Transcript Acute Abdomen

Neonatal Sepsis
NICU Night Team Curriculum
Sepsis: Objectives
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Define Sepsis
Review common pathogens causing
sepsis in a neonate
Review clinical findings
Review the initial work up of an infant
suspected of having sepsis
Review initial management of neonatal
sepsis
While on call in the NICU…
• The nurse pages: A 6 hr-old 36 wk female has
developed apenic and bradycaridic episodes
• Infant was born to G1P1 mother via NSVD who
developed a temperature of 39.1 shortly before the
fetus was delivered. Maternal serologies were
negative except for a GBS positive urine culture at 20
weeks GA. Mom received 1 dose of antibiotics
secondary to a precipitous delivery. Pregnancy was
otherwise unremarkable.
• Infant has been in NICU x 6 hours receiving Ampicillin
and Gentamicin
Physical exam
• T:36.5C, P:170, RR:62, MAP:33, SpO2: 92% on
1LNC
• Gen/Head: AFOSF, atraumatic
• CV: Tachycardic rate with observed episodes of
bradycardia during exam with lowest observed
heart rate of 85, NL S1/S2, No murmur. Cap
refill ~3 sec
• Pulm: Tachypnic rate, subcostal retractions
observed. No crackles, no rales/rhonchi.
• Abd: Soft, non-tender, non-distended.
• Skin: No rash, petechiae or purpura.
Neonatal Sepsis
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Definition:
– A clinical syndrome in an infant 28 days of
life or less, manifested by systemic signs of
infection and/or isolation of a bacterial
pathogen from the blood stream (Edwards,
2004)
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Further Classification:
– Early-onset: Onset of symptoms in first 6
days of life
– Late-onset: Onset of symptoms after first
week of life
Pathogenesis
• Early-onset sepsis:
– Vertical transmission
• Contaminated amniotic fluid
• Vaginal bacteria
– Increased risk with maternal chorioaminitis
• Late-onset sepsis:
– Vertical transmission causing neonatal colonization
that later results in infection
– Horizontal Transmission
• Environmental exposures
• Introduction from instrumentation
– Increased risk with any interruption of fetal immune
system
Clinical Findings
• Subtle changes in
baseline behavior and
feeding patterns
• Fetal distress during
delivery
• Most common findings:
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Hyperthermia
Respiratory distress
Poor feeding
Vomiting
Jaundice
Hepatomegaly
Lethargy
• Less frequently seen:
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Cyanosis
Hypothermia
Irritability
Apnea
Abdominal Distension
Back to the patient…
You are at the bedside and the patient is
continuing to have bradycardic episodes
throughout the exam
• What are your first steps in evaluation?
• How would you treat this patient?
Evaluation
• Culture all body fluids
– Blood
• Positive blood culture is the only method of truly diagnosis neonatal
sepsis
– CSF
– Urine
• Not necessary in infants <6 days as UTIs are rarely the source of sepsis
– Any other sites of infection (pustules, purulent eye drainage)
• CBC
– Increased suspicion with:
• WBC count <5000/microL
• Absolute neutropenia
• Elevation of immature white blood cells when compared to PMNs (I:T ratio)
(Newman, 2010)
• CRP
– Value of > 1.0 mg/dL has a 90% sensitivity of detecting sepsis
(Pourcyrous, 2003) but is not specific and increases in response to
many other factors (maternal fever, hypoxia, IVH)
– Most value when trend is followed over time
• Chest x-ray with signs of respiratory distress
Management
Antibiotic Therapy
– Empiric coverage for common
pathogens
• Early-onset
– Ampicillin and Gentamicin
• Late-onset
– Ampicillin and Gentamicin
– Vancomycin subsituted for
Ampicillin for those with
possible CONS or MRSA
infection
– Clindamycin for those with
suspected anaerobic
infections
– Narrow coverage after
organism is identified
– Duration depends fluid from
which organism was isolated
Supportive Care
– Fluid resuscitation
• Crystalloid
• Colloid
– Pressor support in those who
do not respond to fluid
– Electrolyte replacement
– Ventillatory support when
necessary
References
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Edwards MS, Baker CJ. Sepsis in the Newborn. Krugman's Infectious Diseases of Children, 11th, Gershon AA, Hotez PJ,
Katz SL (Eds), Mosby, Philadelphia 2004. p.545.
Newman TB, Puopolo KM, Wi S, Draper D, Escobar GJ. Interpreting complete blood counts soon after birth in newborns
at risk for sepsis. Pediatrics. 2010;126(5):903.
Pourcyrous M, Bada HS, Korones SB, Baselski V, Wong SP. Significance of serial C-reactive protein responses in
neonatal infection and other disorders. Pediatrics. 1993;92(3):431.