Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Disease of the premature infant: bowel ischemia leads to intestinal mucosal injuryMortality up to 30%Presentation:Abdominal distensionBilious vomitingBloody stoolsPoor feeding, vomitingTemperature instabilityHyperglycemiaToxic appearanceIn severe cases: hypotension, DIC, and metabolic acidosisFree air may be seen on abdominal x-ray once perforated; this is an urgent indication for a surgical interventionMedical management will avoid surgery in 85% of cases:Cessation of feeding with NG suctionTPN, IV fluidsAntibioticsPRBC and platelet transfusionsIndications for surgery:PerforationObstructionPeritonitisWorsening acidosis ++ Typically only the sickest patients fail medical therapy: critically illCorrect as much as possible hypovolemia, metabolic acidosis, coagulopathy, hypocalcemia, thrombocytopenia ++ Standard ASA monitoring in addition to a peripheral arterial lineAdequate venous access is mandatory due to the high fluid requirements ++ Most infants are already intubated; otherwise an awake intubation or a modified rapid sequence is indicated. Risk of intracranial hemorrhage from awake intubation, but it may be the safest technique given the absence of respiratory reserveInduction: succinylcholine or rocuronium; if hemodynamically tolerated, fentanyl with or without sevofluraneMaintenance of anesthesia consists of fentanyl, muscle relaxants, and minimal concentrations of volatile anesthetics, if toleratedNitrous oxide is avoided because of the already distended bowelsUse air/oxygen mixture to maintain SpO2 around 90% (PaO2 50–70 mm Hg)Have PRBC, FFP, and platelets availableA dopamine infusion may be necessary to maintain cardiac output, especially in sepsisExpect very high fluid requirements because of extreme third space losses; give up to 100 mL/kg/h of crystalloidsPrevent hypothermia aggressively:Increase room temperatureRadiant heat lampsWarming blanketWarmed and humidified gasesWrap extremities and head in plastic wrap ++ Ventilation in the NICU. Transport in warmed isolette with full monitoringIntraoperative opioids usually make any further analgesia or sedation unnecessary for the first dayProlonged ileus. Place CVL for TPN if not already in place ++ Remove umbilical artery catheters if possible to improve mesenteric blood flowDramatic fluid requirements once abdomen is open ++1. Pierro A. The surgical management of necrotising enterocolitis. Early Hum Dev. 2005 Jan;81(1):79–85. [PubMed: 15707718] ++2. Hillier SC, Krishna G, Brasoveanu E. Neonatal anesthesia. Semin Pediatr Surg. 2004 Aug;13(3):142–151. [PubMed: 15272422] Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth