Management of NEC in the surgical NICU

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Management of NEC in the surgical NICU

• Dr Lawrence Miall
• Leeds Teaching Hospitals NHS Trust

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Treatment of NEC

• Prevention
• Medical Management
• Transfer to surgical NICU
• Stabilisation prior to surgery
• Surgery
• Post operative period
• Re-establish feeds

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Case presentation

• 27 wks 650g Reversed EDF
• Patent ductus arteriosus d5
• CPR following collapse d6
• Abdominal distension
• Anuria for 12 hrs
• Fresh blood in NGT and PR
• Transferred from network unit
• Ix
• Hb 9.2, Platelets 37, INR 2.9
• Creatinine 145, Na 131
• BP 36/14, Mean 21
• pH 7.1, pCO2 6.8, BE -14
• Cranial USS- normal

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Pathology
Multi-organ failure
Neutrophils activated
Milk
Platelet recruitment

• Platelet activation
• Endothelial activation
• Adhesion molecules
• Cytokines

Nitric oxide
Ischaemia
Gut Immaturity
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Multi-system organ failure

• Gut
• Necrosis
• Perforation
• Peritonitis
• Respiratory
• Abdominal distension
• Acidosis
• RDS
• Circulation
• Septic shock
• Hypotension
• Third spacing

• Blood
• Coagulopathy
• Platelets
• Anaemia
• Renal
• Electrolyte imbalance
• Fluid retention
• Brain
• Hypoxia
• Perfusion injury
• PVL

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Access and Monitoring

• Access
• Central venous catheter- double lumen
• Peripheral cannula
• Peripheral arterial line
• Large bore NGT on free drainage / suction
• Monitoring
• ECG
• Invasive BP
• Oxygen saturation
• Arterial blood gases
• Central and peripheral temperature
• Urinary catheter
• Haematology and Biochemistry

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Ventilation

• Monitor tidal volume
• Oxygen
• Muscle relaxants
• Analgesia
• PEEP
• HFOV
• Bicarbonate
• pCO2

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Circulation

• Optimise cardiac output and tissue perfusion
• Volume-
• NaCl
• Human Albumin Solution
• Fresh frozen plasma
• Inotropic agents
• Dopamine (low dose)
• Dobutamine
• Noradrenaline
• Milrinone
• Hydrocortisone
• Echocardiography

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Sepsis

• Antibiotics
• Gram ve
• Gram ve
• Anaerobes
• Amoxicillin / Gentamicin / Metronidazole
• or
• Ceftazidime / Vancomycin / Metronidazole
• or
• Meropenem
• Antifungal if perforation?

• Adjunctive Rx
• Pentoxifylline
• G-CSF
• Immunoglobulin
• Oral antibiotics
• Lactoferrin
• Probiotics

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Blood

• Anaemia
• Thrombocytopenia
• DIC
• WCC ? or ?
• No evidence for
• T-antigen ve blood

• Optimise Hb 12-14g/dl
• Platelets
• Keep gt50 x109
• Pre-op
• Correct coagulopathy
• FFP
• Vit K
• Cryoprecipitate

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Renal function

• Pre-renal failure
• Volume
• Review inotropes
• Frusemide infusion
• Low K fluids
• Strict fluid balance catheter
• Care with aminoglycosides
• Established renal failure
• Fluid restriction 40mls/kg output
• Maintain normoglycaemia (20 dextrose)

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Brain

• Cerebral perfusion
• Avoid hypoxia
• Avoid hyperoxia if possible
• Normalise BP
• Avoid hypocarbia (pCO2 lt 4 KPa)
• Brain USS _at_ 2 weeks
• Monitor OFC

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Controversies

• When to transfer
• Drain vs Laparotomy
• NICU vs Theatre
• Post-op feeding
• Which milk?
• When?

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