Enterocolitis, necrotising

P77

DESCRIPTION

Neonate presenting with the consequences of bowel wall injury or necrosis.

Risk factors include:

  • prematurity,
  • hypotension/shock,
  • sepsis,
  • early formula feedings
  • high feeding volumes,
  • perinatal asphyxia (hypoxia),
  • patent ductus arteriosus, and
  • polycythaemia.

DIAGNOSTIC CRITERIA

  • Early signs are often non-specific, i.e.:
    • feeding intolerance,
    • significant gastric aspirates,
    • vomiting,
    • body temperature instability,
    • apnoea and lethargy.
  • Non-specific signs may progress to more specific signs including:
    • abdominal distention with ileus,
    • bloody stools,
    • peritonitis,
    • red-purple discolouration of the abdominal wall with abdominal wall cellulitis, and
    • bowel perforation.
  • X-ray of abdomen may show:
    • distended loops of intestines,
    • bowel-wall thickening (oedema),
    • pneumatosis intestinalis,
    • hepatic portal venous gas, and
    • free intraperitoneal air due to perforation.
  • Blood samples for culture and sensitivity testing before starting antibiotic therapy.

GENERAL AND SUPPORTIVE MEASURES

  • Admit to neonatal high-care unit or intensive care unit.
  • Nurse in neutral thermal environment.
  • Insert oro/nasogastric tube and apply free drainage.
    • Suspected cases should be nil per mouth for 72 hours.
    • Confirmed cases should be nil per mouth for at least 7 days.
  • Provide adequate parenteral nutrition as soon as diagnosis is confirmed.
  • Provide cardiovascular and ventilatory support, if necessary.

MEDICINE TREATMENT

Depending on age, weight and hydration status:

  • Neonatal maintenance solution, IV.
    Add volume of gastric aspirates to daily maintenance fluid volume.

If coagulopathy or septic shock:

  • Plasma (lyophilised or fresh frozen), IV, 20 mL/kg over 2 hours.

If haematocrit < 40%:

  • Packed red cells, IV, 10 mL/kg.

Until blood pressure is stabilised:

  • Dopamine, IV, 5–15 mcg/kg/minute.

Empiric antibiotic therapy

  • Ampicillin, IV, 50 mg/kg/dose for 7 days.
    • If age < 7 days: 50 mg/kg 12 hourly.
    • If 7 days – 3 weeks of age: 50 mg/kg 8 hourly.
    • If > 3 weeks of age: 50 mg/kg 6 hourly.

PLUS

  • Gentamicin, IV, 5 mg/kg once daily for 7 days.
    Where available, gentamicin doses should be adjusted on the basis of therapeutic drug levels.
  • Trough levels (taken immediately prior to next dose), target plasma level < 1 mg/L.
  • Peak levels (measured 1 hour after commencement of IV infusion or IM/IV bolus dose), target plasma level > 8 mg/L.

PLUS

  • Metronidazole, IV, for 7 days.
    • Loading dose: 15 mg/kg over 60 minutes.
    • Post natal age < 4 weeks: 7.5 mg/kg/dose 12 hourly.
    • Postnatal age ≥ 4 weeks: 7.5 mg/kg/dose 8 hourly.

Reassess choice of antibiotics when the culture and sensitivity results become available.

Adjust antibiotic regimen according to local susceptibility patterns and suspicion of nosocomial infection, where possible in consultation with a microbiologist or infectious diseases specialist.

SURGICAL TREATMENT

Surgical intervention is required when there is progressive deterioration of the clinical condition despite maximal medical support and/or bowel necrosis with/without bowel perforation.

  • Prior to transport to a tertiary hospital for definitive surgery, insert/place a peritoneal drain in babies presenting with severe abdominal distension, due to free air and/or fluid in the peritoneal cavity, compromising respiration and/or blood pressure.
  • Perform the procedure in a theatre, intensive care or high care unit where facilities for monitoring vital signs, resuscitation, ventilation and temperature control of the environment are available.
  • Obtain consent to perform the surgical procedure.

Method of inserting/placing a peritoneal drain

  • Procedure is sterile; the doctor should be gowned and gloved.
  • Clean and drape the abdomen.
  • Administer an appropriate analgesic (e.g. ketamine, IV) immediately before the start of the procedure.
  • Identify a site in either one of the fossae iliaca, ensuring that it is lateral to the inferior epigastric artery.
  • At the intended surgical incision site, inject:
    • Lignocaine (lidocaine) 1%, SC, 0.5 mL.
  • Make a small skin incision over the “bubble” of lignocaine (lidocaine) (no. 11 blade).
  • Use a mosquito forceps or clamp to dissect down to the peritoneum, pierce the latter with a gentle stab using the closed forceps and slightly stretch the peritoneal puncture site with the forceps.
  • Note what drains from the peritoneal cavity and send a sample for microscopy and culture.
  • Insert a pencil drain of ± 5 mm width with the mosquito clamps or forceps into the peritoneal cavity through the peritoneal stab wound. About 1.5–2 cm of the pencil drain should be inside the peritoneal cavity.
  • Fix the drain to the skin with a size 4 – 0 stitch (e.g. PDS).
  • Cover the drain with a gauze pad or urine collecting bag.

REFERRAL

  • All confirmed cases for specialist care.
  • Deterioration of clinical condition, despite adequate treatment.
  • Signs and symptoms of intestinal perforation and peritonitis requiring surgical intervention.
  • Recurrent apnoea episodes and/or signs of respiratory failure, requiring respiratory support.