Rebecca T Slagle, MN, APRN, NNP-BC. Speak up!!
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1 Rebecca T Slagle, MN, APRN, NNP-BC Speak up!!
2 Objectives: Understand the incidence and prevalence of sepsis in the newborn period Identify the risk factors for neonatal sepsis List the most frequent causative organisms in newborn sepsis Describe the symptoms present in the septic newborn Outline treatment options for newborn sepsis Discuss outcomes after newborn sepsis
3 What is sepsis? A clinical syndrome of systemic illness related to bacteremia with potential for multisystem involvement, failure, and or death. Circling the drain!
4 How big is the problem in the NICU? Term Ranges from 1 per 3000 up to 1.5 per 1000 births Preterm or LBW Wide ranging from 3 to 27 babies per 1000 births
5 That seems pretty low so what s the big deal? Incidence is low in term infants Incidence is much higher in at risk infants (preterm and LBW) More importantly though morbidity and mortality are high
6 Two main sepsis categories: Early Onset: Onset from birth to 72 hours of life (85% in first 24 hrs) Different causative organisms Vertical transmission Risk factors include: preterm (Twice as likely if <28 wks), ELBW/LBW, maternal infection/chorio, PROM, Vaginal delivery versus CS without labor, GBS+/ untreated
7 Two main sepsis categories: Late Onset: Onset after 72 hours of life Different causative organisms Horizontal transmission (Need we talk about hand washing?)
8
9 Two main sepsis categories: Onset after 72 hours of life Different causative organisms Late Onset: Horizontal transmission (Need we talk about hand washing?) Risk factors include: preterm, ELBW/LBW, prolonged intubation, indwelling lines/caths, possibly higher in blacks, delayed achievement of full enteral feeds
10 And that is where you become invaluable SPEAK UP!! I CAN T ALWAYS BE AT THE BEDSIDE!!
11 What does it look like at the bedside?- Lethargy/Listlessness Fever/Temperature instability Glucose troubles Poor feeding or Feeding intolerance/emesis/bloody stools Respiratory distress/apnea Tachycardia Irritability/Seizures Abdominal distention Poor perfusion/hypotension Metabolic Acidosis Unfortunately, it looks like every other NICU diagnosis!
12 Now what do we do? Rule out sepsis 1. Good physical exam is crucial: Appearance, HR, RR, cap refill, BP, temp, glucose 2. Consider CXR/ KUB 3. LP with CSF studies. Success is in the holder 4. Blood culture (Gold standard)-min of 1 ml in bottle. Betadine prep. Some institutions do peripheral and central 5. Acute phase reactants: CRP and procalcitonin 6. Other labs: ABG, Lytes, Lactate, UA and urine culture 7. CBC with differential
13 Let s talk about CBC interpretation: Complete blood count: Just what it says. It is a complete count of the components of your blood. If I count 100 cells in your blood what will I see?
14 White Blood Cells: Leukocytes
15
16 Immature to Total Neutrophil Count: I:T Ratio Add up all the neutrophils including the immature ones and then divide the number of immature ones by the total number of neutrophils. Anything > than 0.2 suggests infection Example #1 Myelocytes 1 Metamyelocytes 2 Bands 20 Segs 30 Therefore immature = 24 Total = = 0.44 I:T ratio Example #2 Myelocytes 0 Metamyelocytes 0 Bands 6 Segs 58 Therefore immature = 6 Total = = 0.10 I:T Ratio
17 Acute phase reactants: Labs that indicate the body s response to infection, inflammation, or injury. CRP Procalcitonin
18 Now that we have determined that we have a problem: Treat antimicrobials, immune globulins Supportive respiratory, metabolic, thermal, nutrition
19 Which drug for which bug?
20 We must make an educated guess at the bug before we can pick the drug! Early Onset infection versus Late Onset infection
21 Common Bacteria in the NICU! EOS Group B Strep E Coli-especially in preemies Listeria *Don t forget HSV LOS Staph, Staph and more Staph (>60%)
22
23 Common Bacteria in the NICU! EOS Group B Strep E Coli-especially in preemies Listeria *Don t forget HSV LOS Staph, Staph and more Staph (>60%) E Coli and other gram negatives such as Klebsiella, Enterococcus, and Pseudomonas * Don t forget Viruses and Fungus!!
24 Common Bacteria in the NICU! EOS LOS Ampicillin and Gentamicin Consider Acyclovir Vancomycin and Gentamicin Add Clindamycin, Cefotaxime (esp with meningitis Consider Amphotericin B or fluconazole
25 Antibiotic Stewardship Accurately identify patients who need antibiotic therapy Obtain two blood cultures for evaluation of late onset sepsis prior to starting antibiotics Utilize local and regional antibiograms- Providers should know what grows at their hospital! Give the right dose and interval of drug and monitor peaks and troughs when indicated Review culture results and adjust antibiotics Stop therapy promptly if indicated by culture results
26 Now that we have started treatment how do we support them until it works? Lethargy/Listlessness-Positioning Fever/Temperature instability-warmer Glucose troubles-dextrose/insulin/ TPN/IL Poor feeding or Feeding intolerance/emesis- NPO, IV fluids, Replogle Respiratory distress/apnea-cxr, CPAP, ventilation Tachycardia- BP support, control fever Irritability/Seizures- sedation, anticonvulsants, narcotics Abdominal distention- Replogle to LIS, KUBs Poor perfusion/low BP/Hypotension-Pressors, volume, PRBCs Metabolic Acidosis- acetate, better perfusion, volume
27 How will it turn out? what does the future look like for this baby and their family? Higher likelihood of dying duh! Prolonged hospital stay and higher financial cost (avg stay extended 19 days) Increased rates of BPD, IVH, NEC, clots/thrombi, seizures, poor growth, vision problems, Neurodevelopmental impairment Hearing damage/loss
28 So what s the bottom line Avoid infection with good prenatal care and diligent hand washing Identify early and treat promptly and effectively. That s why your role is vital! Speak up for the babies Early recognition of symptoms and prompt treatment saves lives and improves outcomes
29
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