Neonatal Hypothermia and Neonatal Sepsis: Nursing Case Study

Introduction

Nursing profession is one of the most rewarded profession, and nursing neonates is highly challenging. Neonates are a specialised cohort of patients requiring an individualised approach in nursing care and the provision of a thermoneutral environment is a corner stone of neonatal care.The Marks-Maran and Rose’s (1997) reflective model and will guide my reflection and analysis of an experience gained in the special care baby unit. This reflective model has four parts: incident, reflective observation, related theory, and future action. In view of confidentiality and anonymity, the baby will be named Andy as per the guidelines determined by Nursing and Midwifery Council, 2018.

The Incident

In one of my shifts, I was tasked to care for baby Andy, 28+4 weeks at birth, weighing 1.240kg, delivered by emergency Caesarian section.  At the time of incident Andy is 8 weeks old with current weight of 1.960kg. Andy is admitted due to prematurity and chronic lung disease. Was nursed in a cot ,well thermoregulated and on Full enteral feeds. Knowing the history of Andy, I performed all the safety checks and prepared the plan of care.

During the mid afternoon it was noticeable that Andy was a bit sleepy, less active, neither woke up crying for feed nor cried during the cares. Andy looked lethargic which was quite unusual to him. I monitored his observations, comparing the baseline data,I noted that his temperature was 36.6 degree centigrade ,which was a decline from 37 degree centigrade. Heart rate was recorded between 110-110beats per minute and the respiratory rate was 62 breaths per minute. I dressed Andy well, covered him with a blanket and re assessed him as per unit guidelines.The temperature instability, reduced heart rate and level of activity prompt me to escalate this incident to the nurse in charge and the doctors. I ensured that parents were updated about the clinical condition of Andy.   Eventually the doctors informed the parents about the possibility of Andy having sepsis due to significant temperature instability. Bloods were taken in order  to rule out sepsis, Furthermore Andy was commenced on Intravenous antibiotic therapy.

Thoughts and feelings

When I was been allocated Andy, I thought it would be a straightforward plan of care.  Being aware of the history, I was quite confident that min is coping well with the baby. I was looking forward to prepare mum to room in the unit so that the transition to going home will be easier for mum and baby. Premature babies have poor thermal stability, that poses a greater risk for respiratory distress and hypothermia (Smith L.S ,2004). This incident made me confused with the signs and symptoms of hypothermia related to sepsis. I was also unsure if I need to escalate these findings for further management. This reflection sought to understand the clinical manifestation of hypothermia and sepsis and be assertive in decision making.

 Related Theory 

Cinar and Filiz (2006) explained that the ability to balance heat production and heat loss in order to maintain body temperature within a normal range is called thermoregulation.Thermoregulation or temperature control in the neonate is a critical physiological function that is strongly influenced by physical immaturity,  of illness and  environmental factors (Thomas, 1996). Furthermore Preterms have decreased capability to maintain homeostasis therefore are extremely vulnerable to body temperature variations.Neonates have decreased subcutaneous fat, a thin Epidermis , a greater body surface related to body mass and also the fact that the blood vessels being closer to the skin surface makes the infant vulnerable for temperature instability (SmithL.S, 2004). In addition newborns are especially susceptible to serious infections (McKenzie,1998).Small infants like Andy with large surface area in relation to body weight tends to loose heat rapidly therefore highly prone to acquire neonatal sepsis. Another reason for underdeveloped thermoregulation is due to the excessive heat loss, about four times more when compared to adults . This is primarily due to the lack of ability to generate heat from shivering, their hypothalamus can be slow to respond to the changes in temperature, and decreased brown fat deposits which is primary source of thermoregulation. (Lodewig et al,1998).Since Andy was born preterm poses a great risk for depleting brown fat stores. According to Çinar and Filiz (2006) neonatal hypothermia is defined as a drop of temperature below 36.5 ºC.

Managing Andy’s hypothermia was the prime objective. It is essential that neonates are nursed within their neutral thermal environment.Waldron and Mackinnon (2007),defined Neutral thermal environment as the environment or the air temperature which an infant with normal body temperature has a minimal metabolic rate and therefore minimal oxygen consumption. Robin knobel (2014) dictates that Neutral thermal environment can be maintained by using radiant warmers, incubators, heated mattress or by skin to skin contact. Radiant warmers increase convective and evaporative heat loss and insensible water loss but eliminate radiant heat loss. The major advantage of radiant warmer is the easy access it provided without disturbing the thermal environment (Bell,1983).with this view point Andy was put under radiant warmer.

Also heat can be lost due to environmental factors . The four ways that heat loss is most common are conduction, when skin comes in direct contact with cold surface; convection , involves heat loss from infant to cold air. Heat loss from radiation involves heat loss to other objects not in direct contact, and evaporative heat loss occurs when fluid evaporates from wet skin into the air(Ellis,2005).There could be a possibility that Andy might be on a wet nappy or a wet bed resulting in heat loss by evaporation. It could also be due to convective heat loss if he was exposed to cold air or left undressed. I noticed that any was nursed in a cot close to the window. Likewise the cold windowpanes could have contributed to heat loss due to radiation.Also conductive heat loss , if Andy was wearing cold clothes or was handled with cold hands. Vital signs were checked continuously to monitor for effectiveness of the interventions. If left untreated Preterm small babies are more likely to experience circulatory, respiratory, thermal and glycemic compromise (Petty.J, 2010).

On the other hand, Sepsis can be life-threatening for infants during the first year of life as a result of weak immune system or any other illness. Since Andy was born before term, prematurity could result in underdeveloped immune system making him prone to develop neonatal infections. Saez-Lopez , Guiral and Soto (2013 )states that Neonatal sepsis can be subdivided sepsis related to age and onset of symptoms .It includes Early-onset neonatal sepsis which occurs within 72 hours of life and late-onset neonatal sepsis at 4 to 90 days of life. Andy being  8weeks old , he could be classified under late- onset  sepsis. According to Brenda (2008), sepsis is more likely to occur in infants who have a low birth weight,Infants who were born with a low APGAR score or Infants whose mother has certain risk factors (such as a low socioeconomic status or premature rupture of the membranes) . In addition, clinical manifestation of neonatal sepsis usually include temperature instability, respiratory problems, apnea, feeding intolerance. However Andy presented with temperature instability , lethargy and poor feeding. According to Polin R.A(2009) the diagnosis of late-onset sepsis is more problematic. It is a high incidence disease, and unlike early-onset sepsis (which more commonly affects term and near-term infants), late-onset sepsis occurs in preterm infants like Andy who are hospitalized for extended periods of time . Since Andy was in the Neonatal unit for 8 weeks he was prone to develop late-onset sepsis. Davies (2012),discussed that neonatal sepsis is  diagnosed based on a combination of clinical presentation; blood CSF and urine cultures; the use of nonspecific markers, including C-reactive protein and procalcitonin (where available) and X-ray. Blood and CSF culture, urine microscopy,  blood cell count C-reactive protein and X-Ray was performed on Andy .

Infants with suspected late onset infection are typically treated with empiric broad spectrum antibiotics while blood culture results are pending (Rubin et al ,2002). A variety of diagnostic tests (complete blood count, acute phase reactants) are commonly obtained, and antibiotics are continued or discontinued based on the results of the laboratory testing, degree of clinical improvement and cultures.Empiric antibiotic treatment varies between neonatal intensive care units and countries. A Combination of glycocopeptide with cephalosporins is most preferred antibiotic regime. Andy received Vancomycin which is a glycopeptide antibiotic and cefotaxime as per the unit guidelines .Punnoose, et al. (2012), stated that antibiotics should not be used without a proven bacterial infection. The usage of broad-spectrum antibiotics in the neonatal intensive care unit is a serious issue, because it promotes the development of resistant flora, prolongs hospitalization and increases costs (Polin.R,2009).However, As stated by Stoll et.al(2002) late-onset sepsis remains an important risk factor for death among VLBW preterm infants and for prolonged hospital stay among VLBW survivor.Also Voller and Myers (2016) explains  that there’s an improved outcome for neonates with sepsis if there are a prompt diagnosis and management, thus, treating Andy with a diagnosis of suspected sepsis is indeed proper.  Strategies to reduce late-onset sepsis and its medical, social, and economic toll need to be addressed urgently. 

To put it into a nutshell , The neonate’s susceptibility to temperature instability needs to be recognised and understood in order to appropriately manage and limit the effects of cold or heat stress (Smith, Alcock and Usher, 2013).Therefore maintaining the thermoneutral environment for sick and premature newborn infants is a key part of the nurse’s role on the neonatal unit as a abnormal temperature is strongly associated with adverse outcome.By choosing and using proper equipment for infant based on his condition and gestational age, we may be able to provide effective and efficient care. In addition nurses play curial role and prime position in the early recognition, diagnosis and treatment of sepsis thus contributing to reduced the morbidity and mortality rate .

Future Action

From this experience I am now more mindful of the importance of proper nursing assessment and ensuring that information is passed on to the doctors and staffs for effective implementation and management. It encouraged me to read more about Hypothermia and neonatal sepsis. I could have acted immediately considering the best interest of Andy. The insight that I have gained from this reflection improved my knowledge, skills and attitude towards neonatal  nursing. In future I aim to be more proactive in dealing with a situation and doing timely referrals.If in doubt I will approach the senior nurses if something appears different in terms of delivering nursing care.Furthermore, I will consider reviewing the history of the patient as this could be very helpful and be a basis of the plan of care. It is obvious that prematurity may cause many potential problems to the neonate so it is necessary as a healthcare professional to be able to foresee these challenges and be prepared for untoward incidents.

References

• Bell, E.F.(1983).‘Infant incubators and radiant warmers. Early Hum Dev’. 1983. 8(3-4) pp.351.
• Çinar, N. D. and Filiz, T. M.(2006).‘Neonatal Thermoregulation’, Journal of Neonatal Nursing, 12(2), pp.69-74.
• Marks-Maran, D. and Rose, P. (1997). Reconstructing Nursing: Beyond Art and Science. London: Balliere Tindall.
• National Health Service/NHS (2017) Hypothermia. Available at: https://www.nhs.uk/conditions/hypothermia/ (Accessed: 26 December 2018).
• National Institute for Health and Care Excellence/NICE Guideline (2017) Sepsis: recognition, diagnosis and early management. Available at: https://www.nice.org.uk/guidance/ng51/chapter/recommendations#risk-factors-for-sepsis (Accessed: 26 December 2018)
• Nursing and Midwifery Council/NMC (2018) The Code. Available at: https://www.nmc.org.uk/standards/code/read-the-code-online/ (Accessed: 26 December 2018)
• Polin, R.A. (2012) ‘Management of neonates with suspected or proven early-onset bacterial sepsis’, Pediatrics, 129 (5), pp.1006-1015.
• Polin,R.A.(2009).’The Ins and Outs of Neonatal Sepsis’.Pediatrics,135(7),pp.2-3.
• Punnoose, A. et al. (2012).‘Antibiotic Resistance’, JAMA, 308(18), pp.1934.
• Roychoudhury.S and Yussef.k(2017).’Thermoregulation:Advance in preterm infants’.Neoreviews,18(12).
• Rubin L.G,et al (2002).’Evaluation and Treatment of Neonates with suspected late-onset sepsis’.Pediatrics,110(4),pp.4-7.
• Saez-Lopez E,Guiral E and Soto S.M(2013).’Neonatal Sepsis by Bacteria:A Big Problem for Children.,Clin Microbial 2(6),pp.1-4.
• Simonsen K.A, Anderson-Berry A.L and Davies H.D(2014).’Early-onset neonatal sepsis’.27(1),pp.21-47.
• Smith L.S.(2004).’Temperature monitoring in newborns:A comparison of thermometer and measurement sites’.12(5),pp.157-164.
• Stoll B.J, Hansen N and Fanaroff A.A .et al.(2002).’Late onset sepsis in very low birth weight neonates’.Pediatric 110(2002),pp.285.
• Tesini B.L.(2008).’Neonatal Sepsis’.Available at : https://www.urmc.rochester.edu/people/27205648-brenda-l-tesini.
• Voller, S. and Myers, P. (2016) ‘Neonatal Sepsis’, Clinical Pediatric Emergency Medicine, 17(2), pp. 129-133.
• Waldron S and Mackinnon R.(2007).’Neonatal Thermoregulation ‘.Infant 3(3),pp.101-103.
• World Health Organization. (2003). Managing newborn problems: a guide for doctors, nurses, and midwives. Geneva: World Health Organization.