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5Problem List
8Support
Respiratory
Surgical Conditions
Thermoregulation
Fluid & Glucose Management
Neurology
Cardiovascular
1Baby at-
risk
Sequences
2 Resuscitation
3PrimarySurvey
4Infection
Consider transport
6
7
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AA lerting signslerting signs
CC ore stepsore steps
OO rganization of rganization of carecareRR esponseesponse
NN ext ext stepssteps
SS pecific pecific managementmanagement
SS pecific pecific diagnosisdiagnosis
Infection SequenceInfection Sequence
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Risk factors for infectionRisk factors for infection
• AntepartumAntepartum– previous baby with GBSprevious baby with GBS– positive maternal GBS screenpositive maternal GBS screen– GBS bacteriuriaGBS bacteriuria– maternal infectionmaternal infection– previous unexplained stillborn at termprevious unexplained stillborn at term
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Risk factors for infectionRisk factors for infection
• IntrapartumIntrapartum– preterm labor preterm labor – PPROM < 37 weeksPPROM < 37 weeks– rupture of membranes > 18 hoursrupture of membranes > 18 hours– maternal temperature maternal temperature ≥≥ 38 38ooCC– signs and symptoms of chorioamnionitissigns and symptoms of chorioamnionitis
• NeonatalNeonatal– need for resuscitation or invasive proceduresneed for resuscitation or invasive procedures– prematurityprematurity
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Infection Risk FactorsInfection Risk Factors
0
1
2
3
4
5
6
7
Lik
elyh
oo
d (
nu
mb
er X
)
PROM
Prematurity
Maternal Chorio
Perinatal Asphyxia
Male
Recent Colonization withGBS, HSV
Multiple Gestation
Foul Smelling at birth
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Respiratory Laboured respiration* Respiratory rate > 60/min* Receiving respiratory support*
Surgical Conditions Anterior abdominal wall defect Vomiting or inability to swallow Abdominal distension Delayed passage of meconium or imperforate anus
Thermoregulation T < 36.3 or > 37.2ºC axillary* Increased risk for temperature instability
Fluid & Glucose Management Blood glucose < 2.6 mmol/L At risk for hypoglycemia Not feeding or should not be fed
Neurology Abnormal tone* Jitteriness Seizures*
Cardiovascular Pale, mottled, or grey* Weak pulses or low BP* Cyanosis unresponsive to O2
Heart rate > 220 bpm
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Clinical signs of infectionClinical signs of infection
• Signs of infection are non-specific.Signs of infection are non-specific.
• Newborns have poor immunity. Infection Newborns have poor immunity. Infection can lead to rapid dissemination and can lead to rapid dissemination and deterioration.deterioration.
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Specific DiagnosisSpecific Diagnosis
• Sepsis without a focusSepsis without a focus
• Sepsis with one or more fociSepsis with one or more foci– pneumoniapneumonia– meningitismeningitis– urinary tract infectionurinary tract infection
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OrganismsOrganisms
• Early onsetEarly onset
GBSGBSE. E.
ColiColiListeriaListeria
H. FluH. FluStrep A Strep A
and Dand D
• Late onsetLate onset
Staph epi Staph epi aureausaureaus Gram NegGram Neg
CandidaCandidaGBSGBS
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PresentationPresentation
• Early onsetEarly onsetFirst 72 hours of ageFirst 72 hours of age
Pneumonia / sepsisPneumonia / sepsisHigh mortality rateHigh mortality rate
• Late onsetLate onsetMore frequently after one week of ageMore frequently after one week of ageFrequently associated with meningitisFrequently associated with meningitisSignificant neurological morbiditySignificant neurological morbidity
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Specific ManagementSpecific Management• Modify antibiotic choices to optimize coverage
– dependent on site of infection– dependent on isolated organism from cultures– dependent on antibiotic sensitivity
• Therapeutic drug monitoring to optimize treatment
• Duration of antibiotic therapy• Need for additional tests and interventions
– surgical consultation and intervention– consultation with Infectious Disease specialist
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Specific ManagementSpecific Management
• Observe for and treat complications of Observe for and treat complications of infection:infection:– shockshock– hypoglycemiahypoglycemia– thrombocytopenia and coagulopathythrombocytopenia and coagulopathy
• Repeat Primary Survey at regular Repeat Primary Survey at regular intervals.intervals.
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TreatmentTreatment
• ANTIBIOTICSANTIBIOTICS
• Supportive CareSupportive Care– Ventilation, oxygenVentilation, oxygen– IV fluids, volume, pressorIV fluids, volume, pressor– Transfusion if indicatedTransfusion if indicated– Thermal regulationThermal regulation– NPO or NG suction if neededNPO or NG suction if needed– FFP/ Cryo if clotting disordersFFP/ Cryo if clotting disorders
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Other conditions that may Other conditions that may present like severe sepsispresent like severe sepsis
• Ductal dependent CHDDuctal dependent CHD
• Congenital adrenal hyperplasiaCongenital adrenal hyperplasia
• Inborn errors of metabolismInborn errors of metabolism
• Abdominal catastrophesAbdominal catastrophes
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AA lerting signslerting signs
CC ore stepsore steps
OO rganization of rganization of carecareRR esponseesponse
NN ext ext stepssteps
SS pecific pecific managementmanagement
SS pecific pecific diagnosisdiagnosis
Infection SequenceInfection Sequence
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IndicationsIndications
• Complete blood count (CBC) with white Complete blood count (CBC) with white count and differential count and differential – Is infection suspected? Is infection suspected?
• Platelet countPlatelet count– Infection? Infection? Maternal ITP?Maternal ITP?– Alloimmunization? Alloimmunization? TORCH?TORCH?
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White blood cellsWhite blood cells
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White blood cellsWhite blood cells
• Variable WBC countVariable WBC count
• Stress Stress neutrophil demargination neutrophil demargination
• Limited storage pool Limited storage pool neutropenia neutropenia
• Immature formsImmature forms
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• WBC is insensitive and nonspecificWBC is insensitive and nonspecific– normal in 50% proven sepsisnormal in 50% proven sepsis
• Low neutrophil count or increased Low neutrophil count or increased band count is more usefulband count is more useful
White blood cellsWhite blood cells
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• sometimes expressed as immature/total sometimes expressed as immature/total (I/T) ratio (I/T) ratio
• > 0.25 suggestive of sepsis> 0.25 suggestive of sepsis
bands (immature)bands (immature)
segmented + band (total)segmented + band (total)
Mature vs. ImmatureMature vs. Immature
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White blood cellsWhite blood cells
• Infection?Infection?• WBC < 5.000 WBC < 5.000 • Neutrophils < 1.750 Neutrophils < 1.750 • Bands > 2.000 Bands > 2.000 • I/T > 0.25I/T > 0.25
Caution!Caution!• Decision to treat sepsis in sick babies is a Decision to treat sepsis in sick babies is a
clinical one.clinical one.• Do not delay antibiotic treatment while waiting Do not delay antibiotic treatment while waiting
for results.for results.
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KevinKevin
• 34 weeks’ gestation34 weeks’ gestation
• PPROM – leaking for 5 daysPPROM – leaking for 5 days
• SVD two hours agoSVD two hours ago
• Apgars 5Apgars 511, 7, 755
• Birth weight 2400 gramsBirth weight 2400 grams
• Grunting and requiring oxygenGrunting and requiring oxygen
• CPAP startedCPAP started
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CBC resultCBC result
WBCWBC
HgbHgb
HctHct
PlateletsPlatelets
Segmented neutrophilsSegmented neutrophils
Band neutrophilsBand neutrophils
MonocytesMonocytes
NormalNormal
4.0 x 104.0 x 1099/L/L (5.0-25.0) (5.0-25.0)
145 g/L145 g/L (135-195) (135-195)
0.0. 4747 (0.45- (0.45-0.66)0.66)
180 x 10180 x 1099/L/L (150-450) (150-450)
0.9 x 100.9 x 1099/L/L (5.0-25.0) (5.0-25.0)
0.6 x 100.6 x 1099/L/L (<1.20) (<1.20)
1.5 x 101.5 x 1099/L/L (0.5-1.8) (0.5-1.8)
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• What is Kevin’s IT What is Kevin’s IT ratio?ratio?
bands (immature)bands (immature)
segmented + band (total)segmented + band (total)
0.60.6
(0.9 + 0.6)(0.9 + 0.6)
IT ratioIT ratio = 0.4= 0.4
KevinKevin
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KevinKevin
• Blood culture results at Blood culture results at 12 hours:12 hours:– Gram positive cocci in Gram positive cocci in
chainschains
• Next dayNext day– Streptococcus group B Streptococcus group B
(GBS)(GBS)