Neonatal+Sepsis

Catch-All Unit
Nsg 3050

Case Study
• Term, uncomplicated pregnancy
• 21 y.o., no medical problems, G
1
P
0
• Group B Streptococcus screening negative
• Membranes ruptured 10 hours before birth
• Apgar scores 7
1
, 8
5
• Birth weight 3.43 kg
• Birth time: 1931
Case Study
• Pale, grunting and retracting after delivery
– Observed in term nursery 5 ½ hours
• Taken to NICU for observation at 0100
Tachypnea, RR = 80
– Tachycardia, HR = 180
– Normotensive, BP = 76/44
– Acrocyanosis
– Capillary refill 4 seconds
Case Study
• Term infant, pale, grunting, retracting

• NICU admission diagnosis: R/O Sepsis
NPO, IV fluids
CBC, blood culture, antibiotics
Chest x-ray
Case Study
Case Study
• CBC
– WBC = 4,100
– Total neutrophils (ANC) = 533
– Differential
• Segmented neutrophils: 13%
• Band neutrophils: 0%
Case Study
Normal
Age = 2 hours
Case Study
• Following admission to NICU
– Progressive deterioration
• Falling blood pressure
– Given albumin infusion to expand blood volume
– Started blood pressure support with dopamine
• Deteriorating lung function
– Intubated and ventilated with increasing difficulty
– Umbilical artery and vein catheters inserted
• Transfer to Primary Children’s at age 12 hours
– Helicopter Transport
– Cardiac Arrest during transport, required chest compression
Case Study
• Following admission to NICU
– Progressive deterioration
• Falling blood pressure
– Given albumin infusion to expand blood volume
– Started blood pressure support with dopamine
• Deteriorating lung function
– Intubated and ventilated with increasing difficulty
– Umbilical artery and vein catheters inserted
• Transfer to Primary Children’s at age 12 hours
– Helicopter Transport
– Cardiac Arrest during transport, required chest compression
Case Study
Age = 6 hours
Age = 2 hours
Case Study
• Following admission to NICU
– Progressive deterioration
• Falling blood pressure
– Given albumin infusion to expand blood volume
– Started blood pressure support with dopamine
• Deteriorating lung function
– Intubated and ventilated with increasing difficulty
– Umbilical artery and vein catheters inserted
• Transfer to Primary Children’s at age 12 hours
– Helicopter Transport
– Cardiac Arrest during transport, required chest compression
Case Study
• Following admission to NICU
– 36 hours after blood culture drawn…
Group B Streptococcus
In Blood Culture
Case Study
• Following Transfer to Primary Children’s
– Blood pressure support 5 days
– Inhaled Nitric Oxide 9 days
– Intubation/Ventilation 11 days
– Oxygen 14 days
– Antibiotics 21 days
Case Study
• Following Transfer to Primary Children’s
– Blood pressure support 5 days
– Inhaled Nitric Oxide 9 days
– Intubation/Ventilation 11 days
– Oxygen 14 days
– Antibiotics 21 days
Normal MRI of Brain
Normal Neurological Examination
Discharge to parents
Neonatal Sepsis
• Perinatal Risk Factors
• Physical Appearance
• Laboratory Tests
• Usual Suspects
• Treatment
• Outcome
Perinatal Risk Factors
• Group B Streptococcus colonization
– 20% of women are asymptomatic carriers
• Prolonged Rupture of Membranes (PROM)
– Especially over 24 hours
• Maternal Fever
– Urinary Tract Infection
– Chorioamnionitis
Neonatal Sepsis
• Perinatal Risk Factors
• Physical Appearance
• Laboratory Tests
• Usual Suspects
• Treatment
• Outcome
Physical Appearance
• Respiratory Distress
– Grunting Respirations
– Retractions
– Pallor or Cyanosis
• Pallor
– Hypotension
– Delayed Capillary Refill
– Hypoxia
• Lethargy
– Poor feeding
– Indifferent to pain/lab testing
Physical Appearance
• Vital Signs
– Tachypnea
– Tachycardia
– Hypotension
– Temperature
• High
• Normal
• Low
Neonatal Sepsis
• Perinatal Risk Factors
• Physical Appearance
• Laboratory Tests
• Usual Suspects
• Treatment
• Outcome
Laboratory Tests
• CBC
– WBC
• High
• Low
– Differential
• Neutrophils (Bands, Segs) ANC [bands + segs x WBC]
• I/T > 0.2 (immature : total neutrophils)

• CRP
• > 1.0

• Blood Culture
• Glucose
ANC
*
* Example
Neonatal Sepsis
• Perinatal Risk Factors
• Physical Appearance
• Laboratory Tests
• Usual Suspects
• Treatment
• Outcome
Usual Suspects
• GBS
• E. coli
• S. aureus
• Enterococcus
• S. epidermidis
• Klebsiella
• Others
Neonatal Sepsis
• Perinatal Risk Factors
• Physical Appearance
• Laboratory Tests
• Usual Suspects
• Treatment
• Outcome
Treatment
• Newly delivered
– Ampicillin
– Gentamicin
Nosocomial in NICU with central catheters
– Vancomycin (Staph)
– Amphoteracin (Candida)


IVIG (?)
Granulocytes (for neutropenia?)
Granulocyte-Macrophage Colony-Stimulating Factor (?)
Neonatal Sepsis
• Perinatal Risk Factors
• Physical Appearance
• Laboratory Tests
• Usual Suspects
• Treatment
• Outcome
Outcome
• High fatality
– Outcome depends on organism
– Morbidity from transplacental cytokines

• Meningitis
– 50% mortality
– Survivors will have morbidity
Neonatal Seizures
• Relatively common
• Varying presentations
• Often is the first sign of neurological
problems
– May be a powerful prognostic sign of long-term
cognitive and developmental impairment

Neonatal Seizures Etiology
• If they are present look for an etiology
– Familial history of neonatal seizures is good-
These usually resolve
– Infectious process (TORCH infections)?
– Was the neonate resuscitated- hypoxic?
– Any stress during labor and delivery?
– Potential electrolyte imbalances (hypoglycemia
too)?
Neonatal Seizures Etiology
• Potential for intracranial bleed?
– Most often preemies
• Sepsis?
• Meningitis?
• Differential is HUGE!
Neonatal Seizures Workup
• Guided to history
• Drug screens
• Chemistries including glucose
• Cranial US or CT scan
• EEG
Neonatal Seizures Treatment
• Treatment is to underlying cause
• Most seizures aren’t in need of anti-seizure
meds but Ativan or Versed may be used
• Phenobarbital is drug of choice for recurrent
seizures
Hydrocephalus
• Large amount of CSF that is not properly
taken back in or circulates
• Cause is not well understood

Hydrocephalus S/S
• Infancy: rapid increase
in head circumfrence
• Older children:
headache
• Vomiting / nausea
• Papilledema
• downward deviation of
the eyes- "sunsetting“
• Problems with balance
• Poor coordination
• Gait disturbance
• Urinary incontinence
• Slowing or loss of
development
• Lethargy
• Drowsiness
• Irritability, or other
changes in personality
• Changes in cognition
including memory loss.


Hydrocephalus Diagnosis
• Serial head circumference measurements
• Ultrasonography
• CT
• MRI
• Pressure-monitoring techniques

Hydrocephalus Treatment
• Typically a shunt is placed to drain CSF usually to
the abdominal cavity (peritoneal shunt)
• Surgery may solve the problem if CSF circulation
is an issue and the blockage can be corrected
• Long term is maintenance of shunt and watching
for CNS S/S indicating shunt is blocked
Cerebral Palsy (CP)
• A persistent disorder of movement and
posture caused by nonprogressive
defects or lesions of the immature brain
• Result from an underlying structural
abnormality of the brain

CP Causes
• Vascular insufficiency during early
prenatal, perinatal, or postnatal stages
due to:
– Toxins or infections
– Pathophysiologic risks of prematurity
• 70-80% of cases of CP
• In most cases, the exact cause is
unknown but is most likely multifactorial

CP Treatment
• Usually mainstay is medications for muscle
spasticity
– Multiple agents from muscle relaxants to anti-
Parkinsons agents
• All cares for wheelchair or bedridden apply
• Assess for and prevent contractures
Gastroschisis
• Gastroschisis: defect in the abdominal
wall that allows the abdominal contents
to protrude outside the body
• No peritoneum covering over the bowel
or other contents with destruction of
bowel possible by amniotic fluid
• Located to the right of the umbilicus and
is completely separate from the umbilicus

Gastroschisis
• The abnormality is usually very small,
exposed contents can range from the
stomach to the rectum
• The stomach may be involved but not the
liver.

Gastroschisis Treatment
• Complete repair with the first surgery if the
abnormality is small- 80% of cases
• If too large the protrusion is covered with a
Silastic Silo, remainder of the abnormality is left
out, and is covered with silastic.
• The Silastic silo is suspended allowing gravity and
daily manual compression of the abnormality to
aid the reduction process
• Eventually the defect is closed

Gastroschisis
Silastic silo
Omphalocele
• Similar to gastroschisis but bowel enclosed
by peritoneum protecting it from the
amniotic fluid
• Less trouble with gut dysmotility or
delayed feeding.

Omphalocele
Tracheoesophageal Anomaly
• Esophageal atresia may be present with or
without communication with the trachea
• Essentially the esophagus is not complete, it
usually has an upper and lower pouch that
don’t communicate
Tracheoesophageal Atresia Tx
• Reduce the risk of aspiration
– 8 French sump tube placed for continuous
suctioning of the upper pouch
– Elevate the infant's head
• Maintenance IV fluids
• O2 to maintain normal oxygen saturation
• Surgery

Tracheoesophageal Anomaly
Diaphragmatic Hernia
• Simply put, there is a defect in the hernia
allowing the abdominal contents to enter the
thoracic cavity
• Presentation:
– Respiratory distress (may contribute to alveolar
hypoxia and thus PPHN)
– Scaphoid abdomen

Diaphragmatic Hernia
Diaphragmatic Hernia
Diaphragmatic Hernia Tx
• Outcome is variable and generally depends
on the amount and maturity of the lung
tissue on the affected side
• Ventilator therapy to maintain O2 Sats
• Surgery to correct the anomaly

Hypocalcemia
• Relatively frequently observed abnormality
seen especially in neonates
• Laboratory hypocalcemia is often
asymptomatic, and its treatment in neonates
is controversial
• Children with hypocalcemia are reported to
have a higher mortality rate in pediatric
intensive care unit (PICU) settings than
children with normal calcium levels.
Hypocalcemia
• Most common is renal failure
• Hypoalbuminemia
• Increased phosphates (cows milk in an
infant)
• Magnesium deficiency
• Hypoparathyroidism
• Malabsorption syndromes
Hypocalcemia S/S
• Newborns
• Possibly, no
symptoms
• Lethargy
• Poor feeding
• Vomiting
• Abdominal distension


• Children
• Seizures
• Twitching
• Cramping
• Laryngospasm, a rare
initial manifestation
Hypocalcemia
• Treat underlying cause
• Administer Calcium
Hypokalemia
• Acute causes:
– Diabetic ketoacidosis
– Severe GI losses from vomiting and diarrhea
– Dialysis
– Diuretic therapy
• Large potassium shifts seen with:
– Alkalosis
– Insulin
– Catecholamines & sympathomimetics
– hypothermia

Hypokalemia S/S
• Usually diagnosed after suspicion and lab
draw done
• Cardiac dysrhythmias may be present and
could be fatal if not corrected in a timely
manner

Hypokalemia S/S
• Potassium replacement
• BE CAREFUL- if bigger doses, cardiac
monitoring is essential (>0.5mEq/kg/h)
• Follow local protocols
Hypoglycemia
• Hypoglycemia indicates that something else is
wrong
• Certain conditions increase risk for neonatal
hypoglycemia:
– Gestational diabetes
– Pre-eclampsia
– Small or large for gestational age
– Fetal distress for any reason
• Poor intake for whatever reason
– Note: first time mothers with nursing

Hypoglycemia S/S
• May be asymptomatic
• Tremulous (often one
of the earliest signs)
• Listlessness
• Irritability
• Hypothermia
• Respiratory distress

• Apnea
• Weak or high-pitched
cry
• Hypotonia
• Poor feeding
• Convulsions, tremors,
seizures or coma (late
signs)

Hypoglycemia Tx
• Neonates and infants
– D10 infusion
– Regular feedings
• Children
– D25 may be used
– If no altered LOC, 15 gms of oral carbs until glucose
normal
– Consider glucagon for home treatment
• Monitor frequently for several hours and ensure
adequate intake