Admission to NICU Flashcards
How does baby with sepsis present
Pyrexia or hypothermia Poor fed Lethargy Early jaundice Hypoglycaemia Hypotonia Hypoxia Resp distress / apnoea Vomiting Collapse DIC Seizure Tachy or Brady Signs of specific infection
What are the causative organisms in sepsis
Congenital
- HSV
- CMV
- Rubela
Early onset <24 hours
Group B strep
E.coli
Klebsiella = more rare
Late - due to line or from others S.Aureus Listeria H. influenza Klebsiella Maternal HX useful in identifying cause
What organism when there is a line in situ
Coagulase negative staph - s.epididermis
What are the RF for sepsis
Have low threshold for Ax if signs
PPROM Premature babies Maternal pyrexia Maternal chorioamnitiis Maternal vaginal GBS carriage GBS in previous pregnancy
If 1+ RF = observe 12 hours Start Ax + sepsis screen in presence of 2+ RF or red flags Benpen and Gentamicin Can stop Gent if CRP <4 x2 Continue Benpen till culture back
When does group B strep sepsis present
Early onset - birth - 1 week Late onset or recurrence up to 3 months - Lines - Malformation - Malnutrition - Immunodeficiency
What are the complications of group B strep
Meningitis DIC Pneumonia Respiratory collapse Hypotension Shock
How do you invetigate sepsis
Admit NNU
SEPSIS 6 Protocol - culture, lactate, 02, fluids, Ax, urine
Full septic screen
Repeat CRP in newborn as could be delayed
Blood gas, FBC, CRP, glucose = helpful
Culture as many places as possible to identify cause before Ax
Consider CXR and LP if CRP increasing / specific signs
How do you manage sepsis
Sepsis 6
IV benpenicillin and gentamicin 1st line at least 5 days
Vancomycin (If MRSA) and gentamicin 2nd line
Add metronidazole if surgical / abdominal
Diff for meningitis - cerftoaxime
Amox if listeria
Consider fungal if failure to respond
IV acyclovir for encephalitis
Fluid management
When CRP <4 for 2x consider stopping Ax (must maintain on benpen till culture back)
Gent trough levels if above need hearing screen
What can congenital infection result in
IUGR Rash - syphillis Brain calcification - CMV Hydrocephalus Neurodevelopmental delay Visual impairment Renitis in toxoplasmosis Microcephalus Deafness Bone marrow failure HSM / jaundice / hepatitis Heart defect
Do you swab for GBS
No
Only swab if previous GBS at 36 weeks
Give Ax if +Ve
Also give Ax to mother if any RF
What do you do if 1 RF
Observe
What do you do if 2 RF / any red flags
Full sepsis screen
IV Ax to baby even if no signs
Benzypenicillin and gentamicin
When can you stop gentamicin
If two CRP come back <4 Keep on benzylpenicillin until culture back Vanc if MRSA Metronidazole If surgical Cefotaxime for menignitis Amoxicillin for listeria
What are the RF for meconium aspiration
LBW Post due date Foetal distress / hypoxia Maternal DM Maternal hypertension / PET Smoking / substance abuse Infections Difficult labour
What are the symptoms of meconium aspiration
Pneumonitis due to aspiration before or during delivery
Green / yellow amniotic fluid - may not aspirate
Meconium staining of neonate - skin / nails
Resp distress
Cyanosis
Increased work of breathing
Grunting
Apnoea
Floppy
Low Apgar score
Complication Airway obstruction Pneumonia Surfactant dysfunction Pulmonary vasoconstriction -> PPH Infection
How do you investigate meconium aspiration
Blood gas
Septic screen
CXR - patchy / atelectasis
How do you treat meconium aspiration
If no Sx = monitor freuqently if at risk every 4 hours
Amnionifusion intra-partum if thin meconium
Inhaled NO = vasodilator
Endotracheal suction at birth below vocal cords if not vigorous
Fluid + IV Ax
Surfactant + ventilation may be required
Respiratory support
ECMO - if all else fails
What requires assessment of neonate if meconium passed
RR >60 Grunting HR >100 CRT <3 Sats <95 Cyanosis
What is the primary phase of birth asphyxia
Acute injury / organ damage within minutes of no 02
What causes birth asphyxia
Placental problems Long delivery Umbilical cord prolapse Infection Neonatal airway problem Neonatal anaemia
What is the primary phase of birth asphyxia
Acute injury / organ damage within minutes of no 02
What is latent phase of birth asphyxia
Reperfusion injury
Toxins released from damaged cells
What is secondary phase of birth asphyxia and what does it lead too
Delayed injury
Secondary energy failure
Leads to hypoxic ischaemic encephalopathy
How do you manage birth asphyxia
Treat seizure Cardiac and respiratory support Monitor renal and liver Fluid resus - avoid if oedema Therapeutic hypothermia Cranial USS MRI at 7-10 days Neurofollow up
What does diaphragmatic hernia cause (usually L M>F)
Pulmonary hypoplasia
How do you treat diaphragmatic hernia
Intubation at birth
Respiratory support - ECMO
Surgery
What can babies with meconium aspiration develop
Persistent pulmonary hypertension of the newborn
What is PPH - persistent pulmonary hypertension and what causes
Failure to change from antenatal circulation to normal circulation resulting in hypertension
- SSRI
- Diaphragmatic hernia
- Meconium aspiration
- PDA
What are the complications of PPH
L-R shunting of blood
Hypoxia
Hypercapnia
Anaerobic metabolism = acidosis
How do you treat PPIH
NO
Airway support - Oxygen
IV prostaglandin
What does NO do
Vasodilator of pulmonary artery
What is the TORCH syndrome
Vertically transmitted infection Toxoplasmosis Other - HIV / chlamydia Rubella CMV Herpes simplex
What are clinical features of TORCH
SGA Fever Poor feed Purpura HSM Jaundice Hearing Autism Specific for each
How do you Rx or prevent TORCH
Manage specific
Vaccination
C-section
What should you do if on fluids
Regular electrolytes
What are neonatal seizures
Most common 12-48 hours after brith
Generalised or focal
Tonic, clonic, myoclonic
What causes neonatal seizures
HIE secondary to hypoxia / birth asphyxia / resp difficulties Metabolic distubance Decreased glucose, Ca, MG Increased Na Intracranial haemorrhage CNS Neonatal withdrawal Kernicterus Infections
How can you Dx neonatal seizures
Can be difficult EEG ? FBC, U+E, LFT, Ca, Mg, glucose, blood gas Cranial USS / MRI ?? TORCH screen Sepsis 6
How do you treat neonatal seizure
ABC Empirical Ax for infection Treat seizure if prolong or repeated Treat cause Support CVS / resp Monitor renal and liver function Fluid resus Therapeutic hypothermia
What do you follow up own after seizure
Development
What is neonatal abstinence syndrome
Withdrawal in neonate due to mother using substances in pregnancy
What can cause
Opiates Methadone Benzodiazpeine Cocaine Amphetamine Nicotine Alcohl
When does it occur
3-72 hours
Methadone / benzo = 24-72 hours
What are signs of withdrawal
CNS Irritable Hypertonia High pitched cry Tremor Seizure
Vasomotor Sweating Tachypnoea Unstable temp / pyrexia Tachycardia
GI / metabolic
Poor feed
Hypoglycaemia
Loose stools
How do you manage
If known substance = baby monitored for 72 hours
If severe
Oral morphine sulphate for opiate withdrawal
Oral phenobarbamtine for non-opiate
Gradually wean off
What are additional things to consider
Test for Hep B, C, HIV
Safeguarding
Follow up HV / GP / social services
Check suitability for breastfeeding
What are main causes of admission to NICU
Sepsis
IRDS
TTN
Meconium aspiration
What causes TTN
Decrease clearance of lung fluid
What are the symptoms
Present in first few hours of life Nasal grunting / flaring Resp distress Tachypnoea Increased O2 requirement
When is TTN common
After C-section as don’t get stimulation to push fluid out
How do you Dx
Blood gas = normal
CXR shows fluid / hyperinflation
When do you not require CXR
If baby is well and O2 levels normal
Can just have clinical Dx
How do you treat
Suppotive
FLuid
O2 through nasal cannula if low sats
Airway support
How long to resolve
1-2 days
If resp distress in neonate what do you think
SEPSIS - Always suspect and give Ax if think - Culture and markers may be -ve so start if RF or suspect IRDS TTN Cardiac
Why do you get pneumothorax in premature
High inflation pressure of intubation but immature lungs
Pulmonary hypoplasia (underdeveloped lung in newborn)
Congenital hernia
OLigohydramnio as less space
