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1.What are the possible causes you have to consider?

Patient in this scenario is having Metabolic acidosis but inadequate respiratory


compensation.

Metabolic acidosis is characterized by decreased pH, HCO3, and PaCO2. The


commonest cause of metabolic acidosis in a sick child is poor circulatory status
associated with anaerobic respiration due to tissue hypoxia, dehydration, catabolism
and sepsis. Metabolic acidosis due to errors of metabolism is usually associated with
an increase in anion gap.

Hypoxemia caused by lung or heart disease often contributes to the tissue hypoxia
and resulting lactic acidosis seen with hypoperfusion states.

Sepsis in the newborn, as in older individuals, may cause metabolic acidosis by


decreasing perfusion and by interfering with cellular aerobic metabolism . To
compensate for metabolic acidosis, term neonates and infants will attempt to lower
PCO2 by hyperventilating; however, compensation is usually not complete as
depicted in this case.

Important causes of acidosis in neonates:

 Perinatal asphyxia
 Sepsis -“Early” Pathogens (first week)-
o Group B Strep (GBS)
o E. coli
o Occasional Salmonella sepsis
o Listeria monocytogenes
o Herpes Simplex
o Enterovirus

 Hypovolaemia
 Low cardiac output and poor tissue perfusion
 Hypothermia
 Anaemia
 Renal bicarbonate losses
 Cardiac failure / congenital cardiac anomalies
 Inborn error of metabolism
2. Outline your assessment of this neonate. (Assessment
means history, examination and investigations)
History- should include asking about most common risk factors associated with
early onset neonatal sepsis Risk factors implicated in neonatal sepsis reflect the
stress and illness of the fetus at delivery, as well as the hazardous uterine
environment surrounding the fetus before delivery such as-

 maternal group B Streptococcus (GBS) colonization (especially if


untreated during labor),
 premature rupture of membranes (PROM),
 prolonged rupture of membranes,
 prematurity,
 chorioamnionitis
 Low Apgar score (<6 at 1 or 5 min),
 maternal fever greater than 38°C
 poor prenatal care,
 poor maternal nutrition,
 low socioeconomic status,
 recurrent abortion,
 maternal substance abuse,
 low birth weight,
 difficult delivery,
 birth asphyxia,
 meconium staining, and
 congenital anomalies.

Examination – A systematic physical assessment of the infant is best performed in


series and should include observation, auscultation, and palpation in that order to
obtain the most information from the examination.

The initial assessment of the patient includes examination of respiratory effort and
circulation of the skin concurrently with their sense of the child's acuity, that is, “sick,
not sick.”
Pediatric Assessment Triangle—Initial Assessment
CIRCULATION TO THE
APPEARANCE WORK OF BREATHING
SKIN

Tone Abnormal sounds: stridor, grunting, snoring, wheezing Pallor

Irritable, Abnormal positioning: sniffing, tripoding, refusal to lie


Mottling
interactive down

Consolable Retractions Cyanosis

Look/gaze Head bobbing Petechiae

Speech/cry Nasal flaring

Effortless tachypnea, or rapid respirations with no increased work of breathing, is


characteristic of this child compensating for metabolic acidosis by increasing the
respiratory rate and driving the pH toward normal.

Compensated shock can be recognized by the presence of pallor. A pale child with a
rapid heart rate should always be considered to be in shock until proved otherwise.

As cardiac output is further compromised and perfusion to vital organs is decreased,


the skin may become mottled. Mottling is manifested by areas of vasoconstriction
and vasodilation in a random pattern on the skin. Mottling is usually an ominous sign.

Investigations:

 Serum Na, K, Cl, and bicarbonate (on ABG) to determine anion gap .
 Blood lactate to confirm lactic acidosis
 Metabolic screen: urine and serum for amino acids and organic acids
 Blood count - sepsis, anaemia
 Blood cultures - sepsis
 LP-it is quite possible to have meningitis along with septicemia without any
specific symptomatology
 Chest Xray
 ECHO - low cardiac output
3. Management-
Supportive:
 Neonate should be nursed in a thermo-neutral environment taking care to
avoid hypo/hyperthermia.
 Oxygen saturation should be maintained in the normal range;
(mechanical ventilation may have to be initiated if necessary)
 If hemodynamically unstable, intravenous fluids should be administered
 Should be monitored for hypo/hyperglycemia.
 Normal tissue perfusion and blood pressure should be maintained. Volume
expansion with crystalloids/colloids and judicious use of inotropes may be
required. Packed red cells and fresh frozen plasma might have to be used in
the event of anemia or bleeding diathesis.

Antimicrobial therapy

Neonates with clinically suspected Sepsis:

 Obtain cultures, CBC & CRP first.


 Start antibiotics with Ampicillin + Gentamicin (or Amikacin,
Tobramycin, Netilmicin).
 Third generation cephalosporins (Cefotaxime, ceftazidime,
ceftriaxone) may replace gentamicin if meningitis is clinically
suspected

Disposition

When the neonate has been stabilized, monitoring of oxygenation, ventilation,


perfusion, temperature, and glucose must continue.

Preparations should be made for transport of the newborn to a neonatal intensive


care unit. A transport team with personnel skilled in neonatal resuscitation should be
employed.

Ideally, before transport, parents should see and touch (and hold if medically
appropriate) their newborn.

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Naveen Mathur