NEONATAL CRISIS

• Neonatal sepsis is a diagnosis made in infants less than 28 days of life and consists of a clinical syndrome that may include systemic signs of infection, circulatory shock, and multisystem organ failure
• Neonatal sepsis remains an important diagnosis requiring high index of suspicion. Immediate treatment with antibiotics is imperative
• Sources of sepsis:

  1. Mother anomalies to fetus
  2. Fetal anomalies
  3. External forces / environmental - nosocomial infection: hospital acquired infection
• Sepsis is a serious medical condition caused by the body's response to infection
• Neonatal sepsis can be caused by bacteria: Escherichia Coli, Listeria and some strains of Streptococcus
• What is the major cause of neonatal sepsis

  Group B Streptococcus
• Pathophysiology of Neonatal Sepsis

  ● The immature immune system of the newborn is the major contributing factor for increased neonatal susceptibility to sepsis.

  ● bacterial infections are the most common cause of sepsis. However, sepsis can also be caused by fungi, parasites or viruses. The infection can be located in any of a number of places throughout the body.

  ● Nosocomial infection- acquired from hospital
• NEWBORNS AT RISK (Neonatal Sepsis)

  ● Prematurity and prolonged period between rupture of membranes and delivery. (prom and incompetent cervix.

  ● Dystocia- prolonged labor

  ● Maternal infection

  ● Small for gestational age

  ● Meconium aspiration - newborn has swallowed meconium intrauterine life.

  ● Iatrogenic infected personnel and equipment which leads to nosocomial infection.
• Other causes/risks (Neonatal Sepsis):

  ● If the mother has an infection of the amniotic fluid (a condition known as chorioamnionitis)

  ● Premature birth (premature newborn are at a higher risk for sepsis)

  ● Low birth weight of the infant (risk factor for sepsis)

  ● If the mother's water breaks early prom (more than 14 hours before the newborn is delivered)

  ● If the newborn is being treated for another condition while still in the hospital.

  ● If the mother's birth canal is colonized with bacteria - sti that was never treated
• Signs and Symptoms of Neonatal Sepsis

  ● Temperature irregularity

  ○ Fever

  ○ Hypothermia

  ● Tone and behavior

  ○ Poor tone

  ○ Weak suck

  ○ Shrill cry

  ○ Weak cry

  ○ Irritability

  ● Skin

  ○ Poor perfusion

  ○ Cyanosis

  ○ Mottling

  ○ Pallor

  ○ Petechiae

  ○ Unexplained jaundice
• Diagnostic tests: tests for sepsis in newborns can include:

  1. Blood tests (Blood cell counts - WBC, blood culture taken- to identify what bacteria/virus has invaded the system so proper medications/antibiotics will be given.)
  2. Urine tests (urinalysis and culture)
  3. Spinal tap (also known as lumbar puncture) to test for meningitis
• A spinal tap is a procedure in which a very small needle is inserted into the space around your child's spine to withdraw spinal fluid to test for infections
• Treatment (Neonatal sepsis):

  ● Intravenous (iv, directly into a vein) fluids

  ● IV antibiotics

  ● Oxygen administration and other forms of respiratory support, if needed

  ● Occasionally, newborn may need blood transfusions
• (Neonatal Sepsis) Nursing Responsibilities:

  ● Isolate newborn

  ● Don handwashing - observe strict asepsis in handling the newborn to prevent nosocomial infection.

  ● Provide oxygen therapy and respiratory support

  ● Administer antibiotics

  ● Keep the newborn warm

  ● Maintain nutrition and hydration: IVF, MIO daily

  ● Check and monitor: signs of dehydration: sunken fontanels, depressed eyeballs, poor skin turgor, oliguria, fever and lethargy.

  ● Meet the newborn's emotional needs

  ● Provide emotional support to the mother and family.
• Meconium aspiration syndrome is a clinical condition characterized by respiratory failure occurring in neonates born through meconium-stained amniotic fluid. when a newborn breathes in a sticky substance called meconium just before or during birth
• Contents of meconium: intestinal epithelial cells of intestines and desquamated epidermis of the skin, lanugo, bile salts, amniotic fluid and mucus.
• Characteristic of meconium: it appears sticky like tar, it is viscous, dark olive green in color, and the smell is almost odorless
• Etiology: Meconium aspiration syndrome occurs when meconium is swallowed by a fetus/neonate into the lungs that would cause problems like respiratory distress syndrome (RDS)
• Pathophysiology:

  ● Meconium mixes with amniotic fluid - in utero swallowed by the fetus - it then enters the lungs

  ● Irritates the airway - causes airway spasm and pneumonia aspiration

  ● Bilateral coarse infiltration in the lungs

  ● Drowns the lungs if the fetus gasps.

  ● Lead to difficulty of breathing

  ● Sepsis

  ● Problems in the vital signs = becomes stable

  ● RDS (respiratory distress syndrome)
• Risk factors of Meconium aspiration:

  1. Overdue pregnancy = more than 40 weeks gestation

  2. Fetal distress caused by:

  a. Maternal hypertension = PIH/HELLP

  b. Preeclampsia

  c. Placental insufficiency

  d. Smoking

  e. Abuse of cocaine

  f. Risk age of pregnancy
• The occurrence of meconium stained amniotic fluid can lead to birth asphyxia, meconium aspiration syndrome that would result in (RDS or hyaline membrane disease), that would lead to an increase in the admission to the neonatal intensive care unit (NICU).
• Signs and Symptoms of Meconium Aspiration

  1. Cyanosis
  2. Weak cry
  3. Rapid breathing
  4. Grunting and apneic episodes
  5. Poor suck
  6. Poor reflexes
• If the newborn is diagnosed with meconium stained/aspiration:

  ● We do not start feeding, keep the newborn NPO. we have to do lavage (wash out until secretions obtained are clear.

  ● Do not feed until VS are stable

  ● Keep NGT in place, maintain it on a gravity drain until drainage is clear.

  ● Only the nurse can start feeding once the drain is clear and after assessment by the doctor.

  ●Gavage: feeding a patient through a tube (NGT/OGT)
• Respiratory distress syndrome (RDS) occurs in premature newborn whose lungs are not fully developed. The earlier the infant is born, the more likely it is for the newborn to have rds and to need extra oxygen and help breathing
• RDS is caused by the newborn not having enough surfactant in the lungs. (Lecithin / Sphingomyelin surfactant) is a liquid made in the lungs at about 26 weeks of pregnancy. as the fetus grows, the lungs make more surfactant
• Etiology of RDS:

  • Immature lungs with decreased surfactant. results in insufficient production of surfactant leads to lungs of the newborn that has problems - respiratory distress syndrome
  • By 24 to 36 weeks gestation, surfactant is not mature enough to enable it to breathe normally outside the uterus
  • With immature lungs there is less production of surfactant causing the lungs to be stiff
  • Resistant to expansion. = leads to difficulty of breathing = RDS.
• Pathophysiology of RDS

  ● Immature lungs of the premature newborn

  ● Less production of surfactant/ low levels of surfactant

  ● Decreased blood perfusion of the lungs

  ● Termination of bronchioles, alveolar ducts and alveoli= result shutdown

  ● Vasoconstriction, decreased pulmonary perfusion

  ● Distressed newborn = vital signs unstable

  ● Death
• Nursing Alert!

  • Signs of RDS begin within the first hour after birth and if not treated with surfactant, may lead to severe conditions.
  • Not all premature births administered with surfactant may be able to survive
• Infants at risk of rds

  ● Premature newborn

  ● Twin or multiple births - (premature)

  ● Meconium stained newborns

  ● C-section delivery

  ● Complications during pregnancy

  ● Mother with untreated infection

  ● Newborn is ill at the time of delivery - intrauterine complications

  ● Newborns delivered with these complications: hypothermia, hyperthermia, hypoglycemia, hyperglycemia and, other complications that the newborn may manifest
• Signs and symptoms of RDS:

  1. Hypoxia - lack or low oxygen supply. bluish discoloration
  2. Fast breathing very soon after birth = tachypnea and tachycardia
  3. Grunting "ugh" sound with each breath
  4. Changes in color of lips (circumoral cyanosis, fingers and toes (acrocyanosis) - entire body (generalized cyanosis)
  5. Nasal flaring (widening) of the nostrils with each breath. Shows the newborn is struggling to breath.
  6. Chest retractions. Sternal retraction. Skin over the breastbone and ribs pulls in during breath
  7. Apneic episodes - cessation of breathing between 10 to 15 second
• Complications associated with RDS:

  1. Retrolental Fibroplasia - permanent blindness. prolonged use of oxygen may rupture/damage retina of the eye. This is caused by injudicious use of oxygen.
  2. Bronchopulmonary dysplasia - chronic lung disease that affects newborn. caused by damaged tissues due to lack of oxygen supply.
  3. Atelectasis - collapsed lungs which can lead to irreversible damage will lead to death. the heart is also affected
• What is the first treatment for RDS mentioned?

  Oxygen administration
• What should be done to secretions in RDS treatment?

  Continue suctioning secretions gently
• When should no be maintained in RDS treatment?

  If signs of RDS are significant
• How is surfactant administered to newborns?

  Directly down the breathing tube
• What is the purpose of surfactant in RDS treatment?

  To replace what newborns do not have
• What does the CAP machine do in RDS treatment?

  It gently pushes air or oxygen into the lungs
• What condition does CAP help prevent?

  Retrolental fibroplasia
• What is the purpose of IVF in RDS treatment?

  To maintain hydration
• When are antibiotics given in RDS treatment?

  If an infection is suspected