Necrotizing Enterocolitis Management

Nonsurgical Medical Management For NEC NPO Platelet transfusions (thrombocytopenia) Gastric decompression FFP for DIC Antibiotics Careful management of I/O’s Serial x-rays (q4-6hrs) Abdominal girth measurements Respiratory support as needed Monitor blood glucose Circulatory support as needed to treat hypotension Frequent CBC and electrolyte panels

Fluid Management Fluid restrict with higher glucose concentration depending on need for volume resuscitation Monitor gi losses from repoglye at low intermittent suction Replace fluid losses mL for mL as needed for excessive losses Replace electrolytes as needed

Management Antibiotics: Vancomycin, Gentamicin and Clindamycin for adequate coverage Continue antibiotic coverage for 10 to 14 days, longer if cultures positive or condition warrants Volume support to keep blood pressure in normal range Inotropic drugs as indicated to improve blood pressure and cardiac output

Surgical Management Surgery is necessary if medical management is not possible or fails.

Surgical Management Indications for surgery Absolute indications: pneumoperitoneum, intestinal gangrene Relative indications: progressive acidosis and/or thrombocytopenia, leukopenia/leukocytosis, progressive pneumatosis, persistent fixed dilated loops of bowel, abdominal wall erythema and/or edema, and portal venous gas

Surgical Procedure Most common Resect obvious necrotic bowel and create stomas If a large amount of bowel is involved, a second exploration is performed 24-48hrs later to reevaluate bowel viability More recently Peritoneal drains for infants <1kg and/or extremely unstable infants

Peritoneal Drains ~ 80% of infants <1kg will NOT survive surgical resection for NEC Peritoneal drains decompress the peritoneal cavity and remove stool/necrotic debris Local anesthetic and sedation Incisions RLQ or RLQ and LLQ Penrose or Jackson Pratt drains Cavity is irrigated (NS) to remove other contaminants Drains remain for 1-2 weeks to allow for drainage Most common complication: stricture formation

Postoperative Care Pain management minimum of 24 to 48 hours PCVL or CVL for long term TPN Antibiotics 14d+ (Vancomycin, Gentamicin, +/-Clindamycin) NPO and Gastric decompression Maintenance of glucose homeostasis, fluid and electrolyte balance Monitor lab work Observation of stomas for color and drainage

Postoperative Care Very slow resumption of feeds 10-14d post-op (varies depending on clinical status and previous feeding history) Consult: Pediatric GI for long term follow up

Reanastomosis Usually 1-2 months post-op Factors evaluated Weight gain Excessive ostomy output Resect during reanastomosis 70-80% survival rate after surgical NEC

Complications/Sequelae of NEC Approximately 75% of infants who develop NEC survive. Half of surviving infants incur long term complications Most common  intestinal stricture

Intestinal Stricture Former ischemic area  heals  fibrosis  scars narrowed lumen Most common in non operative NEC Stricture in L colon is most common Presents as FTT and/or blood stools

Other Sequelae of NEC Intestinal malabsorption Loss of bowel length  decreased absorptive surface Vitamin B12 deficiency Bile salt deficiency Intestinal hypermotility Bacterial overgrowth

Other Sequelae of NEC Cholestatic liver disease and rickets (epiphyseal dysplasia and skeletal deformities) TPN dependence Recurrent NEC 4-6% of patients Neurodevelopmental disorders May be function of prematurity Dumping related to stoma placement and/or short bowel syndrome

Short Bowel Syndrome Syndrome of malabsorption and malnutrition as a result of bowel shortening <30% of small bowel or <75cm of small bowel Severity associated with excess bowel loss and loss of illeocecal valve

A Little Bit of Trivia Estimated length of bowel in neonates 19-27 week GA: 142 + 22cm 32 week GA: 180cm + 42cm 35 week GA: 220cm + 50cm For survival via enteral nutrition, neonates require 15cm of jejunum and ileum with ileocecal valve OR 40cm of jejunum and ileum without ileocecal valve

Prevention of NEC Prevent premature birth If premature birth cannot be avoided, several preventative strategies remain Antenatal steroids  induces gut maturation High index of suspicion Early intervention

Other Sequelae of NEC Early trophic feeding Optimize enteral feedings Mom’s milk is best – feed colostrum/breast milk

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