Leanna R. Miller, RN, MN, CCRN, CEN, NP Education Specialist LRM Consulting Nashville, TN

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Terence Basil Newman
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1 Leanna R. Miller, RN, MN, CCRN, CEN, NP Education Specialist LRM Consulting Nashville, TN Objectives Plan the care for a neonate with sepsis. Compare key interventions for the management of a child with traumatic injury Assess, plan, and manage the care of a child with diabetic ketoacidosis. 13 th leading cause of death in patients older than 1 year of age 9 th leading cause of death in children aged 1 4 years incidence even higher in infants, especially premature mortality = 10% - 40%

2 Baby Smith 3 day old infant 38 weeks gestation mother 24 year old primigravida with vaginal culture 3 weeks prior to delivery positive for group B streptococci received antibiotics for 10 days and 4 days prior to delivery Baby Smith was delivered by spontaneous vaginal delivery 2 hours after ROM Apgar scores were 9 and 9 birth weight was 2.45 lbs. physical exam was unremarkable except pustules on both arms and chest cultures sent for gram stain and virology studies

3 Day 3 cyanotic episode lasting 5 10 minutes other findings include: jaundice poor feeding pustules on legs Transferred to Level III nursery jaundice mildly unwell looking infant well perfused non - irritable no respiratory distress, no hepatosplenomegaly, no dysmorphic features scattered pinpoint scabs on arms and chest

4 Soon after admission: series of apneic episodes mechanical ventilation initiated sepsis workup ordered, started on empiric antibiotics over next 48 hours gradual deterioration: increasing supplemental oxygen; thick, purulent sputum with fresh blood Perfusion: decreased urine output, mottling of extremities, scattered crackles bilaterally, palpable liver 1.5 cm below RCM, palpable spleen tip Hemoglobin 18 mg/dl WBC (total count) 4500 Bands 20% Neutrophils 29% Platelets 56,000 PTT 128 Fibrinogen 60

5 AST 142 Alkaline Phosphatase 203 CK 93 LDH 471 Chest Film coarse bilateral opacification Interventions: given platelets & plasma IV vitamin K Baby Smith became hypotensive Dobutamine was started continued to deteriorate overnight right pleural effusion 6 cm below RCM spleen 3 4 cm progressive shift to left leukopenia and thrombocytopenia placed in isolation

6 next day continues: hypoxemia hypotension renal failure hypoalbuminemia disseminated intravascular coagulation What are the risk factors for sepsis in this case? What are the risk factors for sepsis in this case? GBS infection of mother low birth weight

7 What are other risk factors that are associated with infection? What are other risk factors that are associated with infection? preclampsia premature labor ROM > 12 hours meconium What significant signs and symptoms did Baby Smith present with in: Level 1 Nursery Level III Nursery

8 Level 1 Nursery cyanosis jaundice poor feeding pustules on legs Level III Nursery physical signs & symptoms lab information Clinical Signs of Sepsis temperature instability apneic spells supplemental oxygen need for ventilation tachycardia/bradycardia

9 Clinical Signs of Sepsis hypotension feeding intolerance abdominal distension necrotizing enterocolitis Altered serum parameters white blood cell count absolute neutrophil count band count platelet count High Probable Sepsis (HPS) 3 sepsis related clinical signs CRP > 5 mg/ml 2 other altered serum parameters Blood cultures positive or negative

10 Probable Sepsis (PRS) < 3 sepsis related clinical signs CRP > 5 mg/ml < 2 other altered serum parameters Blood culture: negative Possible sepsis (POS) < 3 sepsis related clinical signs CRP < 5 mg/dl < 2 other altered serum parameters Blood culture: negative What are the nursing priorities for management of Baby Smith

11 What are the nursing priorities for management of Baby Smith core temperature > 36.4 C (97.5 F) nutrition ( kcal/kg/day) average weight gain of g (5 7 oz) per week monitor for hypoglycemia What s New??? vaccination granulocyte colony stimulating factors granulocyte macrophage colony stimulating factor (GM-CSF) What s New??? pentoxifylline (TNF - ) protein C (microcirculation) procalcitonin (marker) melatonin (ROS)

12 Tommy, 3 year old, was found unconscious in the barn stall with a cow and calf apparently kicked or butted spontaneous respirations increased extensor toner responsive to noxious stimuli Other findings: alternates between agitation & flaccidity with apnea GCS 8 large subgaleal hematoma of the right parietal & temporal scalp Other findings: blood draining from left ear abrasions on the forehead and left side of face pupils equal & reactive neck in C - collar

13 Interventions: 1 g/kg IV mannitol orally intubated transported via helicopter to regional Children s Hospital Vital signs during transport: HR 150/minute BP 125/59 RR 30/minute T 37 C Laboratory Data Sodium 134 Potassium 3.4 Chloride 104 BUN 16 Creatinine 0.4 Glucose 308

14 Laboratory Data: Amylase 74 Hemoglobin 12.3 WBC 26, 400 PT 13.7 PTT 23.2 Diagnostics: cervical, thoracic, & lumbar spine radiographs; abdominal & pelvic CT scans negative cranial CT showed large right parieto occipital skull fracture with subarachnoid blood surrounding brainstem and filling superior cerebellar cistern Management Strategies: ICP monitoring ventilatory support minimal isotonic fluids sedation enteral feedings

15 3 rd day sodium dropped to 129 and serum osmolality of th day developed fever 38.5 C 7 th day spontaneous movement of all extremities, localized to stimuli, purposeful movements pupils equal and reactive to light GCS th day weaned & extubated working with physical, speech, & occupational therapy 6 weeks walking with assistance

16 What is the significance of CPP? What are the common causes of secondary brain injury? What are the common causes of secondary brain injury? Hypoxia Hypotension (systemic) Hypercapnia Hypertension (intracranial) Hyperglycemia

17 What strategies are used to reduce secondary brain injury? Identify multisystem changes seen in response to brain injury. 13 year old male found stuporous but responsive to vigorous shaking transported to the ED

18 Initial Assessment: warm, dry, flushed skin poor skin turgor rapid, deep respirations fruity odor to breath finger stick reveals level that exceeds upper limits of dextrometer Management physician notified IV started NS wide open Vital signs: HR 118/minute BP 80/40 RR 24/minute T 37 C (98.6 F)

19 Laboratory Data Sodium 124 Potassium 6.2 Chloride 92 Carbon dioxide 6 Creatinine 1.9 Glucose 804 Laboratory Data: Hemoglobin 12 Hematocrit 36 WBC 24, 000 Platelets 358,000 ABGs ph 7.0 paco 2 17 pao 2 90 HCO 3 4 SaO 2 94%

20 Laboratory Data - Other Serum Ketones 45 Urine Ketones + Anion Gap 26 Carbon dioxide 6 Lungs Clear to auscultation Interventions: cultures: 2 sets of blood, urine & sputum IV NS regular insulin electrolyte replacement Laboratory Data Creatinine Sodium Potassium Carbon dioxide Chloride Glucose Urine Output

21 Laboratory Data Creatinine Sodium Potassium Carbon dioxide Chloride Glucose Urine Output What type of diabetes is most frequently the cause of DKA? What type of diabetes is most frequently the cause of DKA? Insulin dependent Type 1 Juvenile onset

22 How is the anion gap calculated? What is the significance of anion gap? How is the anion gap calculated? What is the significance of anion gap? Na (CO 2 + Cl) What electrolytes are usually abnormal in a patient with DKA?

23 What electrolytes are usually abnormal in a patient with DKA? sodium chloride potassium phosphate How should the acid base imbalance be treated in this patient? How should the acid base imbalance be treated in this patient? insulin fluids bicarbonate?

Infection. Risk factor for infection ACoRN alerting sign with * Clinical deterioration. Problem List. Respiratory. Cardiovascular

Infection. Risk factor for infection ACoRN alerting sign with * Clinical deterioration. Problem List. Respiratory. Cardiovascular The ACoRN Process Baby at risk Unwell Risk factors Post-resuscitation requiring stabilization Resuscitation Ineffective breathing Heart rate < 100 bpm Central cyanosis Support Infection Risk factor for