Necrotizing-enterocolitis final.ppt

Necrotizing enterocolitis

1. NECROTIZING ENTEROCOLITIS
NRSG 328: PEDIATRICS AND CHILD HEALTH NURSING
THE HIGH RISK NEONATE-THE PREMATURE NEONATE

2. DEFINITION
An idiopathic inflammation and transmural
coagulation necrosis of thesmall and
large bowelin a neonatal patient
The most common and serious intestinal
disorder in the newborn period
Survivors often have chronic nutritional
deficiencies requiring hospitalization

3. INCIDENCE
NEC primarily affects premature infants (although
10% of cases occur in Term infants)
The incidence of NEC varies inversely with
gestational age and birth weight
a sharp decrease at 35-36 Post Conceptional Age
Supports the hypothesis that the risk of NEC is
determined by maturity of the GI tract

4. ONSETOFNEC
The age of onset is highly variable but rarely occurs in
the first three days of life.
Among the lowest GA (24-28 weeks) tend to develop NEC
after the second week of life
Intermediate GA (29-32 weeks) develop it within 1-3 weeks
Term infants or >32 weeks tend to develop it in the first
week of life.

5. RISKFACTORS
Prematurity (with immature GI tract and host
defenses) is the primary risk factor
Aggressive enteral feeding ( especially with infant
formula)
Toxic , hypoxic or ischemic injury to the musoca

6. PATHOGENESISOFNEC
•The pathogenic sequence of NEC is multi-factorial and
complex Mucosal Injury

7. CLINICALMANIFESTATIONS
Bell’s staging criteria
Stage I (suspected NEC)
Stage II (definite NEC)
Stage III (advanced NEC, severely ill)
IIIA (without perforation)
IIIB (with perforation)

9. CLINICALMANIFESTATIONS
Stage I
Systemic signs
Intestinal Signs
Radiological signs
Temp instability, increased
Apnea and Bradycardias
lethargy
Increased residuals, mild
abdominal distention,
emesis
Normal or mild dilatation
or ileus

10. CLINICALMANIFESTATIONS
Stage II
Systemic signs
Intestinal signs
Radiologic signs
Same as Stage I with metabolic
acidosis and mild thrombocytopenia
Same as Stage I with decreased
bowel sounds and abdominal
tenderness
Intestinal dilatation, ileus and
pneumatosis intestinalis

11. CLINICALMANIFESTATIONS
Stage III (A & B)
Systemic signs
Intestinal signs
Radiologic signs
Same as II plus hypotension, severe apnea,
DIC, neutropenia, anuria
Same as II with generalized peritonitis,
marked tenderness and distention, and
abdominal wall erythema
Same as II with portal vein gas, definite
ascites pneumoperitoneum

12. MANAGEMENT
•NPO
•Orogastric tube to suction
•IVF/parental nutrition
•Broad spectrum antimicrobial agents
•Cardio-respiratory support
•Serial laboratory studies (chemistries, CBC,
•coagulation) and correction of metabollic derangements
•Serial abdominal X-rays
•Surgical consultation/intervention (20-40%)*
•Parental involvement

13. Indications for surgery
•Absolute indications
– pneumoperitoneum
–intestinal gangrene
(if the patient is extremely unstable some surgeons opt for peritoneal drains
as a bridge to surgery)
Relative indications
•progressive clinical deterioration
•fixed abdominal mass, portal vein gas, abdominal wall erythema
•persistently dilated bowel loop

14. COMPLICATIONS
Mortality is 30-60%
Stricture formation is 25-35%
Bowel obstruction in 5%
Enterocutaneous fistulas
Failure To Thrive secondary to short bowel syndrome
and malabsorption
TPN related cholestasis
Central line sepsis

15. PREVENTION
Antenatal steroids decreased the incidence of NEC in
randomized blinded studies
Use of human milk (1.2% incidence vs. 7.2% incidence in
formula feed premies)
GI priming with cautious advancement of enteral feeding