Neonatal Sepsis Nursing Care Plans

A septic neonate rarely announces itself. You get temperature instability, poor feeding, a baby that is just "not right." By the time blood pressure drops, you are already behind. Your job is to catch it early, support thermoregulation, glucose, perfusion, and breathing, and get antibiotics in fast.

Neonatal sepsis (also called neonatal septicemia or sepsis neonatorum) is a systemic bacterial, viral, or fungal infection that drives hemodynamic instability and carries high morbidity and mortality. It falls into three categories by timing.

Early-onset sepsis presents in the first 3 days of life (under 72 hours), and 85% of cases show up within 24 hours. It comes from vertical transmission: organisms colonizing the mother's genitourinary tract are acquired as the neonate passes through the birth canal, or spread hematogenously and transplacentally from an infected mother.

Late-onset sepsis occurs at 4 to 90 days of life and is acquired from the environment. The infant's skin, respiratory tract, conjunctivae, GI tract, and umbilicus get colonized through contact with caregivers or surroundings.

Very late-onset sepsis is diagnosed in infants hospitalized in the NICU from the first 30 days of life until discharge.

The biggest risk factors are prematurity and low birth weight. Preterm, low-birth-weight babies develop sepsis 3 to 10 times more often than full-term babies with normal birth weight, partly because of low transplacental maternal IgG. Maternal factors that raise the risk of early-onset disease include chorioamnionitis, prolonged rupture of membranes (over 18 hours), intrapartum maternal fever (above 38°C), delivery before 37 weeks gestation, and group B streptococcal (GBS) colonization.

Nursing Care Plans and Management

Care centers on early detection, fast treatment, and supportive care: close monitoring of vital signs, labs, and clinical signs of infection, plus appropriate antibiotics, fluids, and respiratory support.

Nursing Problem Priorities

1. Recognize and treat neonatal sepsis early.
2. Monitor vital signs, lab values, and clinical signs of infection closely.
3. Give appropriate antibiotics and other medications.
4. Provide supportive care, including fluids and respiratory support.
5. Enforce strict infection control.
6. Educate and support parents in caring for the septic neonate.

Nursing Assessment

Assess for the following subjective and objective data:

• Temperature instability (high or low)
• Poor feeding or refusal to feed
• Lethargy or irritability
• Respiratory distress or tachypnea
• Abnormal heart rate or low blood pressure
• Jaundice
• Poor weight gain or failure to thrive
• Abdominal distension or vomiting
• Skin rash or redness
• Signs of infection at the umbilical cord site or other wounds

Nursing Diagnosis

Form your nursing diagnoses from the assessment and your clinical judgment of this neonate's condition. The specific diagnostic labels matter less than acting on what you see.

Nursing Goals

Goals and expected outcomes may include:

• The newborn maintains a normal body temperature and avoids cold stress.
• The newborn shows normal vital signs and Apgar score.
• The neonate keeps plasma glucose between 40 and 60 mg/dL.
• The neonate maintains specific gravity of 1.003 to 1.020 and urine output of at least 1 mL/kg/hr.
• The neonate keeps electrolytes within normal limits.
• The neonate shows improved perfusion: stable vital signs, adequate urine output, palpable peripheral pulses, pale pink nailbeds and lips, and no edema.
• The mother demonstrates techniques to sustain lactation until breastfeeding begins, and the neonate latches and breastfeeds gradually.
• The parents visit and hold the neonate frequently, interact with him in mutually satisfying ways, and speak of him in positive terms.
• The neonate shows a normal respiratory rate and pattern, clear breath sounds, reduced accessory muscle use, and capillary refill within normal range.
• The neonate stays free of signs of infection.

Nursing Interventions and Actions

1. Managing Fever and Promoting Effective Thermoregulation

Temperature instability tracks with neonatal sepsis and meningitis, driven either by pyrogens from the organism or by sympathetic instability. Expect the neonate to run hypothermic. A baby who is hypothermic or outside a neutral thermal environment burns energy trying to compensate, which pushes toward metabolic acidosis.

Monitor the newborn's temperature. Skin temperature drops before the core falls, so use a skin probe for preterm infants, placed in the right upper quadrant of the abdomen. On the first day of life, take and record temperature every 4 to 8 hours.

Perform Apgar scoring. Rate the newborn at 1 minute and 5 minutes after birth. A score of 7 and above is vigorous. If the 5-minute score is under 7, score every 5 minutes until it reaches 7. Heart rate, respiratory effort, muscle tone, reflex irritability, and color are each rated 0, 1, or 2.

Keep care organized and fast. Do early newborn care quickly and expose the baby to cool air as little as possible. Unprotected, the temperature falls below normal almost immediately from heat loss, cool birthing-room air, and the infant's immature temperature regulation.

Place the newborn on the mother's abdomen after birth. Newborns are wet at birth and lose large amounts of heat as amniotic fluid evaporates off the skin. Lay the baby on the mother's abdomen right away and cover with a warm blanket for skin-to-skin contact.

Dry the newborn thoroughly. Drying, especially the face and hair, cuts evaporative loss. The head is a large surface area and a major source of heat loss.

Place the newborn under a radiant warmer or in an incubator. This is an effective way to conserve heat. Adjust the incubator so the neonate's body temperature stays optimal, 36.2°C to 37°C (97.1°F to 98.6°F).

Cover the newborn with warm blankets and a cap. A cap over dried hair further reduces evaporative cooling. Keep the baby covered on the mother's abdomen or in a warm crib.

Cover surfaces with warm blankets. Conduction transfers body heat to cooler solid objects in contact with the baby. A warmed blanket or towel on any surface minimizes conductive loss.

Administer antibiotic therapy as indicated. See Pharmacologic Management.

2. Preventing Dehydration

Sepsis drives dehydration through poor intake, increased losses, and altered fluid balance. The result is reduced tissue perfusion, poor organ function, and impaired healing.

Assess vital signs. Tachycardia reflects decreased intravascular volume, decreased stroke volume, or ineffective cardiac output. Compensatory mechanisms keep blood pressure near normal in mild to moderate hypovolemia; with severe hypovolemia, hypotension is almost always present.

Monitor intake and output. A preterm neonate has immature kidneys and cannot concentrate urine. Weigh the dry diaper, then subtract from the wet diaper to determine output. Urine output should run 1 to 3 mL/kg.

Monitor specific gravity and urine glucose and ketones. Preterm urine output runs high early because of poor concentration, 40 to 100 mL/kg per 24 hours versus 10 to 20 mL/kg in term neonates. Specific gravity is low, rarely above 1.012 (term neonates may concentrate to 1.030). Glucose in the urine can signal hyperglycemia from glucose infusion, which causes diuresis and fluid loss. Ketones appear when too little glucose is supplied and cells burn protein.

Assess blood glucose. Keep determinations between 40 and 60 mg/dL. Hyperglycemia raises mortality compared with normal glucose in neonatal sepsis and indirectly signals sepsis severity, so it can serve as a mortality indicator.

Review electrolytes. Immature kidneys excrete a high proportion of body fluid, contributing to electrolyte imbalance and disturbed acid-base balance. Salt tolerance is limited, edema risk is increased, and dehydration comes on easily.

Monitor weight regularly. Sudden weight changes generally reflect a change in body water. The compartment affected depends on gestational age, associated problems, and care.

Use small-gauge needles for IV infusion when possible. Small-gauge needles exist for small veins, but many preterm neonates lack adequate peripheral veins even for these. They may need an umbilical or central venous catheter.

Encourage early breastfeeding. Put the neonate to the breast within the first hours if the alert state allows suckling and bonding. If the preterm neonate cannot suck adequately, have the mother express milk for gavage feedings. Breast milk delivers the full range of nutrients in the right proportions, provides natural immunity, and avoids contaminated water or improper dilution.

Aspirate stomach contents before gavage feeding. If you aspirate only mucus or air, notify the provider before feeding.

Provide total parenteral nutrition (TPN) as ordered. TPN supplies energy and nutrients for normal growth. Calculate fluid and electrolyte needs from birth weight until the neonate regains it, then use daily weight. Start TPN on the first day of life in neonates unlikely to reach full enteral nutrition within the first week.

Humidify the environment as indicated. High ambient humidity decreases insensible water loss; a radiant warmer or phototherapy increases it. In intubated neonates, inadequate humidification of inspired gas also raises insensible loss.

Administer vitamin K within the first 6 hours after birth. See Pharmacologic Management.

Administer IV fluids via continuous infusion pump. See Pharmacologic Management.

Measure oxygen saturation. Use noninvasive pulse oximetry; a saturation of 92% and above is normal. Apply the sensor to the toe or side of the foot, flush with the skin and secured with wing tapes.

Monitor vital signs for shock. Falling cardiac output shows up as bradycardia and systemic hypotension. Overt shock brings pallor, poor capillary perfusion, and edema. These are late signs of severe compromise tied to mortality, so detect and treat early.

Watch for shock. Septic shock is not diagnosed by a blood pressure drop alone, because the neonate first compensates with tachycardia and peripheral vasoconstriction. Hypotension is an ominous sign that compensation has failed and arrest may be near.

Review labs. Look for positive blood cultures, reduced fibrinogen and thrombocyte levels, and immature white blood cells. Neutropenia, a neutrophil count below 1000/mm³, is an ominous sign.

Educate the mother about vaccines. Immunization against H. influenzae type B (Hib) and the pneumococcal conjugate vaccine (PCV) is recommended for all children 2 months to 4 years of age. These prevent some cases of sepsis, though other bacterial sources remain.

Administer IV fluids as prescribed. Manage intravascular fluid balance meticulously, especially in extremely preterm neonates. Treating hypotension with a fluid bolus followed by antihypotensive infusion is still common, but bolus administration may not help and can be harmful.

Administer vasoactive agents as indicated. See Pharmacologic Management.

Administer oxygen as indicated. Give oxygen via hood or ventilator at concentrations needed to maintain tissue perfusion. Prolonged high-concentration oxygen risks oxygen toxicity.

Administer blood and blood products as appropriate. Packed red blood cells, platelets, and fresh frozen plasma are often indicated. Fresh frozen plasma may reverse the heat-stable and heat-labile opsonin deficiencies seen in low-birth-weight neonates, but controlled studies are lacking and transfusion risks apply.

Prepare for exchange transfusion. This has been used for severely ill neonates, particularly those hypotensive and metabolically acidotic, to raise circulating immunoglobulins, lower endotoxin, raise hemoglobin (with higher 2,3-diphosphoglycerate), and improve perfusion. No controlled prospective studies support it.

3. Promoting Parental Attachment and Breastfeeding

A strong parent-baby bond supports breastfeeding, but the stress and uncertainty of neonatal sepsis disrupts attachment and can derail feeding. Provide emotional support, education, and resources.

Assess the mother's breastfeeding knowledge and prior instruction. Hospital stays are short, so teaching matters. Review her feeding plans before discharge and answer remaining questions. The better informed she is, the more comfortable she will be.

Assess her knowledge of adequate intake. Review the signs that the neonate is feeding enough: 6 to 8 wet diapers a day and stool several times a day, breasts firm before feeds and softer after. A neonate nurses 10 to 15 minutes per breast, 8 to 10 times a day.

Assess her daily fluid intake. Adequate fluid keeps milk supply up. She may need at least 4 to 6 eight-ounce glasses of water a day.

Assess the neonate's ability to breastfeed. Premature or sick neonates have high energy needs but feed poorly by mouth because of weak suck-swallow-breathe coordination, reduced intestinal motility, and immature digestion. Fluttering sucking motions, noisy sucking, or smacking signal nonnutritive sucking or poor mouth position.

Set a visiting schedule or advance warning for feeds. Preterm neonates show hunger like term infants: rooting, crying, sucking. Teaching the mother these cues or scheduling feeding times with the NICU nurse helps build a routine that eases the neonate toward breastfeeding.

Give emotional support and respect her decision about continuing or stopping breastfeeding. Inability to breastfeed can bring decreased milk production, loss of confidence, guilt, anxiety, depression, and stress. Prolactin also falls faster in mothers who cannot breastfeed, which can contribute to postpartum depression. Support keeps her motivated to express milk despite the delay.

Demonstrate portable breast pumps. When breastfeeding must be delayed, teach the mother to pump to maintain supply. Teach her to assemble, disassemble, and clean the pump, and to center the flange over the breast with the nipple in the middle for an airtight seal. Pump about 10 minutes per breast roughly every 3 hours. Breasts should feel soft after pumping.

Review storage and use of expressed milk. Use or store breast milk within 1 hour of pumping to avoid bacterial contamination. Store in glass or hard plastic; clear hard polycarbonate bottles are safe for storing and freezing, and any plastic for infants should be labeled BPA free. Thaw in the refrigerator for 24 hours or under lukewarm running water. Milk keeps at room temperature for 4 to 6 hours in a tightly capped container, or in the back of the refrigerator (4°C / 39°F) for up to 96 hours (4 days). Use single-feeding portions, label with the date, and do not refreeze after thawing.

Provide privacy and calm surroundings. Rooming-in is ideal for a sick or premature neonate because feeding can follow cues. Keep the room comfortable and free of tobacco smoke.

Have the mother perform hand hygiene before breastfeeding. Washing her hands clears pathogens from handling perineal pads or other sources. Washing the breasts is unnecessary unless caked colostrum is on the nipples.

Teach positioning and body alignment. The side-lying position lets the mother rest while feeding. A football hold with the neonate on a pillow helps, especially after cesarean birth. Whatever the position, keep the neonate chest-to-chest with the mother, head and neck in alignment.

Teach proper latch and removal. Brushing the neonate's cheek with the nipple triggers rooting, and he turns toward the breast. Position him at nipple level for easy milk flow. A wide-open mouth before latch gives a better latch as she brings him in; lips should flare outward. Check that the tongue is under the nipple by gently pulling down the lower lip.

Introduce kangaroo care. Skin-to-skin contact, with the neonate in only a diaper held upright against a parent's chest, increases milk production in mothers of premature infants who cannot breastfeed. It supports maternal feelings, lowers stress, and strengthens bonding. Neonates who receive kangaroo care start breastfeeding earlier and breastfeed longer.

Encourage regular sucking. This reinforces that feeding is pleasurable and aids digestion. If a pacifier is used, teach parents to use a one-piece type to prevent choking, secure it with a clip, and never put it on a string around the neck.

Encourage the mother to rest. Fatigue is a problem at home if she does not conserve energy. Sitting relaxed with feet elevated while feeding is good rest and promotes effective feeding.

Provide support if problems arise. Give an individual feeding plan at discharge, ideally with an International Board Certified Lactation Consultant (IBCLC). Early followup and referral to breastfeeding support groups promote success. The first 4 weeks postpartum are the hardest; after that, established breastfeeding is easier than formula feeding.

Note parents' perceptions of their situation. Parents may not be psychologically ready for a preterm birth, which makes it harder to feel they have a child and to start interacting than with a term infant.

Observe parenting behaviors. Watch the affection and interest shown, the physical contact, stimulation, eye contact, and time spent with the neonate. Adults tend to use high-pitched voices with neonates.

Watch for interactions needing intervention. Flags include indifference to hunger or discomfort cues, failure to read the neonate's communication, avoidance of eye contact, or describing the neonate in negative terms.

Encourage parents to express their feelings. Before bonding, parents may need to work through disappointment that the infant is small or guilt that they could not prevent the preterm birth. Helping them air these feelings and build a positive attitude is a core nursing responsibility.

Teach growth and development and address parental perceptions. Discuss expected behaviors and point out unique characteristics to support bonding, especially when the parents' imagined child differs from the real one in sex, appearance, or health.

Involve parents in care they can succeed at. Hands-on involvement helps them learn. Discuss feeding and elimination, observe diaper changes, and review nursing frequency and any difficulty. Parent teaching covers airway maintenance with positioning and a bulb syringe, temperature assessment after discharge, expected voiding and stool changes, feeding, signs of illness to report, and well-baby followup.

Reinforce nurturing behaviors. Positive feedback continues desired behaviors. First-time parents may be sensitive to criticism, so praise their efforts while tactfully suggesting improvements.

Encourage interaction with the neonate. Conserve a preterm neonate's strength by limiting sensory stimulation and handling gently, but preterm babies need as much attention and affection as term ones. Rocking, singing, talking, and gentle holding build a sense of trust. Encourage parents to interact as soon as possible.

Arrange a visitation schedule. Have parents tell the primary nurse when they usually visit so procedures and rest times are scheduled around their visits, leaving uninterrupted time to hold and interact with their child.

Provide photos while the neonate is in the NICU or transferred. Before any transfer to a regional center, make sure parents see the neonate. A photograph makes the birth more real. Encourage frequent visits, and cellphone photos or notes "from the baby" taped to the incubator keep parents involved and support bonding.

Let parents hold the neonate through the incubator or warmer. Warmers, incubators, ventilators, and monitors are routine to you but frightening to parents. Even if the baby cannot come out, parents can handle and stroke him inside. Encourage the mother to hold him before and after gavage feedings and to breastfeed or bottle feed as soon as he is ready.

4. Maintaining Normal Blood Glucose Levels

In sepsis, hypoglycemia develops from the inability to break down glycogen and from hyperinsulinemia, while metabolic changes leave glucagon unable to mobilize glucose from fatty acids and amino acids. Preterm infants worsen it through the extra glycogen demand of the brain, heart, and other tissues during sepsis.

Monitor glucose frequently. Draw heel-stick specimens every 2 hours. Sepsis raises energy demand and strains already-deficient stores. Plasma glucose below 40 mg/dL in a term infant and below 30 mg/dL in a preterm infant indicates hypoglycemia.

Measure birth weight accurately. Sepsis is a leading cause of neonatal mortality, especially in preterm and low-birth-weight infants. Mortality occurs more often at moderate to late preterm gestation and low birth weight, with a median birth weight of 1900 grams (1.9 kg) in one study.

Assess for signs of hypo- or hyperglycemia. Hypoglycemia shows as tremors, weak cries, lethargy, convulsions, and plasma glucose below 40 mg/dL (term) or 30 mg/dL (preterm). Hyperglycemia from sepsis and stress shows as glucosuria and osmotic diuresis, leading to dehydration, ketosis, and metabolic acidosis.

Measure urine output and check for glucose. Glucosuria signals osmotic diuresis. A urine glucose of 2+ or higher raises the risk. Each 18 mg/dL rise in blood glucose increases serum osmolality by 1 mOsm/L.

Provide small, frequent feedings. Preterm infants have a smaller stomach capacity and must be fed more often in smaller amounts than term infants, sometimes as little as 1 to 2 mL every 2 to 3 hours. A preterm neonate needs relatively more nutrients, 115 to 140 calories per kilogram per day versus 100 to 110 for a term infant.

Use gavage feeding when needed. Sucking is present early, but coordinated suck-and-swallow is inconsistent until about 34 weeks gestation, and the gag reflex is not intact until 32 weeks. Ill or respiratory-distressed infants may start on gavage feedings, given intermittently every few hours or continuously through tubes into the stomach or intestine.

Encourage breast milk. Preterm infants grow well on formula, but breast milk is best, supporting immune defenses and helping prevent necrotizing enterocolitis. Mothers can express milk by hand or pump for gavage feedings and freeze it for safe transport and storage.

Organize care to protect rest. The neonate needs rest to combat hypoglycemia and infection. Cluster procedures so he is not awakened constantly.

Administer IV glucose as indicated. Give a bolus of 200 mg/kg (dextrose 10% at 2 mL/kg), then a continuous infusion of dextrose 10% at 5 to 8 mg/kg per minute (80 to 100 mL/kg per day) to hold blood glucose at 40 to 50 mg/dL. Monitor closely, checking glucose as often as every hour for the first 12 hours, then less often once target values are reached.

Administer insulin as prescribed. See Pharmacologic Management.

5. Managing Respiratory Symptoms and Promoting Effective Breathing Patterns

Respiratory status in neonatal sepsis varies with infection severity. Expect tachypnea, grunting, nasal flaring, and retractions as the baby works to oxygenate.

Assess breathing pattern and rate. Respiratory distress may appear after delivery or be delayed several hours. Respirations climb to 60 breaths/min or more, with gruntlike sounds. Expiratory grunting comes from glottic closure that raises alveolar pressure to keep the alveoli from collapsing.

Assess for accessory muscle use. Nasal flaring and sternal and subcostal retractions accompany breathing. As distress rises, seesaw respirations appear: on inspiration the chest wall retracts and the abdomen protrudes; on expiration the sternum rises.

Measure oxygen saturation and review ABGs. The neonate may turn cyanotic as PO₂ and saturation fall in room air. Blood gases may show respiratory acidosis from poor oxygen exchange, tissue hypoxia, and lactic acid release.

Auscultate both lung fields comparatively. Fine rales and diminished breath sounds reflect poor air entry. Worsening distress signals falling air exchange.

Cluster care. Combine assessments and treatments into blocks so the neonate gets uninterrupted rest. Schedule procedures together and time parent visits after he has rested, to conserve energy.

Maintain a neutral thermal environment. Place the neonate in an incubator or under a radiant warmer to minimize cold stress, which raises metabolic oxygen demand. The incubator controls temperature, air, radiating surfaces, and humidity to hold his temperature normal with minimal oxygen consumption. Radiant cribs add easier access while maintaining the environment.

Improve hydration and nutrition. Provide IV fluids and glucose or gavage feedings, since the respiratory effort leaves the neonate too exhausted to suck. Give enteral feedings with breast milk supplemented by high-calorie formula.

Stimulate breathing after apnea. Apnea is cessation of breathing for 20 seconds or longer and may come with bradycardia and cyanosis. Gently rub the ankles, feet, and back to stimulate breathing. If that fails, suction the nose and mouth and raise the head to a semi-Fowler's position.

Administer surfactant replacement as indicated. See Pharmacologic Management.

Administer supplemental oxygen as prescribed. Oxygen is often needed to maintain PO₂ and pH after surfactant, delivered by cannula, mask, continuous positive airway pressure (CPAP), or assisted ventilation with positive end-expiratory pressure (PEEP).

Anticipate ventilator use. Infant ventilators offer a reverse I/E ratio (2:1) and are pressure cycled to control delivery force.

Administer nitric oxide as indicated. See Pharmacologic Management.

Set up extracorporeal membrane oxygenation (ECMO) as appropriate. ECMO manages severe hypoxemia in neonates. Once a mainstay for RDS, it is now rarely needed because surfactant is so effective.

6. Promoting Infection Control and Preventing Infections

Sepsis or serious infection within the first 4 weeks of life kills more than 1 million neonates worldwide every year. A septic neonate may present in or progress to septic shock with cardiovascular dysfunction requiring fluid resuscitation or inotropic support. Unchecked, end-organ damage and death follow.

Perform Apgar scoring at 1 and 5 minutes. Rate heart rate, respiratory effort, muscle tone, reflex irritability, and color 0, 1, or 2. Low 5-minute scores correlate strongly with neurologic illness.

Assess the umbilical cord area. Confirm the cord is clamped securely; if it loosens before the vessels thrombose, hemorrhage can result. Keep the area dry and free of erythema.

Assess vital signs. After the early phase, cardiac output falls further with bradycardia and systemic hypotension. Overt shock brings pallor, poor capillary perfusion, and edema, late signs of severe compromise tied to mortality.

Model strict hand hygiene and wear PPE. Wash hands and arms to the elbows with antiseptic soap before handling the neonate. Wear cover gowns or nursery uniforms for direct care, and gloves and a face mask when handling a sick neonate.

Keep infected people away from the neonate. Exclude staff with infections, particularly sore throats, upper respiratory infections, or herpes lesions, until fully cleared. If the mother may have a contagious illness, keep the neonate out of her room until contagion is no longer possible.

Anticipate intubation. Septic neonates often present with apnea or severe respiratory distress and may need intubation to secure the airway and maintain lung volume.

Consider the Kaiser Sepsis Calculator. This model significantly reduces empiric antibiotic use and blood cultures without raising morbidity, mortality, or readmissions for early-onset sepsis. Limit its use to term and late preterm neonates of 34 weeks gestation or later.

Prepare for central or peripheral catheter placement. A central line or PICC may be needed when prolonged IV antimicrobials are required and peripheral access cannot be maintained.

Obtain specimens for Gram stain and culture. Cultures of blood, urine, and cerebrospinal fluid (CSF) remain the gold standard. A Gram stain gives early gram-negative or gram-positive identification.

Assist with transfer to a specialty center. The neonate may need a level III or IV perinatal center if he requires cardiopulmonary support, parenteral nutrition, or prolonged IV access. Larger centers provide the multidisciplinary services an acutely compromised neonate needs.

Administer supplemental oxygen as prescribed. Increasing inspired oxygen may be needed in septic shock to maximize tissue oxygen delivery, since reduced pulmonary function and higher tissue demand drive hypoxia.

Administer IV fluids as prescribed. For hypotension with or without shock, the recommended first step is a crystalloid fluid bolus, with close monitoring for intravascular volume depletion. Consider aggressive volume expansion in term or older preterm infants. Combine with a 10% glucose solution and frequent monitoring to keep normoglycemia.

Administer IV antibiotics as indicated. See Pharmacologic Management.

Administer vasoactive drugs as prescribed. Dopamine is the first-line vasoactive drug. For shock unresolved by volume and dopamine, epinephrine or norepinephrine may help; neonates with vasodilatory shock can respond to their alpha-adrenergic vasoconstriction.

Transfuse blood and blood products as appropriate. Correcting significant coagulopathy and anemia with fresh frozen plasma or packed red blood cells can improve blood pressure and oxygen delivery.

7. Administering Medications and Providing Pharmacologic Support

Management combines antibiotics, supportive care, and targeted medications. Antibiotics start broad-spectrum, then narrow based on culture and sensitivity. Surfactant improves lung function, IV fluids maintain hydration and electrolytes, and vasopressors support blood pressure and perfusion when needed.

Antibiotics. In the United States and Canada, early-onset neonatal sepsis is treated with combined IV aminoglycoside and expanded-spectrum penicillin. This covers gram-positive organisms, especially group B Streptococcus (GBS), and gram-negative bacteria such as E. coli.

Vitamin K. Give all newborns one IM dose within the first 6 hours after birth, after initial stabilization and newborn-mother interaction. The dose is 0.5 mg for infants weighing 1500 g or less and 1 mg for infants over 1500 g.

Intravenous fluids. Give IV fluids by continuous infusion pump for a constant rate and to prevent overload. Dextrose 10% with electrolytes and Ringer's lactate are common for maintenance or for treating dehydration in older infants. Check the IV site closely, because the preterm neonate's lack of subcutaneous tissue raises the risk of tissue damage if infiltration occurs.

Vasoactive agents. Dopamine is the most common, with a median duration of 46 hours and a median maximum dose of 10 µg/kg/min, followed by epinephrine and dobutamine. These catecholamines stimulate adrenergic receptors in the sympathetic nervous system, cardiomyocytes, vascular smooth muscle, and other cells, producing cardiovascular, renal, and endocrine effects.

Insulin. Give insulin when blood glucose is above 250 mg/dL with glucosuria in two separate urine samples taken at 4-hour intervals and weight gain is insufficient despite reduced glucose infusion. Insulin controls hyperglycemia and promotes weight gain. Measure blood glucose half an hour after each change in insulin infusion.

Surfactant replacement. Giving surfactant at birth to a neonate at risk from low gestational age largely prevents respiratory distress syndrome. Administer synthetic surfactant into the endotracheal tube by syringe or catheter immediately after birth. Place the neonate upright afterward and do not suction the airway, so the surfactant reaches the lower lungs and is not removed.

Nitric oxide. Nitric oxide is a potent vascular dilator that helps oxygenate the lungs. It causes pulmonary vasodilation without lowering systemic vascular tone, entering the alveoli on ventilation and redirecting pulmonary blood by dilating the pulmonary arterioles.