Necrotizing-enterocolitis final.ppt
- 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 the small and large bowel in 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. ONSET OF NEC 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. RISK FACTORS 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. PATHOGENESIS OF NEC • The pathogenic sequence of NEC is multi-factorial and complex Mucosal Injury
- 7. CLINICAL MANIFESTATIONS 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. CLINICAL MANIFESTATIONS 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. CLINICAL MANIFESTATIONS 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. CLINICAL MANIFESTATIONS 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