Neonatal sepsis

Question 1

6-hour old neonate with an increased respiratory rate, tachycardia, and a temperature of 38.1oC. The baby was born at 38 weeks via an uncomplicated NVD with APGARS of 8 and 9 at 1 and 5 minutes respectively. The membranes ruptured 22 hours prior to delivery. Maternal antibiotics were not started in labour and the maternal GBS status is unknown. The birth weight is 3.2kg.

Answer 1

Impression
Given the fevers, ?GBS positive and nil maternal ABx, and PROM; I am concerned about neonatal sepsis. This is a medical emergency and I would be calling for senior help immediately before starting initial assessment to treat this urgently.

Given the timing of the onset of symptoms, the infection is likely to have been transmitted vertically. Therefore, There are a variety of infective causes I would consider including

• systemic bacterial (Listeria, GBS)
• systemic viral (HSV, HIV, CMV, etc)
• systemic fungal (candidiasis)
• systemic parasitic (toxoplasmosis)
• neonatal hypoxia (congenital heart of Lund disease)

Goals
- call for senior help, engage in emergent assessment of the patient,
- start empirical ABx cover immediately, and utilise any other temporising/resuscitative measures, likely for admission to NICU

Question 2

Neonatal sepsis - Assessment

Answer 2

Clinical assessment
- call for senior help,
- consider NETS retrieval and NICU admission
- RISKS for neonatal sepsis: intrapartum fever, PPROM, premature, PROM, GBS status, Intrapartum tachycardia, meconium aspiration, Apgars <6

A - place in neutral position (sniffing morning air), suction as necessary, low threshold for intubation (senior help for airway management), pending AVPU findings. utilise IPPV
B - assess RR, SP02 (And monitoring), supplemental as req (administer IPPV, 5cmH20) aiming sats >90%, also important in patients with men stained liquor). assess for evidence of respiratory distress. bedside CXR to exclude differentials.
C - gain IVC access (IO if unable for venous access, or umbi line), assess Central cap refill, establish BP and HR monitoring bloods (VBG + cord gas, cultures, BSL, FBC with differentials, LFT, CMP, CRP/ESR. Assessment:
o IV fluids for resus, NS. Repeated hydration status assessment
o consider inotrope/vasopressor for circulatory failure, can be given peripherally (seek PICU intensities input)
o start empirical ABx (benpen 60mg/kg and Gentamicin 5mg/kg) +/- additional agents depending on level of suspicion. Can add Cefotaxime if meningitis, Aciclovir if suspected HSV/viral, add metronidazole to cover anaerobes if suspect GI source. IV aciclovir if suspecting viral infection (signs, LFT derangement - on senior advice). Fluclox and Gent if >72 hours neonatal sepsis.
o start BSL and chest compressions if HR<60; give 3:1 compressions to breaths, need 30s of PPV prior to this
o dress any hypoglycaemia
D - AVPU, tone, responsiveness, seizure activity
E - Temp, skin rashes, conjunctivitis, Other sources of infection - LP and Urine MCS
F/G: BSL should be >3.3

Question 3

Neonatal sepsis - History

Answer 3

History
- sx: floppy, unrousable, fevers, poor feeding,
- RISKS: maternal: intrapartum infection, GBS/TORCH status, PROM, Premature. fetal; APGAR<6, mec stained liquor, intrapartum fetal tachycardia
- full obstetric hx: antenatal care

Question 4

Neonatal Sepsis - exam and investigations

Answer 4

Examination and Investigations as per ABCDE assessment

Question 5

Neonatal sepsis - management

Answer 5

Management
- communication with family, acknowledge their distress
- arrangements for transfer, ?mum to travel with baby
- frequent observations
- documentation

Supportive - keep pink, warm and sweet.
- keep warm in incubator
- regular BSL monitoring
- phototherapy as needed
- feeding usually withheld whilst neonate is acutely unwell (incase dealing with NEC) - administer total fluid requirement IV.
- Fluid maintenance

Definitive
- adjust ABx according to sensitivities
- treat with ABx up to 7-10 days
regular obs, PICU admission
- oxygen therapy
- inotropes
- sodium bicarbonate if acidosis is marked