Necrotizing Enterocolitis (NEC)

Know who is on the table - A premature, low-birth-weight neonate days to weeks old, already in the NICU, frequently on ventilatory support, often with a patent ductus arteriosus or congenital heart disease that caused the splanchnic hypoperfusion in the first place. Neonatal physiology, neonatal drug handling, no reserve.

Full stomach, already decompressed - Feeds are stopped and an NG tube is placed for decompression the moment NEC is suspected. Confirm the tube is in and suctioned before induction and treat the airway accordingly.

Sepsis physiology - Expect hypotension, decreased peripheral perfusion, respiratory failure and circulatory collapse. Fluid resuscitation is the answer to hypotension, and PALS drives the response to circulatory collapse. Broad-spectrum antibiotics are already running, typically ampicillin, gentamicin and either clindamycin or metronidazole; confirm redosing with the surgical team.

Labs worth reading - Leukopenia with a white count below 1500 per microliter is a strong indicator of established sepsis. The metabolic panel commonly shows hyponatremia and a low serum bicarbonate. Blood cultures are usually negative, so don't let a clean culture reassure you.

Correct anemia and electrolytes - Routine care in these infants includes monitoring for and correcting electrolyte abnormalities and anemia. Have blood checked and available before you start.

Films tell you when the plan changes - Serial abdominal radiographs every 6 hours track progression until definitive treatment. Free air means perforation. Portal venous air is not always present, but when it shows up it is a poor prognostic sign.

The bedside alternative - Infants too small and too unstable for laparotomy may get a peritoneal drain placed under local anesthesia in the nursery instead. If that is the plan, the decision itself is telling you how little this infant will tolerate.

What the surgeon is doing - Laparotomy is deliberately conservative: only unquestionably necrotic or perforated bowel comes out, and the ileocecal valve is preserved where possible. A diverting ostomy is typical in the infant in shock or with significant peritonitis. Primary anastomosis is generally avoided because of the risk of ischemia at the anastomosis.

Heat and glucose - An open abdomen in a preterm neonate sheds heat fast, so warm aggressively from the start. These infants are NPO on total parenteral nutrition, so don't let the TPN stop without a plan and check a glucose intraoperatively.

Emergence is back to the NICU - Plan to stay intubated. Ventilatory support continues as needed, and after surgery these infants get IV antibiotics and TPN for at least 2 weeks.

You will see them again - Postoperative adhesions and strictures cause obstruction, stomas get reversed once the infant recovers, and prolonged TPN can lead to liver failure and short bowel syndrome. This is a repeat customer, not a single case.

Necrotizing enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency in the neonatal ICU, almost exclusively a disease of neonates and typically appearing in the second to third week of life. Inflammation of the intestinal wall lets bacteria invade, causing cellular destruction and necrosis. Microperforation produces air within the bowel wall, or pneumatosis intestinalis, which is pathognomonic; frank perforation spills bowel contents into the peritoneum and produces peritonitis and sepsis.

Prematurity, low birth weight and formula feeding are the primary risk factors, and nearly 70% of cases occur in infants born before 36 weeks. It also occurs in term infants, usually in the first few days of life and usually tied to a hypoxic event such as a cyanotic congenital heart defect. Anything that reduces splanchnic flow, including patent ductus arteriosus and general hypotension, raises the risk. Overall mortality is 10% to 50%, approaching 100% once there is perforation, peritonitis and sepsis.