lonestargal
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hey guys,
could someone please please clarify the treatment of necrotizing enterocolitis. the kaplan notes make it confusing. i'm not sure if u stop antibiotics, feeding and iv fluids and nutrition or is it NPO, give antibiotics and iv fluids and nutrition. please help!
thanks
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| babli
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* When NEC is suspected, enteral feedings are withheld and parenteral nutrition is initiated. Centrally delivered formulations with maximal nutritional components are preferred. Enteral feedings can be restarted 10-14 days after findings on abdominal radiographs normalize in the case of nonsurgical NEC. Reinitiating enteral feeds in postsurgical babies may take longer and may also depend on issues such as the extent of surgical resection, timing of reanastomosis, and preference of the consulting surgical team.
* Because of the high incidence of postsurgical strictures, some clinicians prefer to evaluate intestinal patency via contrast studies prior to initiating enteral feeds. When feeds are restarted, formulas containing casein hydrolysates, medium-chain triglycerides, and safflower/sunflower oils (Pregestimil/Nutramigen) may be better tolerated and absorbed than standard infant formulas.
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| babli
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Medical Care:
* Diagnosis of NEC is based on clinical suspicion supported by findings on radiologic as well as laboratory studies. Treatment of NEC depends on the degree of bowel involvement and severity of its presentation. Objective staging criteria developed by Bell have been widely adopted or modified to help tailor therapy according to disease severity.
* Bell stage I - Suspected disease
o Stage IA
+ Mild nonspecific systemic signs such as apnea, bradycardia, and temperature instability are present.
+ Mild intestinal signs such as increased gastric residuals and mild abdominal distention are present.
+ Radiographic findings can be normal or can show some mild nonspecific distention.
+ Treatment is NPO with antibiotics for 3 days.
o Stage IB
+ Diagnosis is the same as IA, with the addition of grossly bloody stool.
+ Treatment is NPO with antibiotics for 3 days.
* Bell stage II - Definite disease
o Stage IIA
+ Patient is mildly ill.
+ Diagnostic signs include the mild systemic signs present in stage IA.
+ Intestinal signs include all of the signs present in stage I, with the addition of absent bowel sounds and abdominal tenderness.
+ Radiographic findings show ileus and/or pneumatosis intestinalis. This diagnosis is sometimes referred to colloquially as medical NEC.
+ Treatment includes NPO and antibiotics for 7-10 days.
o Stage IIB
*
o
+ Diagnosis requires all of stage I signs plus the systemic signs of moderate illness, such as mild metabolic acidosis and mild thrombocytopenia.
+ Abdominal examination reveals definite tenderness, perhaps some erythema or other discoloration, and/or right lower quadrant mass.
+ Radiographs show portal venous gas with or without ascites.
+ Treatment is NPO and antibiotics for 14 days.
* Bell stage III - Represents advanced NEC with severe illness that has a high likelihood of progressing to surgical intervention
o Stage IIIA
+ Patient has severe NEC with an intact bowel.
+ Diagnosis requires all of the above conditions, with the addition of hypotension, bradycardia, respiratory failure, severe metabolic acidosis, coagulopathy, and/or neutropenia.
+ Abdominal examination shows marked distention with signs of generalized peritonitis.
+ Radiographic examination reveals definitive evidence of ascites.
+ Treatment involves NPO for 14 days, fluid resuscitation, inotropic support, ventilator support, and paracentesis.
o Stage IIIB
+ This stage is reserved for the severely ill infant with perforated bowel observed on radiograph.
+ Free air visible on abdominal radiograph indicates surgery. Surgical treatment includes resecting the affected portion of the bowel, which may be extensive. Initially, an ileostomy with a mucous fistula is typically performed, with reanastomosis performed later. Strictures may occur, with or without a history of surgical intervention, which may require surgical treatment.
+ If the patient is extremely small and sick, he/she may not have the stability to tolerate laparotomy. If free air develops in such a patient, consider inserting a peritoneal drain under local anesthesia in the nursery. Two retrospective reviews of the use of peritoneal drains as initial therapy for perforated bowel concluded that, while most patients ultimately require open laparotomy, initial peritoneal drainage may allow systemic stabilization and recovery in the smallest, sickest infants until they become better surgical candidates.
Surgical Care:
* Any patient requiring surgical intervention and many of those patients not progressing to surgery require protracted courses of parenteral nutrition and intravenous antibiotics.
o Secure central venous access is optimal for ensuring uninterrupted delivery of antibiotics and nutrition as well as maximizing nourishment with central venous formulations.
o Some units successfully use percutaneously inserted central venous catheters (PCVCs), while other units prefer surgically placed central lines such as Broviac catheters. Both types carry an increased risk of infection, particularly if they are used to administer lipids.
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| lonestargal
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Topics: 3
Posts: 8
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thanks for the quick response and the clarification babli. take care..lonestargal
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