Sepsis Neonatorum

I. Objectives

• Generalized Objectives:

Ø  Have critical thinking skills necessary for providing safe & effective nursing care.

Ø  Familiarize ourselves with effective inter-personal skills to emphasized health promotion & illness prevention.

• Patient and family Centered Objectives:

     

Ø  To identify measures that could minimize the occurrence of the disease.

Ø  To identify possible risk factors that may have contributed to the development of sepsis neonatorum.

Ø  To increase awareness on the risk factors of sepsis neonatorum.

Ø  To develop the family’s support system & distinguish their respective roles in improving patient’s health status.

Ø  Involve them in promoting the health care of the patient.

 Medical Diagnosis

Sepsis Neonatorum

Sepsis in a newborn (sepsis neonatorum) is an infection that spreads throughout the baby’s body. Sepsis occurs in less than 1 percent of newborns (1 out of every 100), but accounts for up to 30 percent of deaths in the first few weeks of life. Infection is 5-10 times more common in premature newborns and in babies weighing less than 5½ pounds than in normal-weight, full-term newborns. Complications experienced during birth, such as premature or prolonged rupture of the membranes or infection in the mother put the newborn at increased risk of infection.

Sepsis, also known as Systemic Inflammatory Response Syndrome (SIRS), is a serious medical condition caused by the body's response to a bacterial infection, which can lead to serious complications that affect the kidneys, lungs, brain, and hearing, and can even cause death. It is a condition in which the body is fighting a severe infection that has spread via the bloodstream.

If a patient becomes "septic," they will likely be in a state of low blood pressure termed "shock." This condition can develop either as a result of the body's own defense system or from toxic substances made by the infecting agent (such as a bacteria, virus, or fungus).

Sepsis is a serious infection usually caused by bacteria - which can originate in many body parts, such as the lungs, intestines, urinary tract, or skin - that make toxins that cause the immune system to attack the body's own organs and tissues.

Sepsis can affect people of any age, but is more common in:

• Infants under 3 months, whose immune systems haven't developed enough to fight off overwhelming infections
• Patients who are in the hospital
• People with a genetic tendency for sepsis
• People with chronic medical conditions
• People with pre-existing infections or medical conditions
• People with severe injuries, such as large burns or bullet wounds
• People with weakened immune systems
• Elderly people
• Very old or very young people
• People whose immune systems are compromised from conditions such as HIV

Causes of Sepsis:
Sepsis can lead to widespread inflammation and blood clotting. Inflammation may result in redness, heat, swelling, pain, and organ dysfunction or failure. Blood clotting during sepsis causes reduced blood flow to limbs and vital organs, and can lead to organ failure or gangrene.

• The most common cause of sepsis is Bacteria
• Sepsis can also be caused by fungal, parasitic, or viral infections.

The source of the infection can be any of a number of places throughout the body. Common sites and types of infection that can lead to sepsis include:

• Abdomen - Infection of the abdominal cavity , and gallbladder or liver infections
• Central nervous system - Infections of the brain or the spinal cord
• Kidneys - Urinary tract infections are especially likely if the patient has a urinary catheter to drain urine
• Lungs - Infections such as pneumonia
• Skin - Bacteria can enter skin through wounds or skin inflammations.

Signs & Symptoms of Sepsis:
The onset of what is called early-onset neonatal sepsis is within six hours of birth in over half the cases and within 72 hours in the great majority of cases.  Sepsis that begins four or more days after birth is called late-onest sepsis, and is probably an infection acquired in the hospital nursery (a nosocomial infection). In both types of neonatal sepsis, the infection may be only in the bloodstream, or may spread to the lungs (pneumonia), brain (meningitis), bone (osteomyelitis), joints, or other organs in the body.

Symptoms of sepsis in newborns and young infants include:

• Changes in rate of heartbeat
• Decreased tone
• Decreased urination
• Difficulty in breathing
• Difficulty in feeding, or vomiting
• High Fever
• Increased crankiness
• Jaundice
• Lethargy
• Pale skin color
• Rash

Older children have might have following symptoms:

• Change in skin color
• Fever
• Lethargy
• Rash
• Trouble breathing
• Vomiting

Diagnosis of Sepsis:

The organism that is causing the infection may be identified by taking cultures of the blood as well as from other sites of the body. Urine samples are often cultured for bacteria to look for an infection in the urinary tract. Because only small samples of blood and other body fluids are taken, sometimes no organism is found. However, the infant may still be treated if other laboratory studies or the infant’s clinical appearance strongly suggest an infection.

Other laboratory studies that doctors use to detect an infection include the following:

• White Blood Cell Count and Differential: When an infant is fighting an infection, their white blood cell count may either go up, as the infant’s body produces more infection-fighting cells, or it might also go down if the infant has used up all of their white blood cells fighting the infection and can no longer keep up with their production of white cells. Another change that is seen when an infant is fighting an infection is an increase in the percentage of immature white cells.  This is due to the increased production rate of white blood cells, such that more immature white blood cells are being released into the blood stream.  This higher percentage of immature white cells is sometimes referred to as a “left-shift,” and is one of the things that can tell the doctors that the infant has an infection.
• C - reactive protein (CRP): This is a laboratory test that measures a protein that is a non-specific marker for inflammation and therefore infection. If the infant has two normal CRP levels measured 24 hours apart, then there is a 99% chance that the infant does not have an infection. Therefore, this test is most useful in ruling out an infection.
• Lumbar Puncture: If the doctor suspects meningitis, which is more common if something has grown in the baby’s blood culture, a spinal tap, or lumbar puncture will be performed. Lumbar punctures allow the doctor to obtain a small amount of cerebrospinal fluid (CSF), which is the protective fluid that surrounds the brain and the spinal cord. The CSF can then be cultured to determine if the bacteria has spread to the nervous system. The doctor, nurse practitioner, or physician’s assistant will very carefully insert a special spinal needle between two vertebrae, or backbones, in the baby’s back at a level below where the actual spinal cord ends, so there is no danger that the needle will come into contact with the baby’s spinal cord. After a very small amount of fluid is removed, the needle is taken out, and a band-aid placed on the baby’s back.

Prognosis and Treatment:

Sepsis in a newborn is treated with antibiotics given intravenously. Antibiotics are often started even before laboratory and culture results are available. The doctor may then switch to a different antibiotic that is more specific to the baby’s infection once the results of laboratory tests are back. The length of antibiotic treatment varies depending on the infant’s clinical status, laboratory test results, and kind of infection. If blood cultures and other laboratory tests are all negative, antibiotics may be stopped after 48 hours of treatment. If the infant’s cultures are positive, or if the laboratory tests and clinical status are suggestive of infection, the infant will be treated with antibiotics, usually anywhere from 7-14 days. When appropriately treated with antibiotics and cared for in the intensive care unit, the great majority of newborns with sepsis live without any long-term problems.

• Drug therapies: Some patients are given new drug therapies
• Intensive Care Unit: Patients diagnosed with severe sepsis are placed in the ICU for special treatment.
• IV fluids: The doctor manages IV fluids to prevent blood pressure from dropping too low.
• Vasopressor medications: Vasopressor medications are needed to achieve an adequate blood pressure. 
• Supportive care: If organ failures occur, appropriate supportive care is provided like dialysis for kidney failure, mechanical ventilation for respiratory failure, etc.

When to seek Medical Advice

Symptoms of sepsis can be very difficult to identify in newborns and young infants, so it is always better to call your health care provider immediately. Emergency medical care is necessary if your baby shows any severe symptoms of sepsis.

The signs don't necessarily mean a child has sepsis, but it's very important that a doctor should know about symptoms to make sure that the infection is sepsis or something else, before it becomes more severe.

Anatomy and Physiology

The Lymphatic System

The lymphatic system, or lymph system, defends the body from foreign invasion by disease causing agents such as viruses, bacteria, or fungi. The lymphatic system consists macroscopically of: The bone marrow, spleen, thymus gland, lymph nodes, tonsils, appendix, and a few other organs.

The lymph system contains a network of vessels that assists in circulating body fluids. These vessels transport excess fluids away from interstitial spaces in body tissue and return it to the bloodstream. Lymphatic vessels prevent the backflow of the lymph fluid. They have specialized organs called lymph nodes which filter out destroyed microorganisms. The functioning of the lymphatic system is most easily seen at the microscopic level. Blood cells are produced in the marrow of human bone.

When mature, white blood cells actively seek out possible pathogens or unknown substances and, using a complex chemical signaling system, can attack directly or provide for the removal of this substance. If a white blood cell is alerted to the presence of unwanted bacteria in the blood, it will find these bacteria and surround it. After a type of white blood cell (a T cell) has the bacteria trapped, it releases a deadly toxin that destroys the bacteria by breaking its outer membrane. The relationship between B-Cells, T-Cells and other cells in the immune system is complex. B and T cells undergo complex transformations in response to signal chemicals and foreign substances. In the transformation of B-Cells, different cancers can present themselves.

Main functions of lymphatic system:

·   To collect and return interstitial fluid, including plasma protein to the blood, and thus maintain fluid balance.

·   To defend the body against disease by producing lymphocytes.

·   To absorb lipids from the intestine and transport them to the blood.

The Cardiovascular System

      

The cardiovascular/circulatory system transports food, hormones, metabolic wastes, and gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system include:

• blood: consisting of liquid plasma and cells
• Blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange occurs.)
• heart: a muscular pump to move the blood

There are two circulatory "circuits": Pulmonary circulation, involving the "right heart," delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from the "right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich blood from the lungs back to the "left heart."  Systemic circulation, driven by the "left heart," carries blood to the rest of the body. Food products enter the system from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems ultimately return to the "right heart" via the inferior and superior vena cavae.

A specialized component of the circulatory system is the lymphatic system, consisting of a moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone marrow, liver, spleen, thymus).  Through the flow of blood in and out of arteries, and into the veins, and through the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion. 

Immune System

An immune system is a system of biological structures and processes within an organism that protects against disease by identifying and killing pathogens and tumor cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own healthy cells and tissues in order to function properly. Detection is complicated as pathogens can evolve rapidly; producing adaptations that avoid the immune system and allow the pathogens to successfully infect their hosts.

To survive this challenge, multiple mechanisms evolved that recognize and neutralize pathogens. Even simple unicellular organisms such as bacteria possess enzyme systems that protect against viral infections. Other basic immune mechanisms evolved in ancient eukaryotes and remain in their modern descendants, such as plants and insects. These mechanisms include antimicrobial peptides called defensins, phagocytosis, and the complement system. Jawed vertebrates, including humans, have even more sophisticated defense mechanisms.^[1] The typical vertebrate immune system consists of many types of proteins, cells, organs, and tissues that interact in an elaborate and dynamic network. As part of this more complex immune response, the human immune system adapts over time to recognize specific pathogens more efficiently. This adaptation process is referred to as "adaptive immunity" or "acquired immunity" and creates immunological memory. Immunological memory created from a primary response to a specific pathogen, provides an enhanced response to secondary encounters with that same, specific pathogen. This process of acquired immunity is the basis of vaccination. Primary response can take 2 days to even 2 weeks to develop. After the body gains immunity towards a certain pathogen, when infection by that pathogen occurs again, the immune response is called the secondary response.

Disorders in the immune system can result in disease. Immunodeficiency occurs when the immune system is less active than normal, resulting in recurring and life-threatening infections. Immunodeficiency can either be the result of a genetic disease, such as severe combined immunodeficiency, or be produced by pharmaceuticals or an infection, such as the acquired immune deficiency syndrome (AIDS) that is caused by the retrovirus HIV. In contrast, autoimmune diseases result from a hyperactive immune system attacking normal tissues as if they were foreign organisms. Common autoimmune diseases include Hashimoto's thyroiditis, rheumatoid arthritis, diabetes mellitus type 1, and lupus erythematosus. Immunology covers the study of all aspects of the immune system, having significant relevance to health and diseases. Further investigation in this field is expected to play a serious role in promotion of health and treatment of diseases.

Blood

Blood is a specialized bodily fluid that delivers necessary substances to the body's cells – such as nutrients and oxygen – and transports waste products away from those same cells.

In vertebrates, it is composed of blood cells suspended in a liquid called blood plasma. Plasma, which constitutes 55% of blood fluid, is mostly water (90% by volume),^[1] and contains dissolved proteins, glucose, mineral ions, hormones, carbon dioxide (plasma being the main medium for excretory product transportation), platelets and blood cells themselves. The blood cells present in blood are mainly red blood cells (also called RBCs or erythrocytes) and white blood cells, including leukocytes and platelets. The most abundant cells in vertebrate blood are red blood cells. These contain hemoglobin, an iron-containing protein, which facilitates transportation of oxygen by reversibly binding to this respiratory gas and greatly increasing its solubility in blood. In contrast, carbon dioxide is almost entirely transported extracellularly dissolved in plasma as bicarbonate ion.

Vertebrate blood is bright red when its hemoglobin is oxygenated. Some animals, such as crustaceans and mollusks, use hemocyanin to carry oxygen, instead of hemoglobin. Insects and some mollusks use a fluid called hemolymph instead of blood, the difference being that hemolymph is not contained in a closed circulatory system. In most insects, this "blood" does not contain oxygen-carrying molecules such as hemoglobin because their bodies are small enough for their tracheal system to suffice for supplying oxygen.

Blood is circulated around the body through blood vessels by the pumping action of the heart. In animals with lungs, arterial blood carries oxygen from inhaled air to the tissues of the body, and venous blood carries carbon dioxide, a waste product of metabolism produced by cells, from the tissues to the lungs to be exhaled.

Pathopysiology Diagram