NECROTIZING ENTEROCOLITIS

Question 1

Approach to the Critically Ill Necrotizing Enterocolitis

Answer 1

Fluid bolus 20 ml / kg

Maintenance Fluid D5 0.45% NS

4 cc/kg/hr for 1st 10 kg
2 cc/kg/hr for 10-20 kg
1 cc/kg/hr for every kg > 20 kg

KCl @ 0.5 mEq/kg/hr IV

Serum potassium <3mEq/L give total of 1 mEq/kg (up to adult dose)
Serum potassium 3-3.5 mEq/L give 0.2 mEq/kg and recheck
morphine 0.05-0.1 mg/kg

Obtain i-STAT labs, including glucose.

Analgesia:
morphine 0.05-0.1 mg/kg IV
OR
fentanyl 1 μg/kg IV

Ondansetron:
2 mg < 15 kg
4 mg > 15 kg
8 mg > 30 kg

Ampicillin 200 mg/kg/day divided into 4 times (ie, 50 mg/kg every 6 hours)

Gentamicin 3-7.5 mg/kg/day divided into 6-12 times (ie, dosed every 2-4 hours)

metronidazole 30-40 mg/kg/day divided into 3 times (ie, 10-13.3 mg/kg/day every 8 hours)

Consider changing ampicillin to vancomycin if patient is critically ill or if methicillin-resistant Staphylococcus aureus is suspected.

Consider amikacin 15-22.5 mg/kg/day divided into 1-3 times (ie, dosed every 8-24 hours)
OR
tobramycin 3-7.5 mg/kg/day divided into 1-3 times (ie, dosed every 8-24 hours) with local resistance to gentamicin.

Consider piperacillin-tazobactam 200 mg/kg/day (of piperacillin component) divided into 3-4 times (ie, dosed every 6-8 hours) if patient has renal impairment/oliguria or is critically ill.

Consider adding fluconazole for preterm infants

NG Tube

NPO

Early Surgical Consultation

Question 2

Pathophys / Key Concepts

Answer 2

Ischemic Necrosis or intestinal mucosa-> Inflammation -> Invasion of Gas forming organisms of colon and terminal ileum

Question 3

History and Physical

Answer 3

Preterm / Low-birth-weight infants

(can be full term)

Change in feeding tolerance

Vomiting (especially bilious)

Abdominal Distension

Hematochezia / Diarrhea

Abdominal erythema, crepitus, induration, bluish hue in the abdominal wall / scrotal wall

DO SERIAL ABDOMINAL EXAMS

Question 4

Investigations

Answer 4

CBC
Lytes
Cr
ABG
Lactate
Coags
Blood Cultures (20-30% are bacteremic)

Supine abdominal radiograph (lacks sn & sp): pneumatosis intestinalis, portal venous gas (curvilinear radiolucency over the liver), dilated loops of bowel, sentinal loop of bowel, pneumoperitoneum

Abdominal Ultrasound is specific but no sensitive: fluid collections, increased bowel wall thickness, increased wall echogenicity indicative of inflammation, loss of peristalsis, gas bubbles in the bowel wall and liver parenchyma, alterations in perfusion (color Doppler), and complex ascites.

Contrast enema is contraindicated

Question 5

Complications

Answer 5

Occur in 50% of survivors

Bacteremia in 20-30% patients

DIC

Subacute / Chronic GI complications(ex/ short gut)

Question 6

Disposition

Answer 6

Admission, NICU is best

Consult surgery