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Chapter 175. Necrotizing Enterocolitis

Philipp J. Houck, MD

  • Disease of the premature infant: bowel ischemia leads to intestinal mucosal injury
  • Mortality up to 30%
  • Presentation:
    • Abdominal distension
    • Bilious vomiting
    • Bloody stools
    • Poor feeding, vomiting
    • Temperature instability
    • Hyperglycemia
    • Toxic appearance
    • In severe cases: hypotension, DIC, and metabolic acidosis
    • Free air may be seen on abdominal x-ray once perforated; this is an urgent indication for a surgical intervention
  • Medical management will avoid surgery in 85% of cases:
    • Cessation of feeding with NG suction
    • TPN, IV fluids
    • Antibiotics
    • PRBC and platelet transfusions
  • Indications for surgery:
    • Perforation
    • Obstruction
    • Peritonitis
    • Worsening acidosis

  • Typically only the sickest patients fail medical therapy: critically ill
  • Correct as much as possible hypovolemia, metabolic acidosis, coagulopathy, hypocalcemia, thrombocytopenia

  • Standard ASA monitoring in addition to a peripheral arterial line
  • Adequate 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 reserve
  • Induction: succinylcholine or rocuronium; if hemodynamically tolerated, fentanyl with or without sevoflurane
  • Maintenance of anesthesia consists of fentanyl, muscle relaxants, and minimal concentrations of volatile anesthetics, if tolerated
  • Nitrous oxide is avoided because of the already distended bowels
  • Use air/oxygen mixture to maintain SpO2 around 90% (PaO2 50–70 mm Hg)
  • Have PRBC, FFP, and platelets available
  • A dopamine infusion may be necessary to maintain cardiac output, especially in sepsis
  • Expect very high fluid requirements because of extreme third space losses; give up to 100 mL/kg/h of crystalloids
  • Prevent hypothermia aggressively:
    • Increase room temperature
    • Radiant heat lamps
    • Warming blanket
    • Warmed and humidified gases
    • Wrap extremities and head in plastic wrap

  • Ventilation in the NICU. Transport in warmed isolette with full monitoring
  • Intraoperative opioids usually make any further analgesia or sedation unnecessary for the first day
  • Prolonged ileus. Place CVL for TPN if not already in place

  • Remove umbilical artery catheters if possible to improve mesenteric blood flow
  • Dramatic fluid requirements once abdomen is open

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1. Pierro A. The surgical management of necrotising enterocolitis. Early Hum Dev. 2005 Jan;81(1):79–85.   [PubMed: 15707718]
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2. Hillier SC, Krishna G, Brasoveanu E. Neonatal anesthesia. Semin Pediatr Surg. 2004 Aug;13(3):142–151.   [PubMed: 15272422]

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