A Changing Definition Andrew M Ellefson MD Neonatologist Christiana Care Health System Edited by Cem Soykan MD Pediatric Hospitalist at CCHS 1 Background amp Definitions Maternal Chorioamnionitis ID: 656237
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Maternal Fever & What it Means for Baby: A Changing Definition
Andrew M. Ellefson, MDNeonatologistChristiana Care Health SystemEdited by Cem Soykan, MD Pediatric Hospitalist at CCHS
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Background & DefinitionsMaternal Chorioamnionitis
A sometimes vague term with flexible definitions that is applied fairly
inconsistently to mother’s with varying
degrees of
fever during the peripartum period. “Triple I” = Intrauterine Inflammation and/or Infection “Triple I” is diagnosed when fever (≥38 C) is present with one or more of the following: Fetal Tachycardia (> 160 bpm > 10 min.)Maternal WBC > 15,000Purulent fluid from the cervical os+ Biochemical or microbiologic amniotic fluid resultsT.I.M.E. = Triple I to Manage Early-onset Sepsis: *** Our new protocol for these babies ***
2Slide3Issues with Current
CDC/COFN GuidelinesMany of the references supporting IV abx for all infants of mothers with chorioamnionitis include data before widespread GBS screening implementation1
GBS screening has reduced incidence of Early Onset Sepsis (EOS) due to GBS by 80% to rate of 0.34-0.37/1000 term newborns2Early Onset Sepsis due to E.coli estimated at 0.07/1000 newborns3
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Taylor JA, Opel DJ.
Choriophobia: a 1-act play. Pediatrics. 2012 Aug;130(2):342-6.Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease—revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010;59(RR-10):1–36.Stoll BJ et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Early onset neonatal sepsis: the burden of group B Streptococcal and E. coli disease continues. Pediatrics. 2011 May;127(5):817-26.Slide4
Impact of “R/O Sepsis - Chorio” AdmissionsAsymptomatic Infant admitted for 48 hrs to NICU:
Mother/baby separationReduction in bondingIncreased parental stress/anxietyReduction in maternal breast milk production and feedingIncreased exposure to formula and IV fluidsU
nnecessary lab draws
Risk for extended hospitalization
prolonged antibiotic use due to “culture negative sepsis” 2nd to non-specific CBC lab abnormalitiesWeaning off of IVF’sAdverse Events - IV infiltratesDollars$500/patient hospital day compared to admission to term nurseryBased on CCHS 2015 “chorio admission” data, this would be ~ $86,000-129,000/year4Slide5
Bottom LineEvidence strongly supports modifying how we manage babies born to mothers with “chorioamnionitis” by using a more EBM approach. Emphasis should be on:Neonatal clinical exam
Maternal risk factorsNOT isolated factors taken separately. Recommend:Discontinue use of the term chorioamnionitis Start using the term “intrauterine inflammation or infection or both” (A.K.A. “Triple I”)*A d
etailed list of references, slides, and segments from Dr.
Ellefson’s
Peds Grand Rounds on this topic are included at end of this presentation.Click Link Below for OB’s “Triple-I” reference Higgins RD, Saade G, Polin RA, et al. Evaluation and Management of Women and Newborns With a Maternal Diagnosis of Chorioamnionitis: Summary of a Workshop. Obstet Gynecol 2016; 127:426.5Slide6
The Newborn Sepsis CalculatorKaiser Permanente study looked at the genuine need for antibiotics in setting of maternal feverThey found the following things were most crucial in determining risk
Gestational AgeTmax of the feverDuration of ROMGBS statusAntibiotic treatment6Slide7
The Newborn Sepsis Calculator: Results / OutputKaiser Permanente then found a way to risk stratify the kids.Based on the clinical exams, there were 3 different potential courses of action to be pursued:No additional care
(= q4h VS here @ CCHS)CBC, Blood culture & VS q4 hours x48 hoursAdmit to NICU for empiric Antibiotics
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www.newbornsepsiscalculator.org
Slide8
Newborn Clinical Exam – DefinitionsWell AppearingNo persistent physiologic abnormalities
Equivocal ExamAny ONE Persistent Physiologic Abnormalities for ≥4 hoursTachycardia (≥160)Tachypnea (≥60)Temperature Instability - Fever (≥100.4°F [≥ 38°C])
Temperature Instability – Hypothermia (< 97.5°F [<36.3°C])
Respiratory Distress (grunting, flaring, retracting) without O
2 needs ORAny TWO or MORE Physiologic Abnormality Lasting ≥2 hours See above list againNote physiologic abnormalities can be intermittent & still count8Slide9
Newborn Clinical Exam – DefinitionsClinical Illness
Simply PUT = Everything worse than Equivocal Exam, but defined below:O2 Supplementation (outside of the delivery room)
N
eed for supplemental O
2 for ≥2 hours to maintain oxygen saturation >90%Respiratory Support (outside of the delivery room) Persistent need for Nasal CPAPPersistent need for High Flow Nasal Canula or Persistent need for mechanical ventilationBlood Pressure SupportHemodynamic instability requiring vasoactive drugsNeonatal encephalopathy/ Perinatal depressionApgar Score of <5 @ 5 minutesSeizure9Slide10
Triple I to Manage
Early-Onset Sepsis T.I.M.E
.
The New Process at CCHS
Andrew M. Ellefson, MDNeonatologistChristiana Care Health SystemEdited by Cem Soykan, MD Pediatric Hospitalist at CCHS10Slide11
L&D Nurse Responsibilities
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A mother with fever ≥38˚ C delivers a baby.
L&D Nurse gets a notification in
PowerChart
when she opens the
baby’s chart
.
L&D Nurse must complete the
“Neonatal Sepsis Calculator”
Powerform
L&D Nurse must notify Pediatric DR provider
The
Powerform
: Neonatal Sepsis CalculatorSlide12
DR Provider Responsibilities
Peds
/DR Provider clicks on Neonatal Sepsis Calculator Form
Should already be filled in by L&D Nurse
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Open Baby’s Chart
Review Nursing portion & complete their portion of the
“Neonatal Sepsis Calculator”
Powerform
Call/Notify PMD of baby’s status
Does NOT have to examine the baby, but may be asked to if any other concerns
The Alerts we will getSlide13Scenario Questions &
IMPORTANT PointsStable baby (even with normal transitional physiology - comfortable tachypnea) may remain with the mother per routine in L&D.
The baby can always be brought to the NICU for OBS if indicated. “Equivocal” exam babies, by definition, require 2-4 hours of persistent symptoms.Therefore, a comfortably tachypneic baby at 1 HOL may simply be demonstrating transitional physiologyWhen the mother is ready for transfer to Well Baby floor, only “Well Appearing” babies are cleared for co-transfer to Well Baby floor. At the time of maternal transfer, any baby with ongoing transitional physiologic abnormalities, or any sign of distress must go to the NICU
(Equivocal & Clinical Illness Babies)
If a baby goes to NICU for OBS and then has complete resolution of symptoms, clinical discretion can be used to allow this baby to return to Well Baby Floor with mother. The Peds/DR provider must notify the Well Baby attending about the baby’s Sepsis Calculator recommendations & disposition. Ensure proper provider-physician hand off. The L&D nurse must also report this information in their handoff to post-partum nursing. 13Slide14
Newborn Physician & Postpartum Nurse Alerts14
Reminds Well Baby Nurse and Physician
Providers
to review the Neonate Sepsis Calculator Form document.
Occurs the 1st time each & every Nurse or Provider opens the baby’s chart on the Well Baby unitSlide15
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Where to Find the Sepsis
C
alculator Recommendations in Baby’s Chart Slide16Well Baby Floor:
Process FlowVitals signs on admission.Vital signs 1 hour after admission to floor, and then Q4hr until 48 hours of life.Nurse gets alert to review Neonatal Sepsis Calculator Form on baby
Daily until 48 HOLWell Baby/Newborn Physician gets alert to review Neonatal Sepsis Calculator Form on baby Daily until 48 HOL16Slide17Key Issues to Remember
The goal is to reduce unnecessary admissions to the NICU.Any Well Baby/Floor newborn with any possible sign of distress needs to be discussed with NICU team & the covering well baby doctor.Don’t delay in transferring a baby who has abnormal vitals or signs of distress to the NICU.
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