The Newborn at Risk: Birth Related Stressors

1
The Newborn at Risk Birth Related Stressors

• Chapter 29
• 1) Newborn at Risk for Asphyxia
• 2) Care of the Newborn with Respiratory Distress
• 3) Transient Tachypnea of the Newborn (TTN)
• 4) Meconium Stained Amniotic Fluid
• 5) Newborn at Risk Cold Stress
• 6) Hypoglycemia
• 7a) Hyperbilirubinemia
• 7b) Hemolytic Disease of the Newborn
• 8) Newborn at Risk for Anemia
• 9) Newborn at Risk Polycythemia
• 10) Antibiotic Therapy

2
All Infants-Nursing Care

• -A, B, Cs
• -NTE
• -Early detection/treatment of hypoglycemia
• -Support the family

3

• Nursing care
• Should always include these
• How do you maintain a NTE?
• - cap on head
• - radiant heat source
• - keep infant dry
• - warm objects prior to contact with infant
• - positioning of the infant (flexed posture)
• Early detection/treatment of hypoglycemia

4
1) Newborn at Risk for Asphyxia

• Asphyxia is severe, prolonged hypoxia
• Can occur during antepartum, intrapartum, or
  postpartum
• Causes respiratory, circulatory, and biochemical
  changes

5
Risk Factors for Asphyxia

• Before and during labor
• Biophysical profile
• Fetal heart rate nonreassuring
• Due to complications causing low O2
• Low fetal scalp pH
• Meconium stained fluid
• Prematurity
• Multiple gestation

6

• Biophysical profile
• - fetal breathing movement
• - fetal movement of body/limbs
• - fetal tone
• - amniotic fluid volume
• - reactive FHR with activity
• FHR
• - decreased variability
• - normal FHR 110-160 baseline
• - decelerations
• Scalp pH
• - 7.25 or gt considered normal

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Risk Factors for Asphyxia

• At birth
• Diffcult birth
• Low cord pH - acidosis
• APGAR
• Male
• SGA
• Sepsis
• Congenital heart/lung defects

8
Asphyxia
0305

• Newborn may be unable to make the transition to
  extrauterine circulation
• Reverts to fetal circulatory patterns
• pulmonary hypertension
• increasing hypoxia
• acidemia
• Requires intensive supportive care to reverse

9
Newborn at Risk Asphyxia(Rlt60, start chest
compressions)

• Nursing care
• Oxygen
• IV fluids
• May need newborn resuscitation (NRP)
• Relate appropriate information to parents

10
2) Care of the Newborn with Respiratory Distress
535

• Respiratory Distress Syndrome
• Prematurity
• Surfactant deficiency disease
• Transient Tachypnea of the Newborn
• Meconium Aspiration Syndrome

11
605
12

• How would we know that the infant has high CO2,
  or is acidotic?
• ABG or Capillary Blood Gas (CBG)
• Normal PH 7.30-7.40 after birth.
• Co2 arterial 35-45 capillary 35-50
• Po2 on room air arterial 50-80 capillary
  35-45
• Bicarbonate 19-22 arterial or capillary l
• Sao2 per pulse ox probe gt90
• What would be normal for a cord pH?
• Look it up!

13
Newborn at RiskRespiratory Distress

• Respiratory distress syndrome (RDS) aka. Hyaline
  membrane disease (HMD)
• ? surfactant
• Hypoxia
• Respiratory acidosis which can develop
• Into Metabolic acidosis
• RDS- indicates a failure to synthesize surfactant
• So who is at risk?
• more frequent in caucasian
• more frequent in males than females
• prematurity

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Newborn at RiskRespiratory Distress

• Nursing assessment, youre going to see
• Respiratory tachypnea, apnea (Normal is 30-60)
• Chest retractions, grunting, nasal flaring
• Skin color pallor, mottling, cyanosis

16

• Nursing Care Plan, page 744, Care of the Newborn
  with Respiratory Distress
• Turn to
• Table 28-1, page 742 Clinical Assessment
  Associated with Respiratory Distress
• Respiratory
• - tachypnea (RR gt 60) is the most frequent
• and easily detected sign of respiratory
  distress
• - apnea (bad sign)
• sign of
• -metabolic alterations
• - CNS disease
• -IVH
• -sepsis
• -prematurity
• Chest
• work of breathing
• -retractions -grunting -nasal flaring

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Newborn at RiskRespiratory Distress
1010

• Nursing Care
• Surfactant replacement
• Oxygen ventilation (ex oxy hood/tent)
• ABGs monitored
• IV fluids/TPN (ex Central lines)
• Cluster care
• Supportive care

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3) Transient Tachypnea of the Newborn (TTN)
1218

• Failure to clear airways of lung fluid (in utero
  fluid is produced, if this fluid isnt cleared
  from the pressures on chest from birth, then TTN.
  C-Section dont get this squeeze.)
• Mild intrauterine asphyxia
• Maternal over sedation, bleeding, IDM
• Difficult birth
• Breech birth, prolapsed cord
• C/Section birthInfant may have tachypnea with
  shallow rapid respirations or grunting
  respirations. Retractions and increased effort
  with breathing nasal flaring.
• REVIEW
• Normal Respiratory Rate 30-60 per minute

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TTN Nursing Assessment

• Little or no difficulty breathing at birth
• Shortly after
• Grunting
• Flaring
• Mild cyanosis
• Tachypnea- usually by 6 hours of age
• RR as high as 100-140/min.

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TTN Nursing Care

• Supplemental O2
• IV Fluids

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4) Meconium Stained Amniotic FluidAs the baby
stays in the fluid, this fluid will stain the baby
1505 WTF 1635

• MAS
• - 13 of births have meconium stained fluid
• - of those 4-11 develop MAS
• Represents a fetal asphyxial insult
• before/during labor
• Risk factors
• Term SGAs
• Postterm
• Long labors

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Meconium Aspiration Syndrome (MAS)Meconium fluid
has aspirated into the babys lungs

• Air trapping, if not released can
  rupture/pneumothorax
• Alveoli overdistention
• Possible pneumothorax
• Chemical pneumonitis

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Nursing Care of the Newborn with Meconium
Aspiration Syndrome
1940

• Prevention of aspiration (Prevent!!)
• Detect meconium stained amniotic fluid
• Suction ASAP
• Mechanical ventilation
• Surfactant
• Antibiotics
• Supportive care

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5) Newborn at RiskCold Stress
2035

• Cold stress- excessive heat loss resulting in the
  use of compensatory mechanisms (increased
  respirations, nonshivering thermogenesis)
• Infant heat production is by nonshivering
  thermogenesis
• Burning of brown fat
• Requires energy utilizes O2 and glucose
• Leading to Hypoxemia ( lt 40mg/dL )
• Which Produces acids
• Decreases surfactant production

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Cold Stress Chain of Events
27

• Ladewig et al, P. 697
• Figure 268 Cold stress chain of events. The
  hypothermic, or cold-stressed, newborn attempts
  to compensate by conserving heat and increasing
  heat production. These physiologic compensatory
  mechanisms initiate a series of metabolic events
  that result in hypoxemia and altered surfactant
  production, metabolic acidosis, hypoglycemia, and
  hyperbilirubinemia.
• Cold stress is excessive heat loss resulting in
  the use of compensatory mechanisms to maintain
  core body temperature
• Heat loss occurs in the newborn through
  evaporation, convection, conduction, and
  radiation.

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Methods of Heat Loss
2155

• Evaporation loss of heat incurred when water is
  converted to a vapor. Drying the newborn and
  etc.
• Convection-the loss of hear from the warm body
  surface to the cooler air currents (ie. air
  conditioned rooms, air currents, O2 by mask,
  removal from incubator into cooler air)
• Conduction-the loss of heat to a coolder surface
  by direct skin contact (cold hands, cool scales,
  cold stethoscope etc)
• Radiation heat transfers from heated body
  surface to cooler surfaces and objects NOT in
  direct contact with the body (wall of a room or
  incubator, objects near the infant

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Newborn at RiskCold Stress

• Signs/Symptoms
• ? movement
• ? respirations
• ? skin temperature
• ? peripheral perfusion (cyanotic looking)
• Hypoglycemia- producing heat uses up stores
• Metabolic acidosis

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Newborn at RiskCold Stress

• Nursing care
• Dont let it happen!!
• Assess skin temperature q 15-30 minutes
• Warm slowly rapid temperature elevation may
  produce apnea
• Remove plastic wrap, caps, or heat shields while
  re-warming
• Warm intravenous fluids prior to infusion
• Block heat loss by evaporation, radiation,
  convection, and conduction
• Asses for hypoglycemia

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• Dont let it happen!!
• - the amount of heat loss of an infant
• depends a great deal on the nurses actions
• What are some ways we can decrease heat loss?
• - NTE
• - prewarm surfaces
• - avoid drafts
• - ..
• Warm slowly
• - rapid temperature elevation may cause
• HYPOTENSION
• APNEA

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6) Hypoglycemia
2520

• Why treat?
• To prevent CNS damage or death

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Hypoglycemic Neonate

• At Risk
• Sick and stressed neonates
• Infants of diabetic mothers
• SGA infants
• Smaller twin will have less stores
• Male infant
• Preterm AGA
• Mother with preeclampsia

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Signs of hypoglycemia

• Lethargy or jitteriness/tremor
• Poor feeding
• Vomiting
• Pallor, cyanosis
• Apnea, Irregular Respirations, Respiratory
  Distress
• Tremors, jerkiness, seizure activity
• High pitched cry (meaning neurological origin)

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Glucose level

• Hypoglycemic newborns plasma glucose
  concentration is 40 mg/dl or lower.
• Signs of hypoglycemia may occur before 40 mg/dl
  and require intervention

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Capillary blood specimen site
2755

• To check blood glucose, capillary blood is
  usually drawn from newborns heel. Avoid the
  shaded areas to prevent injury to arteries or
  nerves in the foot.

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Care of the Hypoglycemic Neonate

• Early formula feeding or breastfeeding
• If too ill, gavage feeding or IV infusion of D5W
  
• Continue to monitor adequacy of treatment
• Conserve energy stores
• Maintain a neutral thermal environment

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7a) Hyperbilirubinemia
3040

• Bilirubin (Normal bilirubin level is 10-14)
• potential toxin collects in fatty tissue and
  brain - kernicterus
• Jaundice skin yellow due to deposit of
  bilirubin in tissues
• Up to 60 of term newborns will have clinical
  jaundice ? for premature infants
• Unconjugated bilirubin is a breakdown product
  derived from hemoglobin released from destroyed
  RBCsindirect bilirubin
• To be eliminated from the body, conjugation of
  bilirubin occurs. Conjugation is the conversion
  of yellow lipid soluble pigment into
  water-soluble pigmentdirect bilirubin

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Newborn at RiskHyperbilirubinemia
3155

• Risk factors
• Fetal-maternal ABO/Rh incompatibilities
• Prematurity
• Cephalohematomas- from birth trauma
• Bruising
• Birth trauma
• Polycythemia
• Delayed meconium passage, which are normally
  excreted thru stool

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Newborn at RiskHyperbilirubinemia

• Classification
• Physiologic jaundice
• Breastfeeding / Breast milk jaundice
• Pathologic jaundice

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• Physiologic jaundice in the term newborn
• - typically peaks at 3-4 days
• then declines over the first week of life
• usually the total bili will be lt 12 mg/dL- bili
  can go as high as 17 with multiple risk factors

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• Breastfeeding jaundice (early onset)
• compared to formula fed infants--- breast fed
  infants
• are 3-6X more likely to develop moderate to
  severe
• jaundice (moderate biligt 12, severe bili
  gt15 mg/dL)
• due to mild dehydration (decreased volume of
  breast milk)
• - dehydration may cause a delay in meconium
  passage

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• Breastmilk jaundice (late onset)
• - occurs laterbili usually peaks at day 6-14
  can develop in up to 1/3 of healthy breast fed
  infants bili can vary from 12-20, at this age it
  would not be considered pathologic- bili level
  usually continually falls after 2 wks of age,
  however, it may remain elevated for 1-3 months.
  if the cause of the jaundice is in question, the
  mom may be asked to stop breastfeeding, but
  continue to express breastmilk, with formula
  substitution, if the bili drops rapidly over 48
  hours, this confirms breastmilk jaundice and
  breastfeeding may be resumed.

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Hyperbilirubinemia - Physiologic
3252

• RBCs shorter life span
• Immature liver
• Lack of intestinal bacteria to conjugate
  bilirubin
• Poor hydration hinders urine bowel elimination

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Newborn at RiskHyperbilirubinemia

• Nursing Care
• IO
• Hydration
• Observe for jaundice
• Phototherapy
• Transfusions
• Nursing care plan, page 779-780

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• IO
• - monitor for first stool WHY?
• Hydration
• - early frequent feeds
• - more severe IVF
• Jaundice
• - note when it occurs
• - monitor progression
• - transcutaneous bili check before discharge
• Phototherapy
• - use of visible light to convert bilirubin into
• water soluble isomers that can be eliminated
• without being conjugated in the liver
• Transfusions
• - for severe anemia
• - exchange transfusions
• to replace the babys damaged blood
• ? RBC count and ? bili level

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HyperbilirubinemiaPathologic Jaundice
3530

• Hemolytic disease of the newborn (HDN) due to a
• Rh incompatibility
• ABO incompatibility
• Jaundice at birth or in the first 24 hours of
  life
• Physiologic jaundice occurs after 24hrs
• Hydrops fetalis- massive edema in the fetus or
  newborn, usually in association with RBC
  destruction. (blood incompatibility) Rhogam to
  prevent.
• Kernicterus- toxic accumulation of bilirubin in
  tissues caused by hyperbilirubinemia.

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• Rh incompatibility
• - Rh negative Mom/Rh positive Dad
• have an Rh positive baby
• - babys blood cells cross over to the Rh
  negative Mom
• - Mom develops antibodies (Rh sensitization)
• - subsequent pregnancies are at risk for HDN
• - How do we avoid this? RhoGAM
• Signs/Symptoms
• During pregnancy
• - placenta helps rid some bili, but not all
• mild anemia/hyperbilirubinemia/jaundice
• - liver/spleen and bone marrow cant keep
• up with RBC destruction
• severe anemia liver/spleen enlargement
• - babys organs cant handle the severe anemia
• leading to heart failure with fluid buildup
  in tissues
• and organs hydrops fetalis
• After birth
• - babys liver cant conjugate the large amount
  of bili

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7b) Hemolytic Disease of the Newborn

• Rh incompatibility
• Rh neg mother with Rh positive newborn
• Jaundice, anemia, hemolysis of RBCs, increased
  immature RBCs
• Most severe form of hemolytic disease of newborn
  Hydrops Fetalis
• Multi-organ system failure due to severe anemia
• Rhogam for the block

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• Hemolytic disease of the newborn secondary to Rh
  incompatibility
• Isoimmune
• Rh neg mother with Rh positive newborn passes
  maternal antibodies to fetal circulation that
  destroy the fetal RBC
• Jaundice, anemia, increased immature RBCs
  (erythroblasts) r/t hemolysis of RBCs,
• Most severe form is hydrops fetalis occurs when
  maternal antibodies attach to the Rh site on the
  fetal RBC, making them susceptible to destruction
  by phagocytes multi-organ system failure
  frequently fatal

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Hemolytic Disease of the NewbornSame thing, but
not as severe
3820

• ABO incompatibility
• Mother blood type O infant A or B can result in
  jaundice but rarely hemolytic disease
• Jaundice, hyperbilirubinemia, hepatosplenomegaly
  r/t hemolysis of RBCs
• Rh is not a factor

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Care of Newborn at Risk for Hyperbilirubinemia

• Identifying the Cause of Hemolytic Disease
• Blood type
• Coombs test
• Indirect- amount of Rh antibodies in mothers
  blood
• Direct- presence of antibody coated Rh RBCs in
  newborn
• Serum bilirubin
• CBC
• Reticulocyte count

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Care of Newborn at Risk for Hyperbilirubinemia
3935

• Alleviate anemia
• Exchange transfusion
• Withdraw replace all newborns blood with donor
  blood
• Increase serum albumin levels
• Reduce serum bilirubin
• Phototherapy
• Drug therapy- Phenobarbital (Bilirubin binds to
  Phenobarbital, so when it goes the bilirubin
  does too)

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8) Newborn at Riskfor Anemia

• Normal Hgb
• Term 15-20 g/dL, less 14 anemia
• Preterm 14-18 g/dL, less 13 anemia
• Hemoglobin levels lt 14g/dl in term infant or 13
  g/dl in preterm

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Common Causes of Anemia

• Blood Losses
• Placental bleeding
• Intrapartal blood loss
• Umbilical cord bleeding
• Birth trauma
• Cerebral bleeding
• Hemolysis
• Impaired red blood cell production

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Physiologic anemia
4210

• Decreased hgb first 6-12 weeks
• Production of RBCs stopped in response to
  elevated O2
• Hgb levels decrease, bone marrow production
  resumes

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Care of the Newborn with Anemia

• Early Detection and correction of pathological
  anemia
• Pale infant, poor weight gain, tachycardia,
  tachypnea, apneic episodes
• Ensure newborn well-being. Follow checklist
  airway, breathing, circulation, neutral thermal
  environment, early detection and intervention of
  hypoglycemia, promote comfort bonding
• Monitor total blood out

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Anemia

• Signs Symptoms
• ? Hgb
• Pallor
• ? BP
• Tachycardia
• Tachypnea
• Apneic episodes

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Nursing Care - Anemia

• Mild anemia
• Iron supplement
• More severe
• Hydration
• Blood Transfusion

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9) Newborn at RiskPolycythemia

• ? blood volume
• ?Hct gt 65-70
• Hgb gt 22 g/dl
• More common in
• IDM
• SGA
• Postmature
• Term infants with delayed cord clamping
• Maternal-fetal transfusion
• Twin-to-twin transfusion

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Newborn at RiskPolycythemia

• Often asymptomatic
• S/S
• CHF - Tachycardic, Respiratory distress (30-60
  is normal)
• ? bili
• ? peripheral pulses

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Nursing Care

• Exchange transfusion with FFP or albumin
• Monitor VS during transfusion
• /- phototherapy
• Treatment goal
• Reduce hematocrit to a range of 55-60, this is
  a success

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Newborn at RiskInfection
4838

• Sepsis Neonatorum
• Newborns up to 1 month of age are particularly
  susceptible
• Prematurity increases risk
• Caused by organisms that do not cause infection
  in older children

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Predisposing Factors

• Maternal antepartal infections
• TORCH - Toxoplasmosis, Rubella, Cytomegalic
  Inclusion Disease, Herpes (all deadly to
  newborns)
• Intrapartal
• Amnionitis, passage through the birth canal,
  Group B hemolytic Strep, Herpes, Gonococci,
  Listeria
• Nosocomial
• Pseudomonas, Staphylococcus aureas and epi

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Diagnosis
5043

• Usual Lab work
• CBC, Blood Cultures (best) and Sensitivity with
  Gram Stain, Urine for antibody screen, C-Reactive
  Protein level, other cultures as recommended or
  ordered
• Chest x-ray
• If viral infection is suspected TORCH
  (toxoplasmosis, other, rubella, cytomegalovirus,
  herpes virus) titers are drawn. Skull and bone
  x-rays to check for any damage.

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Nursing care
5142

• Infants with sepsis can rapidly deteriorate!
• Supportive care
• Administer medications as ordered
• Recognition of the signs of sepsis- hypotonia,
  color changes pallor, dusky, cyanosis, grey,
  temperature instability, feeding intolerance,
  hyperbilirubinemia, tachycardia, apnea,
  behavioral changes, RDS-type symptoms
• Respiratory Distress symptoms
• Incr respirations, nasal flaring, retractions,
  grunting, peripheral edema
• A sub normal temperature, is a cardinal sign of
  sepsis.

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10) Antibiotic Therapy
5342

• Review proper dose/kg
• Therapeutic peak/trough values
• Method of administration (thru IV, Central line
  is better)
• Incompatibilities
• Side effects

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Duration of Antibiotic Therapy
5423

• Therapy initiated before test results are final
• Treatment of infection with 2 broad spectrum
  antibiotics per intravenous route
• When the pathogen and its sensitivities are
  determined appropriate specific antibiotic
  therapy is implemented for 7-14 days.