surgery is employed for more definitive treatment. The following preventive measures can be adopted; 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

  • Cyanosis is coined from the word kuaneos which is greek for dark blue. This is as a result of the bluish discoloration of the skin or mucous membranes depending on etiology. [1]

Classification

  • Cyanosis is classified into two major types:[2]
    • Peripheral Cyanosis (acrocyanosis) which is located on the hands and feet. It is mostly physiological and relatively common.
    • Central cyanosis which is considered to be pathological and requiring immediate evaluation until proven otherwise.

Pathophysiology

Causes

  • A systematic way of classifying 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, Polglase 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.
  7. https://learn.pediatrics.ubc.ca/body-systems/neonate/approach-to-neonatal-cyanosis/