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Good Morning!!

Tuesday, July 17, 2012. Good Morning!!. Semantic Qualifiers. Illness Script. Predisposing Conditions Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult

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Good Morning!!

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  1. Tuesday, July 17, 2012 Good Morning!!

  2. Semantic Qualifiers

  3. Illness Script • Predisposing Conditions • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) • Pathophysiological Insult • What is physically happening in the body, organisms involved, etc. • Clinical Manifestations • Signs and symptoms • Labs and imaging

  4. NEC: Predisposing Conditions • Prematurity (<34WGA) • Weight < 1500g • Enteral feedings • Congenital heart disease • Hypoxic-ischemic event • ~10% of cases occur in term infants • Typically have a preexisting illness: CHD, Sepsis, Seizures, Hypoglycemia, Severe IUGR, Hypercoagulable state, Gastroschisis, Congenital HSV

  5. NEC: Pathophysiology • Multiple contributing factors • Ischemic necrosis of intestinal mucosa • Inflammation • Invasion of enteric gas forming organisms • Dissection of gas into the muscularis and portal venous system

  6. NEC: Clinical Manifestations** Classic Symptoms • Abdominal distension • Increased gastric aspirates/emesis • Heme-positive stools Systemic Symptoms • Lethargy • Temperature instability • Increased As/Bs • Respiratory failure • Bacteremia (in 20-30%)

  7. Diagnosis • For any patient with clinical findings suggestive of NEC  prompt evaluation including: • Abdominal radiographs • Lab studies • CBC, electrolytes, blood gas, +/-coags • Stool analysis

  8. Abdominal Radiographs • Two views • Supine • Left lateral decubitus or cross-table lateral • Q 8 to 12 hours • Early sign: persistently dilated bowel loops

  9. Pneumatosisintestinalis**

  10. Abdominal Radiographs Football sign Portal venous gas

  11. Abdominal Radiographs FREE AIR!!

  12. Labs • CBC • Leukocytosis, bandemia • Neutropenia • Thrombocytopenia • Coags • Not routine, but obtain if infant has thrombocytopenia or bleeding (r/o DIC) • Serum chemistries • Hyponatremia, hyperkalemia, increasing glucose levels, and metabolic acidosis suggest necrotic bowel or sepsis • Sepsis evaluation • Blood cx, stool cx, CSF cx (if indicated)

  13. Management** • Medical management • Supportive care • Bowel rest • Stop feeds, Gastric decompression, TPN • Correction of hematologic and metabolic abnormalities • Antibiotic therapy • Close lab and radiologic monitoring • Surgical consult • 1/3 of patients will need intervention

  14. Antibiotic therapy • Empiric regimens to provide coverage for pathogens that cause late-onset bacteremia • Anaerobic coverage should be considered • Especially if perforation or necrosis is suspected • Recommended regimens • Vanc + gent + clinda • Vanc + gent + metronidazole • Vanc + gent + piperacillin-tazobactam

  15. Complications** • Acute • Infectious • Sepsis, peritonitis, abscess • DIC • Hypotension, shock, resp. failure • Late • Stricture formation** • If bowel resection necessary: short bowel syndrome, FTT, hyperalimentation hepatitis

  16. Have a great day!! Noon Conference Status Epilepticus, Dr. McGuire

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