Signs of Potential Sepsis in Premature Babies
Recognize septic shock in premature infants through clinical examination before hypotension develops, focusing on temperature instability, altered mental status, abnormal heart rate, and impaired peripheral perfusion as the key warning signs. 1
Critical Early Warning Signs
Temperature Instability
- Hypothermia or hyperthermia are primary indicators of potential sepsis in premature infants 1, 2
- Temperature instability occurs before other hemodynamic collapse signs 2
Altered Mental Status
- Lethargy, decreased responsiveness, or irritability are key neurological signs 2
- Changes in mental status should prompt immediate evaluation 1
Abnormal Heart Rate Patterns
- Heart rate <90 bpm or >160 bpm in infants is associated with increased mortality 1, 2
- Both tachycardia and bradycardia are critical warning signs 2
Impaired Peripheral Perfusion
- Capillary refill time >2 seconds is a critical "red-flag" sign 1, 2
- Poor peripheral pulses with weak or absent distal pulses indicate abnormal perfusion 2
- Peripheral vasoconstriction ("cold shock") or vasodilation ("warm shock") patterns 1
Respiratory Signs
- Tachypnea (increased respiratory rate) is a common early sign 2, 3
- Respiratory distress with increased work of breathing, grunting, and retractions 2
- Respiratory distress is the most common presenting symptom, though it can have noninfectious etiologies 3
Progressive Severity Indicators
Mortality risk increases progressively with specific hemodynamic patterns: 1, 2
- Eucardia (1% mortality)
- Tachycardia/bradycardia (3% mortality)
- Hypotension with capillary refill <3 seconds (5% mortality)
- Normotension with capillary refill >3 seconds (7% mortality)
- Hypotension with capillary refill >3 seconds (33% mortality) 1
Special Considerations for Very Low Birth Weight (VLBW) Infants
Unique Vulnerabilities in Premature Infants <32 Weeks Gestation
- Hypoglycemia risk due to reduced glycogen stores and limited muscle mass for gluconeogenesis 1, 2
- Patent ductus arteriosus may persist, complicating hemodynamic assessment 1
- Risk of intraventricular hemorrhage with rapid blood pressure shifts requires more cautious fluid resuscitation 1
Additional Metabolic Considerations
- Calcium deficiency from relative parathyroid hormone axis deficiency 1
- Thyroid hormone deficiency may require replacement 1
- Impaired thermogenesis requiring external warming 1
Critical Monitoring Parameters
Continuous monitoring should include: 2
- Temperature monitoring
- Preductal and postductal pulse oximetry
- Intra-arterial blood pressure
- Continuous electrocardiogram
- Serial capillary refill assessments every 5-15 minutes during resuscitation 2
Common Pitfalls to Avoid
Do Not Wait for Hypotension
- Hypotension is a late finding indicating decompensated shock 1, 2
- Diagnosis should occur before hypotension develops based on perfusion abnormalities 2
- Early recognition based on clinical examination, not biochemical tests, is recommended 1
Do Not Assume Adequate Perfusion with Normal Blood Pressure
- Compensated shock can exist with normal blood pressure but abnormal capillary refill and mental status 2
- Clinical signs of poor perfusion take precedence over blood pressure readings 1
Do Not Rely Solely on Laboratory Tests
- The American College of Critical Care Medicine recommends early recognition using clinical examination, not biochemical tests 1
- Laboratory tests alone have poor predictive value in preterm early-onset sepsis 4
Additional Clinical Context
Timing of Presentation
- Infants often present within the first 24 hours after birth with clinical signs of sepsis 3
- Early-onset sepsis occurs within the first 7 days of life 5