Clinical Judgment: Multisystem and Professional Caring and Ethical Practice
Sepsis and shock
Early-onset sepsis (first 72 hours) is usually group B Streptococcus or E. coli; late-onset is often coagulase-negative Staphylococcus and fungal in the very preterm on broad-spectrum antibiotics. Signs are nonspecific - temperature instability, apnea, poor perfusion, glucose swings. Draw cultures, then treat promptly. Neonatal shock: give 10 mL/kg isotonic fluid boluses and reassess; preterm infants tolerate volume poorly and may need early vasopressors (dopamine, epinephrine) and hydrocortisone for adrenal insufficiency. DIC presents with oozing from puncture sites and both bleeding and thrombosis.
Multisystem thinking
A single deterioration should prompt review of all systems: ventilation, perfusion, glucose, temperature, and infection. Transport adds risk; stabilize before moving, and communicate with a structured handoff.
Ethics and professional practice
Consent in the NICU comes from parents acting as surrogates under the best-interest standard; older children may give assent. Values conflicts, requests for futile treatment, withdrawal of life-sustaining treatment, and DNR orders are resolved through structured ethics consultation, not unilateral action. Palliative care is compatible with curative care. Report suspected abuse or neglect as legally required. Know your scope: delegation to unlicensed personnel must match their training, and you remain accountable for the assessment.
Traps
Equating a DNR order with withdrawing all care; assuming parents can demand any treatment; documenting opinions instead of objective findings.
Rule of thumb
When values conflict, name the disagreement, involve the family and ethics committee early, and keep the infant's best interest as the fixed point.