Transcript Neonatal fever 新生兒發燒

Neonatal fever
新生兒發燒
General data
 Name:黃ㄨ瑩之子
 Gender: male / 1-day-old
 Hx: 2791668
 Ward: PICU-CN02
 Admission Date: 2014/10/24
 Time of birth: 2014/10/24 22:05
 GA: 39 1/7 weeks, BBW: 3458gm
Chief complaint
 Fever 38.3℃(Anal temperature) after birth.
Present illness
2014/10/24
13:30
2014/10/24
16:00
2014/10/24
22:05
 His mother experienced rupture of
membrane at 13:30
 His mother had fever up to 38.7C at 16:00
Ampicillin 2 doses before delivery
 The baby was born at 22:05 with gestational
age 39 1/7 weeks via NSD at TSGH OBS.
Mild meconium stain was noted, but no
meconium was seen at vocal cord and
epiglottis.
Floppiness and delay crying.
Apgar score: 1’(7), 5’(9)
Fever, 38.3C
Prenatal history
產婦轉診: 無
產檢醫院: TSGH
Maternal disease: HBV carrier
Tocolysis: None
HBs Ag: Positive, HBe Ag: Positive, VDRL:
Negative
 GBS culture: Negative
 Rupture of membrane: 9 hrs
 Drug: Ampicillin (Dosage before delivery: 2)
 NTISS: 15
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Birth history
 G: 0, P: 0, GA: 39 1/7 weeks, BBW: 3458gm
 Delivery: NSD
 出生醫院: TSGH
 Time of birth: 20141024 22:05
 Fetal distress: mild, Meconium stain: mild
 Apgar score: 1’(7), 5’(9)
 產房急救: O2 support
 HEPATITIS B IMMUNOGLOBULIN+
HEPATITIS B Vaccine
Family history
Physical examination
 Vital sign: PR: 140 /min RR: 42 /min BT: 38.3 ℃ BW:
3458gm (75th percentile), HC: 33.5cm (50th percentile),
BL: 51cm (75th percentile)
 Skin: no petechiae or ecchymosis, no skin rash, no jaundice
 HEENT: no pale conjunctiva, no icteric sclera, no stiffness,
no cervical lymphadenopathy, no oral ulcer, no congestion
throat, no congestion of eardrum, bil
 Chest: well expansion, clear breathing sound, no chest wall
deformity; no respiratory retraction; no rhonchi, no
wheezing, no rales, no suprasternal retraction, no subcostal
retraction
Physical examination
 Heart: regular heart beat, no murmur, no heave or thrill
 Abdomen: ovoid in shape, no palpable mass, no
hepatomegaly or splenomegaly, bowel sound increasing,
tympanic percussion sound, no rebounding pain &
tenderness
 Extremities: no deformity of the spine or limbs, no joint
stiffness, no clubbing finger
 Neurologic: normal Moro reflex, normal rooting reflex,
normal grasp reflex, present Barbinski sign, normal sucking
reflex
10/25 00:23 Lab. data
10/25 00:25 Lab. data
10/25 Chest X-ray
13
10/24 05:00 Maternal Lab. data
Impression
 Fever, supect neonatal sepsis
 Suspected meconium aspiration syndrome
Plan to do
 1.Empiric antibiotic use with Ampolin
(150mg/kg/day) and Gentamicin (4mg/kg/day) to
cover possible pathogen.
 2.Adequate fluid supplement and nutrition support
to the patient.
 3.Monitor vital signs, RDS and activity closely.
Definition
rectal temperature ≥ 38ºC (100.4ºF)
2. Vaccinations and bundling may affect body
temperature
~~ a fever >38.5ºC (101ºF) should not be
attributed to bundling regardless of the manner taken
1.
Immunity
 Immunologic competence improves steadily in the
first 3 months of life
 more susceptible to serious bacterial infection
(Pneumococcus and Hemophilus influenza type b)
Etiology-virus
 Viral infection : the most common cause
1. vertical transmission
2. family members and hospital personnel
 Pathogens
1. Herpes simplex
2. Varicella
3. Enteroviruses
4. Influenza virus
5. Adenoviruses
6. Respiratory syncytial virus
Etiology-bacteria
 Serious bacteria infection
1. bacteremia
2. bacterial meningitis
3. bacterial pneumonia
4. skin and soft tissue infections
5. osteomyelitis
6. bacterial gastroenteritis
7. septic arthritis
8. urinary tract infection
 Pathogens
1. Escherichia coli (<3 m/o)
2. Group B streptococcus (<3 m/o)
3. Listeria monocytogenes (<1 m/o)
4. others: Staphylococcus aureus, Streptococcus
pneumoniae, Salmonella species, Enterococcus
faecalis, Enterobacter cloacae, Moraxella
catarrhalis, Klebsiella species, and Citrobacter
species
Signs/Symptoms
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
Signs/Symptoms
Feeding Problems
 Vomiting
 Diarrhea
 Abdominal
distension
 Hypo or
Hyperglycemia
Cardiopulmonary
 Tachypnea
 Retractions
 Tachycardia for age
 Bradycardia in first
few days of life
 Hypotension for age
 Low SpO2
Not doing well !
Evaluation
 Higher risk-- WBC
1. serum ≥ 20000/uL
2. CSF ≥ 8-10/uL
3. UA ≥ 10/hpf
4. Stool ≥ 5 WBCs or RBCs
5. infiltration over CXR
Sepsis Work-Up
 Blood cultures
 Confirms sepsis
 Urine cultures
 Don’t need in infants <24 hours old because UTIs are
exceedingly rare in this age group
 Lumbar puncture
Suspect Meningitis
 Others: Tracheal aspirates, tapping for pleural
effusion/ascites, ….etc.
Other studies
 CBC/DCs
 CRP
 CXR
 Obtain in infants with respiratory symptoms
 Renal ultrasound or VCUG in infants with
accompanying UTI
Maternal Studies
 Examination of placenta and fetal membranes for
evidence of chorioamnionitis
Management
 Neonates should be considered high risk!
-> a complete sepsis evaluation with hospital
admission are warranted regardless of clinical
picture and laboratory results
 Antibiotics
1. ampicillin and gentamicin
2. ampicillin and cefotaxin (meningitis)
3. vancomycin and gentamicin/cefotaxin
(nosocominal infection)
Thanks for your attention!