Understanding And Managing Maternal Sepsis

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Vol.Vol.31 29 APRIL April20192016PERINATALTimesin this issue:Understanding and ManagingMaternal SepsisandBubble CPAPA Simple Ideathat Changedthe WorldSt. Mary’s Hospital – St. LouisCardinal Glennon Children’s Hospitallastnext

Vol. 31 April 2019THE PERINATAL OUTREACH PROGRAMThe Perinatal Outreach Program is a collaborative effort betweenSSM Health Women’s Health at SSM Health St. Mary’s Hospital St. Louis, SSM Health Cardinal Glennon Children’s Hospital andSaint Louis University School of Medicine.It is designed to improve outcomes for mothers and babies througheducational programs and quality improvement activities for regionalperinatal care providers in eastern Missouri and southern Illinois.SSM Health Cardinal Glennon Children’s Hospital and SSM HealthSt. Mary’s Hospital - St. Louis are designated by the Illinois Department ofPublic Health as the Administrative Perinatal Center for Southern Illinois.PERINATAL TIMES EDITORIAL BOARDMeredith Meyer, MSN, RNC, EditorSSM Health CardinalGlennon Children’s HospitalGlenn Barber, BSN, RNCChristopher Brownsworth, MDRobyn Gude, MSN, RNMary Hope, BSN, RNJustin Josephsen, MDSSM Health St. Mary’sHospital – St. LouisShilpa Babbar, MD1NRP IN THE KNOWProviding EffectiveVentilation4FORMULARY FACTS8MATERNAL TOPIC14NEONATAL TOPIC18FETAL CARE IN FOCUSUnderstandingGastroschisisSutureless Closure21THE MONITOR CORNERFetal TachycardiaTreating Maternal SepsisUnderstanding andManaging Maternal SepsisEmily Berghult, MSN, RNGilad G. Gross, MDKathleen Klug, BSN, RNLaurie Niewoehner, PharmDWilliam Keenan, MDPam Randazzo, BSN, RNCPatricia OberkirschSharon Rector, MSN, RNCRebecca Petersen, MDINSIDE THIS ISSUE:Judy Wilson-Griffin, MSN, PNCNS, RNCFUNDINGFinancial support for The Perinatal Times is provided by SSM Healthand the Illinois Department of Public Health.LETTERSBubble CPAP —A Simple Idea thatChanged the WorldThe Perinatal Times welcomes comments on any of its articles andwill consider such letters for publication. Suggestions for future topicsof interest or announcements are encouraged.PLEASE SEND CORRESPONDENCE TO:The Perinatal TimesMeredith Meyer, EditorSSM Health St. Mary’s Hospital6420 Clayton RoadSt. Louis, MO [email protected] receive an electronic version of The Perinatal Times, please emailPatricia Oberkirsch at [email protected] vol. 31 april 2019St. Mary’s Hospital – St. LouisCardinal Glennon Children’s Hospital

NRP in the KNOWNRP in the KNOWProviding EffectiveBy Marya Strand, MD, MS & Justin Josephsen, MDCARDIOVASCULAR TRANSITION AT DELIVERYAbout the AuthorsBlood flow during fetal life is focused on perfusion ofthe brain and major organs with oxygenated bloodand avoidance of perfusion of the fluid-filled lungs.The oxygenated blood from the placenta travelsthrough the umbilical vein, up to the right side of theheart, and is preferentially shunted across the patentforamen ovale to the left side of the heart (Figure 1 ).Less than 10% of the cardiac output of the fetus ispumped into the pulmonary arteries prior to delivery.1Marya Strand, MD, MS is an associate professor in theDepartment of Pediatrics, Division of Neonatology,at Saint Louis University School of Medicine andspecializes in the care of newborns, with particularinterest in neonatal resuscitation, medical educationand simulation-based education. She treatspremature and extremely premature infants, normaland sick newborns, and patients in a Level II nurseryto Level IV neonatal intensive care. She also providesoutpatient care in the high-risk nursery clinic andantenatal consultation for expectant mothers. Dr.Strand is involved in clinical and educational researchand directs the research program for pediatricresidents. Dr. Strand is a member of the NeonatalTaskforce for the International Liaison Committee onResuscitation, an international group of physiciansthat determines guidelines for resuscitation ofinfants. She is also an active member of the NeonatalResuscitation Program Steering Committee.Normal cardiopulmonary transition for the newbornat delivery requires a rapid and complex processof fetal lung fluid clearance, expansion of the lungswith air and redirection of cardiac output toward thelungs. All of these events take place independent ofintervention in the majority of newborn infants at thetime of delivery. 2 Failure of any of these events cancause delays in transition or progress to depression inthe newborn.Fetal lung fluid produced by the lung tissue fills thepulmonary spaces during gestation. The pressureof the fluid within the air spaces and resistance tooutflow through closed vocal cords facilitates thegrowth and development of the lungs. Rapid fetallung fluid clearance at birth likely occurs by severalmechanisms, including fetal postural changes, cellularsodium channel pumps, and transpulmonary pressurefrom inspiration at delivery. 3 Apneic infants, whoJustin Josephsen, MD is an assistant professor in theDepartment of Pediatrics, Division of Neonatology,at Saint Louis University School of Medicine, Directorof the Neonatal Resuscitation Video-Review QIProgram at SSM Health St. Mary’s Hospital - St. Louis,and the Neonatal Co-Lead for the Illinois PerinatalQuality Collaborative. He specializes in the careof critically ill newborns and his interests includecommunity outreach, improving the management offrail neonates in the delivery room, and simulationbased medical education research.homethe PERINATAL Times 1next

Effective Ventilation(continued)don’t contribute the transpulmonary pressure, canhave significantly compromised fluid clearancefrom the air spaces.Once the fluid is cleared and air fills the alveoli,the pulmonary arterial pressure drops rapidly toincrease blood flow from the heart to the lungs.With this change in cardiac output and transitionof gas exchange to the pulmonary bed, the leftventricular volume shifts from the umbilical venousreturn from the placenta to pulmonary venousreturn. The peripheral vascular resistance increasessimultaneously to result in left-to-right flowthrough the ductus arteriosus and the beginningof ductal closure.4Lung expansion and establishment of baselinepulmonary expansion (functional residual capacity,FIGURE 1Oxygenated Placental Blood Flow1FRC) is vital to the normal transition of the newborn.When the umbilical cord is clamped and cut atdelivery the venous return from the placenta abruptlyceases. If the lungs have not yet expanded andestablished vascular perfusion before the clamping ofthe umbilical cord the blood return to the left ventricleis compromised and cardiac output falls. With a lowcardiac output, the infant becomes hypoxemic andbradycardia ensues with further respiratory failureand asphyxia.ESTABLISHING FRCIn a normal delivery of a term infant, FRC isestablished primarily by the newborn breathingspontaneously as the fetal lung fluid is reabsorbed.Lack of pulmonary inflation, whether from apneaor surfactant deficiency as seen in prematurity, maycause the infant to require assistance to establishFRC at delivery. Being mindful of establishingFRC when delivering PPV is helpful to assist in thetransition of the compromised neonate. Positive endexpiratory pressure (PEEP) is critical in maintaininglung expansion during PPV. 5 PEEP can be providedusing the T-piece resuscitator, flow-inflating bagor self-inflating bag with a PEEP valve in place. Anappropriate inspiratory time is also important inestablishing the FRC. With a PPV rate of 40 to 60breaths/minute the inspiratory time should be 0.3 to0.5 seconds for each breath. Very short inspiratorytimes do not allow for inflation of the air spacesand FRC cannot be effectively established. Theventilator should be mindful of both the PPV rate andthe inspiratory time by counting in her or his head“Breathe-two-three, breathe-two-three, ” duringventilation. This rhythm assures a 1:2 inspiratory:expiratory ratio.For premature infants with surfactant deficiency,administration of exogenous surfactant can beextremely helpful in both increasing lung complianceand increasing FRC. Further discussion of exogenoussurfactant is outside the scope of this article, butLesson 9 of the NRP Textbook is an excellent resourceon this topic.1ASSESSMENT OF VENTILATIONAn increasing heart rate is the most reliable indicatorof adequate ventilation.6 When PPV is begun in aneonatal resuscitation, the assessment (within 15previous2 vol. 31 april 2019

NRP in the KNOWseconds) must include an indication of heart rateresponse. The person assessing ventilation shouldrelay the presence or absence of chest wall rise ANDany changes in heart rate found during auscultation.Colorimetric carbon dioxide monitoring has beenstudied as a proxy for adequacy of gas exchangeduring PPV. Placement of the CO2 monitor in line withthe PPV device and mask can reflect the inspiratory/expiratory cycle of PPV. A cycling color change duringPPV indicates the presence of a patent airway.7A change in color on the monitor, when used, is alsoseen prior to the response in heart rate, indicatingefficacy of ventilation precedes a heart rate response. 8TROUBLESHOOTING INEFFECTIVE VENTILATIONA lack of heart rate response to PPV requiresimmediate investigation. The mnemonic MR. SOPAhas been introduced through NRP.1 This mnemonicaddresses the fact that usually the difficulty witheffective PPV results from mask leak or position aswell as maintaining an open airway.9 If repositioningthe airway and adjustment of the mask to eliminateleak do not result in lung expansion with increasein heart rate there may be a blockage to airwaypatency. Suctioning with a bulb or catheter maybe indicated. Opening the mouth of the newborndecreases resistance to airflow compared to thenares. If PPV remains ineffective, the newborn mayrequire increased pressure to inflate the lungs andestablish functional residual capacity. If the newborndoes not respond to increased inspiratory pressurean alternative airway, such as a laryngeal mask orendotracheal tube, may be required. This entireprocess of troubleshooting ventilation should becompleted in 15-30 seconds, exclusive of alternativeairway placement. A video demonstrating thetroubleshooting can be found on the NRP mobile app.SUMMARYNormal cardiopulmonary transition in the newbornis dependent upon lung inflation and establishmentof FRC. While most newborns will achieve thisindependently, compromised infants must besupported in this transition. Infants are effectivelyresuscitated when the newborn providers areknowledgeable about the physiology underlyingthis transition and are skilled in providingPPV appropriately.References1 Textbook of neonatal resuscitation. Elk GroveVillage, IL: American Academy of Pediatrics;2016.2 Perlman JM, Risser R. Cardiopulmonaryresuscitation in the delivery room. Associatedclinical events. Archives of pediatrics &adolescent medicine 1995; 149:20-25.3 Jain L, Eaton DC. Physiology of fetal lung fluidclearance and the effect of labor. Seminars inperinatology 2006; 30:34-43.4 Hooper SB, Te Pas AB, Kitchen MJ. Respiratorytransition in the newborn: A three-phaseprocess. Archives of disease in childhood Fetaland neonatal edition 2016; 101:F266-271.5 Hooper SB, Te Pas AB, Lewis RA, Morley CJ.Establishing functional residual capacity atbirth. NeoReviews 2010; 11:e474-481.6 Wyckoff MH, Aziz K, Escobedo MB, KapadiaVS, Kattwinkel J, Perlman JM, Simon WM,Weiner GM, Zaichkin JG. Part 13: Neonatalresuscitation: 2015 american heart associationguidelines update for cardiopulmonaryresuscitation and emergency cardiovascularcare (reprint). Pediatrics 2015; 136 Suppl 2:S196-218.7 Leone TA, Lange A, Rich W, Finer NN.Disposable colorimetric carbon dioxidedetector use as an indicator of a patent airwayduring noninvasive mask ventilation. Pediatrics2006; 118:e202-204.8 Blank D, Rich W, Leone T, Garey D, Finer N.Pedi-cap color change precedes a significantincrease in heart rate during neonatalresuscitation. Resuscitation 2014; 85:1568-1572.9 Schmolzer GM, Kamlin OC, O’Donnell CP,Dawson JA, Morley CJ, Davis PG. Assessmentof tidal volume and gas leak during maskventilation of preterm infants in the deliveryroom. Archives of disease in childhood Fetaland neonatal edition 2010; 95:F393-397.homethe PERINATAL Times 3next

Formulary FACTSTreating MaternalBY LAURIE NIEWOEHNER, PHARM DRecent estimates suggest that infection accounts for 12.7% of maternal mortalityin the United States, 6% of this group are characterized as having sepsis. Recentdata suggests that infection is currently the third most common cause ofmaternal death, and in contrast to maternal deaths from hypertensive disorders andhemorrhage, the number of deaths relatedto infection are increasing. Undetectedor poorly managed maternal infectionsAbout the AuthorLaurie Niewoehner, PharmD is a clinicalpharmacy specialist at SSM Health St. Mary’sHospital – St. Louis. She attended the Universityof Minnesota and completed a specialtyresidency program in pediatrics at Children’sMercy Hospital and the University of MissouriKansas City School of Pharmacy in Kansas City.Laurie is also a preceptor for neonatologyand women’s health pharmacy students.previous4 vol. 31 april 2019can lead to sepsis, maternal morbidity ormortality, and increased likelihood of earlyneonatal infection or adverse outcome.Maternal sepsis is a life-threatening organdysfunction resulting from infection duringpre gna ncy, childbir th , p ost-a b or tion ,or the postpartum period.

Formulary FACTSSEPSIS BUNDLE — FIRST 3 HOURSDuring the first three hours of recognition of suspectedsepsis, the following are essential components:➊➋➌➍Early recognition of sepsis allowsfor achievement of the threeprimary goals:Lactate level should be obtained ertinent cultures including: blood, urine,Psurgical, wound, or airway cultures, andMRSA status via nose swab➊➋➌Initiation of broad spectrum antibiotics dministering 30 mL/kg LR or NS forAhypotension or lactate 4 mmol/L, whichindicates tissue hypo perfusionT