Transcript NEC

NEC
Nawaf Al-Dajani
Disclosure
NEC
Definition
Early history
Epidemiology
Pathophysiology
Presentation
Prevention
Treatment
Definition
Acute
inflammatory disease process
affecting GI tract of neonates.
Usually ass’ necrosis of affected
part.
Unpredictable course.
History
Not
known prior 1950’s
First described by Schmid &
Quaiser.
Well recognized entity 1960-1970.
High MR
Idiopathic GI perforations.
Epidemiology
Affect 1-5% all NICU admissions.
Up to 10% of prem. less than 1.5 kg.
10% occur in term neonates
M=F
Black >
Onset inversely related to GA.
10* in infant who have been fed.
Clusters may occur.
Pathophysiology
NECROTIZING
ENTEROCOLITIS
Pathophysiology:
UNKNOWN
CAUSE…….
Preemies gut is different
Inadequate IgA
Scanty T lymphocytes
Lack of adequate antibody response
Higher membrane permeability
Lower motility and emptying
Mucin blanket
Tight junction are deficient
PRIMARY INFECTIOUS AGENTS
CIRCULATORY INSTABILITY
Bacteria, Bacterial toxin, Fungus
Hypoxic-ischemic event
Polycythemia
MUCOSAL INJURY
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage)
Platelet activating factor (PAF)
Tumor necrosis factor (TNF)
Leukotriene C4, Interleukin 1; 6
ENTERAL FEEDINGS
Hypertonic formula or medication,
H2 gas production,
Endotoxin production
Preemies gut
Luminal flow
Mucin
Inflammation
PMN
M0
PAF
TNF
Immune cells
Vasoconstriction
Tissue permeability
Risk factors
IUGR
RDS
Cyanotic
Blood
heart disease
Tx
Gastroschisis
Presentation
Feeding intolerance
Increased gastric residuals
Abdominal distention
Occult blood/ Hematochezia
Peritonitis
Discoloration of abdominal
wall
Abdominal mass
Temperature instability
Apnea
Episodes of Bradycardias
& Desaturation
Lethargy
Acidosis
Thrombocytopenia
Shock
Bell’s Stages
I. Suspected disease
Mild systemic signs (apnea, bradycardia, temperature instability)
Mild intestinal signs (abdominal distention, gastric residuals, bloody stools)
Nonspecific or normal radiological signs
II. Definite disease
Mild to moderate systemic illness
Additional intestinal signs (absent bowel sounds, abdominal tenderness)
Specific radiologic signs (pneumatosis intestinalis or portal venous air)
Laboratory changes (metabolic acidosis, thrombocytopenia)
III. Advanced disease
Severe systemic illness (hypotension)
Additional intestinal signs (marked abdominal distention, peritonitis)
Severe radiologic signs (pneumoperitoneum)
Additional laboratory changes (metabolic and respiratory acidosis, DIC)
Radiographs
Management “same same”
Medical emergency:
Cardiorespiratory support:
Ventilation “avoid CPAP”
Fluid +/- inotrops
Invasive monitoring
Maintain Sat. higher than acceptable
GA.
NPO, NG (IMS)
for
CBC
Coags
Lytes
SWU
& BG
Antibiotics
Maintain
Hg > 12
Maintain BS
Strict ins/out
Surgical referral
Serial X-ray is not advisable routinely
Have a wise mind & strong arms to push
the surgeons when approriate
Be aggressive when u have to B
Optimize nutritional support
Closely
follow hg/plt/BG
May need to use diuretics early
Serial clinical assessment
Follow SWU
Watch for opportunistic infections
Counsel the family about prognosis
Surgical approach???
Free
air remain the strongest
indication??
Newer trend to use peritoneal drain
initially!!
Moss et al NEJM,2006
Rees et al, Ann Surg,2008
Emil et al, Eurp J Surg, 2008
Complication
Death
20-40% (early/late)
Bleeding
Stricture
Short bowel syndrome (27%)
Abscess
Neurodevelopmental delay
Breast Milk
Probiotics
Slow feeding
Prevention
Standardized
Of NEC
Feeding
protocols
Antibiotics
Immunoglobulin
Prevention
Breast
milk:
Most “only” known safe preventive
measure.
926 pts in prospective study.
6-10* risk of NEC in formula vs BM
3 times if formula + BM
Lucas & Cole, Lancet, 1990
Schanler, 1999
McGuire, 2003
Contin…
Feeding strategies:
One large trial showed
benefit of slow rate
@ 20 cc/kg/d, stopped early.
Berseth et al, 2003
Many
other trials & meta-analyses; showed
no difference
Kennedy,2003
Kamitsuka, 2000
Feeding
protocol:
Modest evidence that protocol for
feeding may reduce the risk of NEC
Schurr & Perkins, Cochrane review
Trophic
feeds:
Tyson & Kennedy
Example of guidelines
Feed
#
1
2
3
4
5
6
7
8
9
10
11
12
1
1
1
1
1
1
1
1.5
1.5
1.5
1.5
1.5
1.5
2
2
2
2
2
2
2
2.5
2.5
2.5
2.5
2.5
2.5
Day 3
3
3
3
3
3
3
3.5
3.5
3.5
3.5
3.5
3.5
4
4
4
4
4
4
4
4.5
4.5
4.5
4.5
4.5
4.5
5
5
5
5
5
5
5
5.5
5.5
5.5
6
6
6
6
6
6.5
6.5
7
7
7
7
7.5
7.5
7.5
6.5 6.5
Probiotics
Probiotics:
for life
Dani et al, no difference
Other, Lin, Bin-Nun
2 meta-analyses, Al-faleh, Deshpande
Showed decrease NEC-II &
Mortality
Many unanswered Qs?
Amino
acid supp:
Arginine supp, Amin, 2002
Enteral glutamine, Vaughn, 2003
Immunoglobulin:
IgG/IgA
po, no difference, Foster, 2004
IVIG, Faranoff, 1994
Antibiotics:
Oral Gentamicin:
Meta-analysis of
5 studies showed
efficacy in reduction of NEC (Bury,
2004)
Erythromycin
Ng et al
PO/IV;
H2 hitamine
blocker:
Usage of H2 blocker ass’ NEC
Guillet 2006
•
Indomethacin****
Conclusion
A
disease of medical progress
Encourage EBM
Control multiple pregnancy “induced”
Standardized feeding protocol
Probiotics looming around
Medical care 1st & scalpel