Tuesday, July 17, 2012. Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple...

GOOD MORNING!!Tuesday, July 17, 2012

Symptoms

Acute /subacute Chronic

Localized Diffuse

Single Multiple

Static Progressive

Constant Intermittent

Single Episode Recurrent

Abrupt Gradual

Severe Mild

Painful Nonpainful

Bilious Nonbilious

Sharp/Stabbing Dull/Vague

Problem Characteristics

Ill-appearing/Toxic

Well-appearing/Non-toxic

Localized problem

Systemic problem

Acquired Congenital

New problem Recurrence of old problem

Semantic Qualifiers

Illness Script

Predisposing ConditionsAge, gender, preceding events (trauma, viral illness,

etc), medication use, past medical history (diagnoses, surgeries, etc)

Pathophysiological InsultWhat is physically happening in the body, organisms

involved, etc. Clinical Manifestations

Signs and symptoms Labs and imaging

NEC: Predisposing Conditions Prematurity (<34WGA) Weight < 1500g Enteral feedings

Congenital heart disease Hypoxic-ischemic event

~10% of cases occur in term infantsTypically have a preexisting illness: CHD, Sepsis,

Seizures, Hypoglycemia, Severe IUGR, Hypercoagulable state, Gastroschisis, Congenital HSV

NEC: Pathophysiology

Multiple contributing factors Ischemic necrosis of intestinal mucosa

InflammationInvasion of enteric gas forming organismsDissection of gas into the muscularis and

portal venous system

NEC: Clinical Manifestations**

Classic Symptoms Abdominal distension Increased gastric aspirates/emesis Heme-positive stoolsSystemic Symptoms Lethargy Temperature instability Increased As/Bs Respiratory failure Bacteremia (in 20-30%)

Diagnosis

For any patient with clinical findings suggestive of NEC prompt evaluation including: Abdominal radiographsLab studies

○ CBC, electrolytes, blood gas, +/-coags○ Stool analysis

Abdominal Radiographs Two views

SupineLeft lateral decubitus

or cross-table lateral

Q 8 to 12 hours

Early sign: persistently dilated bowel loops

Pneumatosis intestinalis**

Abdominal Radiographs

Football sign Portal venous gas

Abdominal Radiographs

FREE AIR!!

Labs CBC

Leukocytosis, bandemiaNeutropeniaThrombocytopenia

CoagsNot routine, but obtain if infant has thrombocytopenia or

bleeding (r/o DIC) Serum chemistries

Hyponatremia, hyperkalemia, increasing glucose levels, and metabolic acidosis suggest necrotic bowel or sepsis

Sepsis evaluationBlood cx, stool cx, CSF cx (if indicated)

Management**

Medical managementSupportive care

○ Bowel restStop feeds, Gastric decompression, TPN

○ Correction of hematologic and metabolic abnormalities

Antibiotic therapyClose lab and radiologic monitoring

Surgical consult1/3 of patients will need intervention

Antibiotic therapy Empiric regimens to provide coverage

for pathogens that cause late-onset bacteremia

Anaerobic coverage should be considered Especially if perforation or necrosis is

suspected Recommended regimens

Vanc + gent + clindaVanc + gent + metronidazoleVanc + gent + piperacillin-tazobactam

Complications**

AcuteInfectious

○ Sepsis, peritonitis, abscessDICHypotension, shock, resp. failure

LateStricture formation**If bowel resection necessary: short bowel

syndrome, FTT, hyperalimentation hepatitis

Status Epilepticus, Dr. McGuire

Noon Conference

Have a great day!!