Cyanosis resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and keywords: Cyanosis approach in children, Cyanosis workup pediatrics, Cyanosis management in newborn, Approach to blue discoloration of skin in infants, Hypoxemia approach in children, Hypoxia approach in children

Cyanosis resident survival guide (pediatrics) Microchapters


Cyanosis can be defined as bluish discoloration of skin and mucosa and can also be a manifestation of oxygen desaturation of arterial or capillary blood. Cyanosis, hypoxemia, and hypoxia should be differentiated and can occur independently. The causes of cyanosis in a newborn range from congenital cardiac conditions to life-threatening conditions such as exposure to toxic gases or infections leading to sepsis. The management of cyanosis depends upon the etiology and emergent cases with respiratory distress need rapid evaluation and response with immediate establishment of airway access and oxygen support.


Life-Threatening Causes Pulmonary Causes Congenital Cardiac Conditions Hematological Causes Peripheral Cyanosis
Decreased inspired FiO2
Upper airway obstruction

Pulmonary vascular disorders

Other Causes

FIRE: Focused Initial Rapid Evaluation

  • A Focused Initial Rapid Evaluation (FIRE) should be performed to identify the patients in need of immediate intervention.[3]
Patient presents with cyanosis
No Respiratory Distress
Respiratory Distress
Peripheral Cyanosis
Central cyanosis
Differential Cyanosis
No Obstruction
Reassurance and Warming
Hypoxia Test
Cardiac Evaulation
Hypoxia Test
Give oxygen and Positive Pressure Ventilation
PaO2 100-150
PaO2 <100
PaO2 100-150
PaO2 >150
ENT Evaluation
Cardiac Evaluation
Persistent pulmonary hypertension of newborn, Cardiac Evaluation
Cardiac Cause
Persistent pulmonary hypertension of newborn
Respiratory management, Give oxygen and positive pressure Ventilation

Complete Diagnostic Approach

Patient presents with cyanosis
Physical Examination
Diagnostic Studies


Treatment depends upon the etiology of cyanosis
Respiratory Compromise
No Respiratory Compromise
*An adequate airway should be established and supplemental oxygen is given.
Depending upon etiology
  • Sepsis: Broad-spectrum antibiotics should be initiated such as ampicillin and gentamicin.
  • Blood cultures should be obtained to identify the causative agent.

    TGA, TAPVR ,Truncus arteriosus
    Ebstein anomaly
    Hypoplastic left heart syndrome
    Sepsis, shock, low cardiac output state, cold exposure, metabolic disorder, polycythemia
    Eisenmenger syndrome with pulmonary hypertension
    Infusion of prostaglandin, diuretic therapy, and surgery.[5]
    Infusion of prostaglandin for keeping patency of ductus arteriosus, infusion of vasodilator for reduced systemic resistance, mechanical ventilation in shock state and imposing hypercapnia and alveolar hypoxia for increased pulmonary resistance
    Tricuspid valve repair[6]
    Hypoplastic left heart syndrome
    Treatment of underlying disorder
    Phosphodiesterase-5 inhibitor (sildenafil, tadalafil). Endothelin receptor antagonist (bosentan,macitentan, ambrisentan).[7]
    Infusion of methylene blue, dextrose, N-acetyl cysteine




    1. McMullen, SM; Patrick, W (2013). "Cyanosis". The American journal of medicine. 126 (3): 210–2. doi:10.1016/j.amjmed.2012.11.004. ISSN 0002-9343. PMID 23410559.
    2. Sasidharan, Ponthenkandath (2004). "An approach to diagnosis and management of cyanosis and tachypnea in term infants". Pediatric clinics of North America. Elsevier BV. 51 (4): 999–1021. doi:10.1016/j.pcl.2004.03.010. ISSN 0031-3955. PMID 15275985.
    3. 3.0 3.1 Dasgupta, Soham; Bhargava, Vidit; Huff, Monica; Jiwani, Amyn K.; Aly, Ashraf M. (2016-09-30). "Evaluation of The Cyanotic Newborn: Part I—A Neonatologist's Perspective". NeoReviews. American Academy of Pediatrics (AAP). 17 (10): e598–e604. doi:10.1542/neo.17-10-e598. ISSN 1526-9906.
    4. "Congenital Heart Disease". NCBI Bookshelf. 2010-07-22. Retrieved 2020-10-13.
    5. Rao, P. Syamasundar (2013). "Consensus on Timing of Intervention for Common Congenital Heart Diseases: Part II - Cyanotic Heart Defects". The Indian Journal of Pediatrics. 80 (8): 663–674. doi:10.1007/s12098-013-1039-2. ISSN 0019-5456.
    6. 6.0 6.1 Holst KA, Connolly HM, Dearani JA (2019). "Ebstein's Anomaly". Methodist Debakey Cardiovasc J. 15 (2): 138–144. doi:10.14797/mdcj-15-2-138. PMC 6668741 Check |pmc= value (help). PMID 31384377.
    7. de Campos F, Benvenuti LA (2017). "Eisenmenger syndrome". Autops Case Rep. 7 (1): 5–7. doi:10.4322/acr.2017.006. PMC 5436914. PMID 28536680. Vancouver style error: initials (help)
    8. Gobergs R, Salputra E, Lubaua I (2016). "Hypoplastic left heart syndrome: a review". Acta Med Litu. 23 (2): 86–98. doi:10.6001/actamedica.v23i2.3325. PMC 5088741. PMID 28356795.
    9. O’Brien, Patricia; Marshall, Audrey C. (2014). "Tetralogy of Fallot". Circulation. 130 (4). doi:10.1161/CIRCULATIONAHA.113.005547. ISSN 0009-7322.
    10. . doi:10.1161/STROKEAHA.116.012882Stroke. Missing or empty |title= (help)