Chart 4
SCORE 0 1 2
APPEARANCE (color)
blue, pale body pink, extremities blue
pink
PULSE (heart rate) absent below 100 above 100
GRIMACE (response to stimulation)
none cry, some
motion vigorous cry ACTIVITY (muscle tone) flaccid some flexion well-flexed and active RESPIRATION (rate, effort) absent slow, irregular good, deep inspiration
After assigning a numerical score for each category, the scores are added. Normal infants are usually scored from 7 to 10. Moderately depressed infants receive scores of 4, 5 and 6. Severely depressed infants receive lower scores less than 4. However, in the clinical situation such infants are not scored immediately. It is so blatantly obvious they are in severe distress, resuscitation measures are instituted before there is time to obtain a score.
The infant is assessed at both one minute and five minutes after birth. The one minute score determines what type of care and/or resuscitation is required. The five minute score establishes how stable the newborn is and how successful your care has been. The five minute score may be higher or lower than the one minute score. As the baby makes the successful transition to
extrauterine life, the score may increase. Meconium babies also can have a low one minute score due to intubation during that first minute. As they get over this trauma, the five minute score is higher. On the other hand, upon cessation of the massive stimulation associated with birth, both activity and respiration of the infant may decrease. This results in a lower five minute score in some infants.
The five minute score correlates well with morbidity, mortality, and neurological status at one year. There is 50 % mortality (within 48 hours) for a five minute score of 0 to 1. 0 to 3 at five minutes is associated with cerebral palsy. Less than 6 correlates with a decrease in central
NEONATAL RESPIRATORY CARE: ESSENTIAL CARE
nervous system (CNS) function. Whenever the five minute score is low (less than 7) one should repeat the scoring at 10 minutes.
A limitation of the Apgar system is that it was not designed for premature infants. This makes it difficult to evaluate muscle tone, color, and reflex irritability in this patient population.
Umbilical cord pH or the Silverman-Anderson scoring system may be more valuable for evaluating premature infants.
The Silverman-Anderson scoring system (Chart 5) is designed to assess the degree of respiratory distress. It evaluates five parameters like the Apgar system and assigns a numerical score for each parameter. Unlike the Apgar score, a lower the number using the Silverman-Anderson system, reflects a healthier baby. The best score the infant can be awarded in each category is a 0. The five parameters assessed are: retractions of the upper chest, lower chest, and xiphoid, degree of nasal flaring, and amount of expiratory grunt present. (Unfortunately, this scoring system is vastly underutilized. It is presented here primarily for the interest of the practitioner).
SILVERMAN-ANDERSON SCORING SYSTEM Chart 5 SCORE 0 1 2 UPPER CHEST RETRACTIONS synchronized lag on inspiration see-saw movement LOWER CHEST RETRACTIONS none just visible marked
XIPHOID RETRACTIONS none just
visible
marked
NASAL FLARING none minimal marked
EXPIRATORY GRUNTING none stethoscope only
naked eye and ear
No retractions, flaring or grunting with synchronized respiratory movements are scored with 0’s. A visible retraction of the lower chest and xiphoid, with the upper chest lagging the lower on inspiration, receives a 1. Minimal nasal flaring and an expiratory grunt heard only with a stethoscope also receive a 1. Marked retractions with a “see-saw” movement of the upper and
NEONATAL RESPIRATORY CARE: ESSENTIAL CARE
lower chests deserves a 2. Marked nasal flaring and audible expiratory grunting also deserve a 2. Normal babies have a cumulative score close to 0. Severely depressed babies score close to 10.
BLOOD GAS VALUES
f course, blood gas values will differ dependent upon where and when the gases are drawn. Generally speaking, at birth, the pH, whether a term or premature infant, whether venous, arterial or capillary, is acidotic, the base deficit/excess is alkalotic, the PO2 is
low, and the PCO2 fairly within range transitioning to a child, adolescent and adult range after
one day.
Arterial Blood Gas Values (puncture or arterial line)
4 “ 8” 16” 32” 1 ‘ +/- 1 day Infant Children/Adolescents and Adults pH 7.20 7.24 7.30 7.32 7.29-7.37 7.35-7.40 7.35-7.45 7.40 7.35-7.45 PCO2 46 40 35 35 34-56 35-40 35-45 40 35-45 PO2 53 62 68 70 52-80 70-100 80-100 95 85-100 BE 10 9 8 6 -5 to +4 0 -2 to +2 HCO3 20-25 20-24 22-26 24 22-26
Please note that there are numerous variations in the values and ranges in the table above and the values provided are only a general idea of the progression of blood gases from birth until
childhood. Critical values are often set by laboratories and are also not detailed above. A capillary PCO2 of < 15 or > 70 mmHg and/or a pH of < 7.2 or > 7.6 are examples of critical
values reported immediately to the physician. The discussion of interpretation of blood gas values in the neonate and pediatric patient could entail an entire separate course.
Capillary partial pressures of O2 are usually 10 Torr less than those drawn from an arterial
source (if the sample is well-arterialized and collected properly). The partial pressure of the capillary CO2 usually correlates with the arterial CO2 partial pressure. Capillary blood gases can
be inaccurate in the older infant and child and thePpO2 may not reflect arterial trends. True
arterial sampling from a neonate can be obtained via arterial puncture or a peripheral arterial
line. One important advantage of arterial puncture is that both pre and post-ductal values can be
analyzed. Blood may also be drawn from the Umbilical Artery Catheter, but this blood has a post-ductal admixture which can result in lower PO2 values that those delivered to the retina.
Sometimes, the Umbilical Vein Catheter values are analyzed to assess acid-base status when other sites are limited. Venous gases will have a lower pH, high PCO2, lower PO2 than those of
arterial gases. For example, when the ABG normal range for pH is 7.35-7.45, the VBG will have a normal pH range of 7.25-7.35 and the PCO2 normal range for ABG is 35-45 Torr, whereas the
VBG PCO2 normal range is 41-51 Torr.