NECROTISING ENTEROCOLITIS

Speaker: Dr Bhagirath.S.N

Moderator: Dr Sarika

Necrotising Enterocolitis

• Incidence in low birth weight babies (<1500g): 10% - 15%

• predominantly seen in

premature babies (gestational age less than 32 weeks)-80%

rapid feeding increases the risk

• gastrointestinal pathology with systemic ramifications

secondary to sepsis.

• Exact etiology is unknown. May be multifactorial.

• Most common site is the ileocolic region

• The triggering event in the cascade is a decreased ability to absorb substrate.

Necrotising Enterocolitis-aetiopathogenesis cascade• decreased ability to absorb

• Stasis of bowel contents

• Bacterial proliferation

• Infection

+ Ischemia

• Necrosis of the intestinal mucosa

• perforation of the intestinal mucosa

Fluid loss

Gangrene of the gut wall

Peritonitis

Septicemia

Disseminated Intravascular Coagulation

Increasing gastric aspirates

Abdominal distension

Irritability

Pneumatosis intestinalis

hypovolemia

Metabolic acidosis

Bloody diarrhea

Thrombocytopenia, anemia,

coagulopathy

Necrotising Enterocolitis-approach to the problem

•Essentially a medical disease rather than a surgical problem

fluid resuscitation

stopping enteral nutrition decompressing the stomach with a nasogastric tube

antibiotics.

If condition worsens and the neonate becomes more septic

• Exploratory laparotomy-removal of the gangrenous bowel

• Ileostomy

• Peritoneal drain

Necrotising Enterocolitis-Pre-operative approach

• Debilitated condition warrants intubation and elective ventilation

• fluid replacement to replenish the losses (third space & surgical

losses)

• Investigations: coagulation profile serum electrolytes arterial blood gas analysis Hematocrit glycemic status

• Vascular access-arterial line, central venous line

• Blood must be cross matched.

• Keep platelet and packed red cells ready for transfusion

Necrotising Enterocolitis-Anesthetic considerations

• Continue resuscitation

• adequate relaxation for surgery

• careful titration of anesthetic drugs (increased sensitivity)

• Rapid sequence intubation with Ketamine and succinylcholine (dead bowel-high K+ levels-may warrant rocuronium usage)

• Maintenance of anesthesia use of opioid supplementation with Ketamine low dose inhalation agent, oxygen and air.

• Avoid nitrous oxide for fear of causing gas pockets in abdomen

• Continue IPPV by a T-Piece rather than a ventilator

• Ventilatory requirements increase during surgery as handling of bowel reduces lung compliance.

Necrotising Enterocolitis-Anesthetic considerations

• prevent hypothermia by using increasing ambient temperature, warmed fluids, warming mattress, warm air blanket.

•Surgery-bowel resection, primary anastamoses, enterostomies

• better not to extubate

Necrotising Enterocolitis-Prognosis

• long term survival depends on

degree of prematurity

associated congenital anomalies

degree of surviving bowel

total length of affected bowel

• Mortality rate (especially in < 1500g) – 25% - 50% mortality