Neonatal Case Conference Flashcards
A 8 day old female infant born at 36 weeks gestation presented to the ED with feeding difficulties, intermittent cyanosis and apneic spells.
First Impressions?
Initial Differential Diagnosis
Sepsis Inborn error of metabolism (IEM) TORCH infections Congenital heart disease Hypoxic ischemic encephalopathy Intracranial bleed Seizures
Neonatal Sepsis
Definition- a clinical syndrome in the neonate characterized by systemic signs of infection with bacteremia in the first month of life
Meningitis is usually a sequela of bacteremia and usually shares a common cause and pathogenesis
Typical organisms include both gram (-) and gram (+) organisms
Two patterns of disease- early and late onset
Organisms Associated with Bacterial Sepsis
Gram Positive organisms Group B strep (GBS) (EOS and LOS) Staphylococci aureus (LOC) Coagulase negative staphylococcus (CoNS) (LOS) Listeria monocytongenes
Gram Negative organisms E. coli (EOS and LOS) Haemophilus influenza Citrobacter Fungi Candida albicans
Diagnosis of Neonatal Sepsis
Blood culture remains the gold standard
Serum biomarkers can serve as an adjunct to culture based diagnosis
The ideal marker
- Elevates early in the infectious process
- Stays elevated to allow appropriate sampling
- Have well defined values that differentiate infection from other entities
- A very high sensitivity and negative predictive value
C-Reactive Protein (CRP)
Most commonly used biomarker
Synthesized within 6 hours of exposure to an infectious process
But takes up to 24 hours after onset of infection to become abnormal
Is also elevated with trauma and ischemia
A good indicator of neonatal sepsis??
CRP does have high specificity between 93-100% meaning what??
our patient’s initial positive results:
CSF showed mononuclear pleocytosis of 330 cells/µL
EEG showed multifocal epileptic potentials consistent with encephalitis
CRP 5 mg/L (Normal is less than 10)
Empirical treatment with amoxicillin, gentamicin and acyclovir were started. A loading dose of phenobarbital was given.
Despite antibiotic therapy the baby continues to deteriorate with tachycardia and increasing respiratory distress requiring intubation.
EKG showed ST depressions
Final diagnosis: Coxsackie B3 Myocarditis
Enteroviral Infections in the Newborn
Among the most common viruses causing disease in humans with approximately 10-15 million symptomatic infections yearly in the USA
Infections tend to have a seasonal pattern during summer and fall
Illnesses range from a nonspecific febrile illness, mild URIs, self limiting gastroenteritis to myocarditis, hepatitis and encephalopathy
Enterovirus Neonatal Transmission
Can be acquired antenatally, intrapartum and postnatally
In-utero transmission can be by transplacentally or by ascending infection
Clinical Features of Enterovirus Infection
Associated with wide spectrum of signs and symptoms ranging from nonspecific febrile illness to fatal multisystem disease which is frequently called “Neonatal Enterovirus Sepsis”
Most common presenting features include fever, irritability, poor feeding and lethargy
A nonspecific rash is seen in approximately half of infants infected
Approximately half have evidence of hepatitis or jaundice. Hepatomegaly may be present but splenomegaly is rare
How did we deal with our patient?
IV immunoglobulin was given
Because of the decreased cardiac output and developing arrhythmias dopamine and milrinone were started
Over the next 48 hours the infant became refractory to amiodarone and electroconversion for tachyarrhythmia
ECMO (Extracorporeal Membrane Oxygenation) was started
ECMO was continued for 3 weeks with adequately decompressed heart chambers and without major bleeds or infection, however, left ventricular function did not improve and ECMO was withdrawn
when is ECMO more frequently used?
diaphragmatic hernia, at least that’s where it started to be used.
birth weight classifications
ELBW less than 1 kg
VLBW less than 1.5 kg
SGA less than 10th percentile
AGA 10th-90th percentile
LGA more than 90th percentile
Sulfonamide ADA in infants
kernicterus
Displaces bilirubin from protein-binding sites, bilirubin deposits in the brain, results in encephalopathy
Chloramphenicol ADA in infants
gray baby syndrome
Abdominal distension, vomiting, diarrhea, characteristic gray color, respiratory distress, hypotension, progressive shock
Thalidomide ADA in infants
Congenital abnormalities; also: polyneuritis, nerve damage, mental retardation
