Point of Care Neonatal Ultrasound in Late-Onset Neonatal Sepsis

 - Journal of Neonatology

Neonatal sepsis remains one of the commonest causes of neonatal morbidity and mortality. It’s accountable for 30% to 50% of neonatal deaths in developing countries. Incidence of neonatal sepsis in India is 21.8 per 1,000 live births. Lateonset neonatal sepsis (LONS) occurs as nosocomial infection and presents after 72 h of age. As per large multicenter studies in India, they are mainly caused by gram-negative bacilli and present as septicemia, pneumonia, meningitis, or urinary tract infection.

Bedside ultrasound is useful in neonates with sepsis for evaluating cardiac status, brain injury, lung, or intraabdominal pathology. This also includes functional echocardiography for assessing altered hemodynamics in critically ill infants and allows the clinician to customize the treatment accordingly.

Neurosonogram is a useful tool for early, safe, and easy diagnosis, management, and predicting outcome of intracranial pathology. Lung ultrasound is helpful in diagnosing pleural effusion, pneumonia which is a common manifestation of LONS. The findings of point-ofcare ultrasound are therefore helpful in making timely and accurate decisions while managing sick infants. Currently, data available on point-of-care ultrasound in neonates with sepsis is scarce. We therefore aimed to perform bedside ultrasound screening (cardiac, brain, lungs, and abdomen) in neonates with late-onset culture positive sepsis admitted in our tertiary care neonatal unit and study the patterns of abnormalities and also their role in change of management.

This prospective observational study was conducted at a tertiary-level neonatal intensive care unit (NICU) of a university medical college in western India from March 2017 to May 2018. All neonates admitted in the NICU with suspected late onset sepsis (onset after 72 h of life) on the basis of clinical and laboratory findings underwent point-ofcare ultrasound (cardiac, brain, lungs, and abdomen). Neonates with major congenital malformations and genetic syndromes were excluded.

Clinically suspected sepsis was defined as presence of 3 or more of the following categories of clinical signs:

(a) temperature instability (hyperthermia or hypothermia);

(b) cardiovascular (tachycardia, bradycardia, poor perfusion, cyanosis, or hypotension);

(c) respiratory (tachypnoea, intercostal retractions, grunting, or apnea);

(d) gastrointestinal (abdominal distension or feed intolerance);

(e) neurologic (lethargy, hypotonia, or seizures); and

(f) metabolic (hypoglycemia, hyperglycemia, or metabolic acidosis).

Whenever sepsis was suspected from the clinical findings, a sepsis screen was performed which included a full blood count with immature-to-total neutrophil (IT) ratio, C-reactive protein, and blood, cerebrospinal fluid (CSF), and urine cultures. Chest or abdomen x-rays were taken as indicated. Demographic details, clinical examination, and point-of-care ultrasound findings were recorded.

Point-of-care ultrasound findings were recorded under the following headings: (a) Cardiac ultrasound (i) cardiac output—increased/decreased/ normal, (ii) cardiac contractility—increased/decreased/ normal, (iii) PDA—open/closed, flow—left to right/right to left/bidirectional, and (iv) pulmonary pressure—increased/ normal); (b) brain ultrasound—germinal matrix/ intraventricular hemorrhage, cerebral oedema, meningeal enhancement/altered echoes in ventricles, hydrocephalus; (c) lungs ultrasound—consolidation, pulmonary oedema, pleural effusion; and (d) abdominal ultrasound—free fluid/ascites, bowel wall oedema. Approval from institutional ethics committee was obtained. Informed consents were taken from parents of infants.

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