pediatrics
Necrotizing Enterocolitis
Treatment of Necrotizing Enterocolitis
Feedings stopped Nasogastric suction Fluid resuscitation Broad-spectrum antibiotics Total parenteral nutrition (TPN) Sometimes surgery or percutaneous drainage The mortality rate is 20 to 30%. Aggressive support and judicious timing of surgical intervention maximize the chance of survival. Nonsurgical support is sufficient in > 75% of cases. Feedings must be stopped immediately if NEC is suspected, and the intestine should be decompressed with a double-lumen nasogastric tube attached to intermittent suction. Appropriate colloid and crystalloid parenteral fluids must be given to support circulation because extensive intestinal inflammation and peritonitis may lead to considerable 3rd-space fluid loss. TPN is needed for 10 to 14 days while the intestine heals. Systemic antibiotics should be started at once with a beta-lactam antibiotic (eg,ampicillin) and an aminoglycoside (eg,gentamicin,amikacin). Additional anaerobic coverage (eg,clindamycin,metronidazole) may also be considered. Antibiotics should be continued for 10 to 14 days. Because some outbreaks may be infectious, patient isolation should be considered, particularly if several cases occur within a short time. The infant requires close monitoring; frequent complete reevaluation (eg, at least every 12 hours); and serial abdominal x-rays, complete blood counts (CBCs) including platelet counts, and blood gases. Surgical intervention is needed in<25% of infants. Absolute indications are intestinal perforation (pneumoperitoneum), signs of peritonitis (often absent in NEC but include absent intestinal sounds and diffuse guarding and tenderness or erythema and edema of the abdominal wall), or aspiration of purulent material from the peritoneal cavity by paracentesis. Surgery should be considered for an infant with NEC whose clinical and laboratory conditions worsen despite nonsurgical support. Primary percutaneous peritoneal drainage is an option and can be done at the bedside. In this procedure, the surgeon makes an incision in the right lower quadrant through which the abdomen is irrigated with warm saline solution. A drain is then placed to allow continued drainage of the abdomen. When drainage has stopped, the drain can be pulled back a little each day and subsequently removed. This procedure is done more commonly in very sick, extremely low-birth-weight infants who would be at risk if taken to an operating room; however, it may be associated with a higher mortality. For infants undergoing laparotomy, the gangrenous bowel is resected, and ostomies are created. (Primary reanastomosis may be done if the remaining intestine shows no signs of ischemia.) With resolution of sepsis and peritonitis, intestinal continuity can be reestablished several weeks or months later. Strictures secondary to NEC require resection. 