ABO INCOMPATIBILITY/ SEPSIS

[drrameshkumarmuhilai]

Hai all i need your help,

I have a neonate with 38 wks,BW-2.6kg, delivered by LSCS, asymptomatic at birth, developed repiratory distress with abd distension at 22 hours of life, sepsis screen positive, no maternal risk for sepsis,sbr -12 mg/dl, ABO setup, started on phototherapy, higher antibiotics,at 32 hours persistent distress,ABG ph 7.23,pco2 40,po2 60,bicarb-16,sbr total 12, direct 3,echo is normal, DCT negative,retic 15%, elevated renal parameters,, started on ivig, and inotropes, my point is, is it ABO hemolysis, or sepsis plus hemolysis

[drrameshkumarmuhilai]

every one is having hectic schedule i believe

[Stefan Johansson]

I think the major problem here is the infection itself. Jaundice is not uncommonly seen in septic babies.

So my (general) advice is to give antibiotics as specific therapy and continue with supportive care for jaundice, and respiratory and hemodynamic stability.

If the baby continues to be unwell, despite that the infection is under control - then you will need to investigate for causes of hyperbili.

[yuriyko]

I think this can be sepsis + hemolytic disease. Retic count is rather high suggesting hemolysis

[drrameshkumarmuhilai]

Baby is hemodynamic ally stable, on higher antibiotics day 10, on breastfeeding , cholestasis recovering, except for high leucocyte count 38,000 and positive crp, initial smear showed neutrophilia, initial leucocyte was too high. ... Could this be leucocyte adhesion defect or partially treated sepsis

Dr ramesh kumar

[Stefan Johansson]

... except for high leucocyte count 38,000 and positive crp

How high is the CRP and how has it developed over the 10 days?

Did you get a positive blood culture?

[drrameshkumarmuhilai]

Hai Stephan, crp 8-9 mg/dl, value is persistent, culture no growth

Dr ramesh kumar

[Stefan Johansson]

Ok, that seems rather high with crp at that level.

What antibiotics combination do you use?

To me it seems that the infection is only partially treated.

[Guest Omer]

Hi Dr. Rames

I look at this baby's presentation this way; 22hour old, term 38 weeks, smallish with a birth wt of 2.6kg, with respiratory distress and abdominal distention.I will take this chance and get some education out of this .I usaully start with a good maternal history looking at Mother age, parity, prenatal follow up, findings on ultrasound scans.Her blood type and GBS status and the rest of her serology.Also important is GDM and HTN during pregnacy.Get an idea if mom smokes, use ETOH or drugs during prency. I will try to get some family history e.g Jaundice, haemolysis, etc. I would look at any issues during labour, e.g prolonged rupture of membranes, maternal fever, fetal tacycardia.I will try to find the indication for C.section and whether there was fetal distress or not. What was the baby APGAR score and was there any resuscitation needed. Was the baby kept with mom or was he/she admitted to the NICU from case room/labour &delivery.  I will try to figure  out if the baby had been feeding well and if there  was an  issue of stooling , urine out put .Was there any emesis or not. If there is emsis , was it bile stained.etc.

I understand , sometimes we get very sketchy histroy during our day to day work.

After collecting a good history , I will start a detailed exam from head to toe. I will start with a general exam: Get baby's Vital signs and a check for tissue perfusion and saturation. Is baby dysmorphic, pale,or  cyanosed. Is this baby just tachypneic or there is reall increased work of breathing, active alae nasi, grunting and retractions. listen to the air entry, try to figure out if there is abnormal sounds. Feel the precordium and see if its active or not. listen for the first and second heart sound and check if there is cardiac murmur or not.listen to murmur between scapulae(coarctation) Check the femoral pulses. Check the abdominal exam.palpate for the hepatosplenomegaly(congenital infection) and listen and check the anus if patent or not. Don't forget a female baby could have an anorectal anomaly and rectovaginal fistula and will be passing stool through the ****** and no body will notice it for  few days because the baby is in diapers. do a quick MSK and CNS check to see if the baby is active /lethargyic etc. don't forget to check the anterior fontanelle and don't forget to figure out if there is abnormal odor.

I think from the above strategy, I should be able to put a differential diagnosis which might include the following:

1) Sepsis: Septicemia presenting other historical issue( poor feeding, lethargy etc). the baby is tachypneic trying to compenaste for metabolic acidosis from poor perfusion and septic shock. Here you lactae will be high and blood gas will show metabolic acidosis. The pcos will be lowish as the baby is trying to compensate. Unless the baby is tired out and is developing a respiratory failure. The abdominal distension as you know could be due to septic ileus. Or the primary infection is NEC. keep in mind this baby is not yet 24 hrs old. But we have seen NEC in babys with bowel ischemia fro a cardiac cause or from hypoxic ischemia. The bay could have meningitis as a primary source and LP is indciated if the baby's conditionwill allow.The lungs could be the souce of infection e.g congenital pneumonia.

2)Cardiac causes: the first thing that comes to my mind is Heart failure or any duct dependand systemic circulation lestions e.g Coarctation, interupted aortic arch or hypoplastic left heart syndrome etc. you examination, chest xrays and echo will be very helpful here.

3)Respiratory : infection as we mentioned early. Respiratory distress syndrome( less likely in a term and ?SGA) but you never know. Structural lung lesions etc.

4)GI; NEC, Malrotation and volvulus, intestinal atresia etc.

5)Metablic: acidemias can present with abdominal distension , vomiting and metabolic acidosis.

6) Hemalogic: severe anemia due to any reason e.g haemolysis will lead to anemic heart failure

7) CNS: I remember a baby with AV malformation of Galen presenting with pulmonary hypertension and respiratory distress in the immediate neonatal period. put your stethoscope to the head.

8) Other , keep your mind open to anything that could be included in the differential .

I hope this helpful for students and residents

Omer Hamud

Neonatal-Perinatal Medicine

Toronto, Ca.

[drrameshkumarmuhilai]

On vanco and meropenam

[Dinesh N Patel]

have you rule out inborn error of metabolism ?does baby is on oral feeding/parental feeding. IEM may present after starting oral feed  same way as Sepis and improve transiently on parental fluid .

sepsis like presentaion 

renal and hepatic involvement (direct  sbil was high)