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A 1.5-kg, 28-week premature neonate develops abdominal distention and bloody stool after first feedings. Patient appears lethargic with increasing respiratory effort.

Laboratory: Hematocrit (Hct) 25; platelets 50,000; blood gas: pH 7.2, CO2 65, BE10, HCO3 18.

Abdominal x-ray: Free air with bowel distention.


Necrotizing enterocolitis (NEC) affects 1-7% of patients admitted to the neonatal intensive care unit. It’s a life-threatening intestinal inflammation where the injury is caused by reduced mesenteric blood flow. Mortality due to NEC is 55%. Risk factors are multifactorial prematurity, although cardiac and pulmonary diseases play a major role.

Patients present with increased gastric residuals with feeding, abdominal distention, bilious vomiting, lethargy, fever or hypothermia, and gross or occult rectal bleeding. Abdominal x-rays show distended loops of bowel, pneumatosis intestinalis, and air in the portal vein or pneumoperitoneum. The complete blood cell count and electrolytes may be altered, and the patient may develop disseminated intravascular coagulation (DIC).

Medical management is attempted first, with the patient being given nothing by mouth, and antibiotics, hemodynamic support, and transfusion as needed. If there is evidence of free air, patients may need to have surgery.


  • If patient is not intubated, then take full stomach precautions; do rapid-sequence induction or awake intubation.

  • Continuous and aggressive fluid resuscitation may require up to 100 mL/kg.

  • Prevention of hypothermia is required.

  • Inotropic agents should be given if needed for cardiovascular support.

  • Transfusion of fresh frozen plasma, red blood cells, and platelets may be needed, since patients may present with DIC.

  • An opioid-based anesthetic is best tolerated.


Postoperative ventilation is required. Patients may come back to the operating room 24-48 hours later for a second look exploration. Long-term complications may include intestinal strictures and short gut syndrome.

DOs and DON’Ts

  • ✓ Do awake or rapid-sequence induction.

  • ⊗ Do not start the case without having blood products immediately available.

  • ✓ Do prevent hypothermia.


Exploratory laparotomy with resection of the necrotic segment of the intestine and an ileostomy is performed. If the infant is <1000 g and hemodynamically unstable, a bedside percutaneous intraperitoneal drain is placed.


NEC is rarely seen in full-term neonates. It continues to be a significant cause of mortality and morbidity in preterm patients. Even with aggressive medical management and timely surgical intervention, the mortality remains >50%.

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