الفهرس 
Septic Shock in NeonatesOnly 14 pages are availabe for public view
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Abstract
Neonatal sepsis (NS) is recognized as a leading global public health challenge and has a fulminant and fatal evolution if the treatment is not commenced promptly. Sepsis is the commonest cause of neonatal mortality and is responsible for 30-50% of total neonatal deaths each year in developing countries. It is estimated that up to 20% of neonates develop sepsis and approximately 1% die from a sepsis related cause, NS is characterized by systemic signs of infection frequently associated with bacteremia. In addition to short term morbidities and mortality, it is associated with neurodevelopmental impairment and cerebral palsy. Treating sepsis is a challenge, and it is one of the leading causes of admission to pediatric intensive care units. The initial manifestations can often be nonspecific and misleading. Severe sepsis is frequently complicated by disseminated intravascular coagulation (DIC) and multiple organ dysfunction syndromes (MODS). Deterioration from sepsis to septic shock and MODS most often occurs in the first 24 hours. Septic shock has a specific definition requiring several conditions to be met for diagnosis: First, systemic inflammatory response syndrome (SIRS) must be diagnosed. Second, there must be sepsis and not an alternative cause of SIRS. Sepsis requires evidence of infection, which may include positive blood culture, signs of pneumonia on chest x-ray, or other radiological imaging and laboratory evidence of infection. Third, signs of end-organ dysfunction are required such as renal failure, liver dysfunction, changes in mental status, or elevated serum lactate etc. Finally, septic shock is diagnosed if there is refractory hypotension which does not respond to intravenous fluid administration alone. The serum Thrombomodulin level is elevated in diseases associated with endothelial injury, such as acute respiratory distress syndrome,
Summary
112 disseminated intravascular coagulation, and organ dysfunction induced by sepsis. Therefore, Thrombomodulin level is known to be a biomarker of endothelial injury. Since endothelial dysfunction plays an essential role in the pathogenesis of sepsis, some studies have focused on serum Thrombomodulin level as a predictor of the severity of sepsis and mortality in adults. However, few pediatric studies have examined the role of serum Thrombomodulin level as a biomarker to predict the clinical course of septic shock. The aim of this work was to measure serum Thrombomodulin level in neonates with septic shock and to study its clinincal importance.
Patients and Methods
Patients
This was a case control study, which was done on 40 neonates who were divided into two groups.
group I:
Included 20 neonates with septic shock (admitted in the neonatal intensive care unit at Menoufia University Hospital); in the age group of 1-28 days as a patient group.
group II:
Included 20 apparently healthy neonates, age and sex matched to the patient group as a control group.
Criteria of septic shock:
Septic shock has a specific definition requiring several conditions to be met for diagnosis: First, SIRS (systemic inflammatory response syndrome) must be diagnosed. Second, there must be sepsis and not an alternative form cause of SIRS. Sepsis requires evidence of infection, which may include positive blood culture, signs of pneumonia on chest x-
Summary
113
ray, or other radiological imaging or laboratory evidence of infection. Third, signs of end-organ dysfunction are required such as renal failure, liver dysfunction, changes in mental status, or elevated serum lactate etc. Finally, septic shock is diagnosed if there is refractory hypotension does not respond to intravenous fluid administration alone.
Inclusion criteria:
Neonates with septic shock.
Gestational age: both preterm and full-term infants.
Both sexes.
Exclusion criteria:
Cardiogenic shock.
Hypovolemic shock.
Infant of diabetic mother.
Congenital anomalies.
Methods
All included patients and control neonates were subjected to the following:
Detailed history (antenatal and neonatal)
Thorough clinical examination:
General examination and local examination to detect signs of septic shock.
Laboratory investigations:
Complete blood count
Quantitative measurement of the level of C-reactive protein (CRP)
Blood cultures
Serum soluble Thrombomodulin level.
Summary
114
This study showed that:
The most common complications in neonates with septic shock were (thrombocytopenia, metabolic acidosis, NEC, IVH, DIC and pneumothorax).
CBC of neonates with septic shock showed leukocytosism increased I/T ratio and decreased hemoglobin and platelets.
Regarding the causative organisms, gram negative organisms were detected in (45%) of patients, Klebsiella represented commonest gram-negative organisms (30%).
There was a statistically significant increase Thrombomodulin serum level among neonates with septic shock.
There was a statistically significant increase in Thrombomodulin serum level among died than survived septic neonates.
There was a statistically significant positive correlation between Thrombomodulin serum level and CRP.
At a cut off value of 20 ng /ml the sensitivity of Thrombomodulin level was 91.5%, specificity (84.7%). PPV (91.9%), NPV (88.3%) while accuracy was 92.94%.
There was statistically significant increase of NICU stay, PRISM score and SOFA score among died patients than improved patients (p<0.05).
Serum Thrombomodulin level can be used as a reliable diagnostic and prognostic biomarker in neonates with septic shock.
Measurements of serum Thrombomodulin level may help to early recognize the development of septic shock.
Measurements of serum Thrombomodulin level, can give a clue about disease severity as regarding morbidity and mortality.
Summary
115
Serum Thrombomodulin level should be measured in septic neonates especially in those with maternal risk factor, low birth weights, APGAR scores, high blood pressure and CRP.