Tuesday, July 17, 2012

Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple StaticProgressive ConstantIntermittent Single EpisodeRecurrent AbruptGradual SevereMild PainfulNonpainful BiliousNonbilious Sharp/StabbingDull/Vague Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problem Systemic problem AcquiredCongenital New problem Recurrence of old problem Semantic Qualifiers

Illness Script  Predisposing Conditions Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)  Pathophysiological Insult What is physically happening in the body, organisms involved, etc.  Clinical Manifestations Signs and symptoms Labs and imaging

NEC: Predisposing Conditions  Prematurity (<34WGA)  Weight < 1500g  Enteral feedings  Congenital heart disease  Hypoxic-ischemic event  ~10% of cases occur in term infants Typically have a preexisting illness: CHD, Sepsis, Seizures, Hypoglycemia, Severe IUGR, Hypercoagulable state, Gastroschisis, Congenital HSV

NEC: Pathophysiology  Multiple contributing factors  Ischemic necrosis of intestinal mucosa Inflammation Invasion of enteric gas forming organisms Dissection of gas into the muscularis and portal venous system

NEC: Clinical Manifestations** Classic Symptoms  Abdominal distension  Increased gastric aspirates/emesis  Heme-positive stools Systemic Symptoms  Lethargy  Temperature instability  Increased As/Bs  Respiratory failure  Bacteremia (in 20-30%)

Diagnosis  For any patient with clinical findings suggestive of NEC  prompt evaluation including: Abdominal radiographs Lab studies ○ CBC, electrolytes, blood gas, +/-coags ○ Stool analysis

Abdominal Radiographs  Two views Supine Left lateral decubitus or cross-table lateral  Q 8 to 12 hours  Early sign: persistently dilated bowel loops

Pneumatosis intestinalis**

Abdominal Radiographs Football sign Portal venous gas

Abdominal Radiographs FREE AIR!!

Labs  CBC Leukocytosis, bandemia Neutropenia Thrombocytopenia  Coags Not routine, but obtain if infant has thrombocytopenia or bleeding (r/o DIC)  Serum chemistries Hyponatremia, hyperkalemia, increasing glucose levels, and metabolic acidosis suggest necrotic bowel or sepsis  Sepsis evaluation Blood cx, stool cx, CSF cx (if indicated)

Management**  Medical management Supportive care ○ Bowel rest Stop feeds, Gastric decompression, TPN ○ Correction of hematologic and metabolic abnormalities Antibiotic therapy Close lab and radiologic monitoring  Surgical consult 1/3 of patients will need intervention

Antibiotic therapy  Empiric regimens to provide coverage for pathogens that cause late-onset bacteremia  Anaerobic coverage should be considered Especially if perforation or necrosis is suspected  Recommended regimens Vanc + gent + clinda Vanc + gent + metronidazole Vanc + gent + piperacillin-tazobactam

Complications**  Acute Infectious ○ Sepsis, peritonitis, abscess DIC Hypotension, shock, resp. failure  Late Stricture formation** If bowel resection necessary: short bowel syndrome, FTT, hyperalimentation hepatitis

Noon Conference Have a great day!!