Changes in the surgical management of necrotizing enterocolitis

Abstract

JM is a 655 gram, 25-week-gestation female infant who was delivered vaginally to a 20-year-old Gravida 1 Para 0, white female. The maternal history revealed the following: blood type B , hepatitis screen negative, rubella immune, rapid plasma reagin (RPR) nonreactive. Prenatal care was started at approximately 8 weeks gestation. Pregnancy complications included maternal smoking, premature labor, and premature rupture of membranes 11 days before delivery. Medications during labor included ampicillin, Zithromax (Pfizer, New York, NY), and magnesium sulfate. The infant required intubation and ventilation, chest compressions, and 2 doses of epinephrine at delivery. Apgars were 1 and 6 at 1 and 5 minutes, respectively. Admitting diagnoses included respiratory distress syndrome (RDS), sepsis, extreme prematurity, and hypotension. The infant received a course of indomethacin (0.2 mg/kg MCN 0.1 mg/kg 0120 3 total doses) starting on day of life (DOL) 2 and completed on DOL 3. Oral feedings were never attempted. Nutrition was supplied with TPN until therapy. On DOL 5, she developed abdominal distension and significant discoloration of her abdominal skin. An abdominal x-ray revealed a pneumoperitonium with suspected intestinal perforation, and possible necrotizing enterocolitis (NEC) (Figs 1 and 2). A one-eighth-inch Penrose drain was inserted surgically approximately 3 inches into the right lower quadrant of the abdominal cavity. Air and bilious, dark-colored material was evacuated from the abdominal cavity at the time of drain placement. An abdominal x-ray obtained after the procedure showed evacuation of the free air (Fig 3). By DOL 12, the white blood cell (WBC) count remained persistently elevated, suggesting continued From the University of Cincinnati, Department of Parent Child Health Nursing, Cincinnati, OH; and Neonatal Nurse Practitioner Program, Pediatrix Medical Group of Ohio, Dayton, OH. Address reprint requests to Valerie K. Moniaci, Pediatrix Medical Group of Ohio, One Wyoming, Dayton, OH 45409. © 2003 Elsevier Inc. All rights reserved. 1527-3369/03/0302-$30.00/0 doi: 10.1053/nbin.2003.36104 Fig 1 Anterior-posterior (AP) radiograph showing evidence of NEC. Note the large pneumoperitoneum present. Fig 2 Left lateral decubitus radiograph showing evidence of NEC. Note the accumulation of air in the upper portion of the abdominal cavity.