NEC
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Transcript of NEC
NECNEC
Nawaf Al-DajaniNawaf Al-Dajani
Disclosure Disclosure
NECNEC Definition Early history Epidemiology Pathophysiology Presentation Prevention Treatment
Definition Early history Epidemiology Pathophysiology Presentation Prevention Treatment
Definition Definition
Acute inflammatory disease process affecting GI tract of neonates.
Usually ass’ necrosis of affected part.
Unpredictable course.
Acute inflammatory disease process affecting GI tract of neonates.
Usually ass’ necrosis of affected part.
Unpredictable course.
History History
Not known prior 1950’s First described by Schmid &
Quaiser. Well recognized entity 1960-1970. High MR Idiopathic GI perforations.
Not known prior 1950’s First described by Schmid &
Quaiser. Well recognized entity 1960-1970. High MR Idiopathic GI perforations.
Epidemiology 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.
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 Pathophysiology
NECROTIZING ENTEROCOLITISNECROTIZING
ENTEROCOLITIS Pathophysiology:
Pathophysiology:
UNKNOWN CAUSE…….
Preemies gut is differentPreemies gut is different
Inadequate IgAScanty T lymphocytesLack of adequate antibody responseHigher membrane permeabilityLower motility and emptyingMucin blanket Tight junction are deficient
PRIMARY INFECTIOUS AGENTS
Bacteria, Bacterial toxin, Fungus
CIRCULATORY INSTABILITY
Hypoxic-ischemic event Polycythemia
MUCOSAL INJURY
ENTERAL FEEDINGS
Hypertonic formula or medication, H2 gas production,
Endotoxin production
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4, Interleukin 1; 6
Preemies gut Preemies gut
PMNM0
Immune cellsPAFTNF
Luminal flow
Mucin Inflammation
VasoconstrictionTissue permeability
Risk factorsRisk factors
IUGR RDS Cyanotic heart disease Blood Tx Gastroschisis
IUGR RDS Cyanotic heart disease Blood Tx Gastroschisis
Temperature instabilityApneaEpisodes of Bradycardias & DesaturationLethargyAcidosisThrombocytopenia Shock
Feeding intoleranceIncreased gastric residualsAbdominal distentionOccult blood/ HematocheziaPeritonitisDiscoloration of abdominal wallAbdominal mass
Presentation
Bell’s Stages
I. Suspected diseaseMild systemic signs (apnea, bradycardia, temperature instability)Mild intestinal signs (abdominal distention, gastric residuals, bloody stools)Nonspecific or normal radiological signs
II. Definite diseaseMild to moderate systemic illnessAdditional intestinal signs (absent bowel sounds, abdominal tenderness)Specific radiologic signs (pneumatosis intestinalis or portal venous air)Laboratory changes (metabolic acidosis, thrombocytopenia)
III. Advanced diseaseSevere systemic illness (hypotension)Additional intestinal signs (marked abdominal distention, peritonitis)Severe radiologic signs (pneumoperitoneum)Additional laboratory changes (metabolic and respiratory acidosis, DIC)
Radiographs Radiographs
Management “same same” Management “same same” Medical emergency: Cardiorespiratory support: Ventilation “avoid CPAP” Fluid +/- inotrops Invasive monitoring Maintain Sat. higher than acceptable for
GA. NPO, NG (IMS)
Medical emergency: Cardiorespiratory support: Ventilation “avoid CPAP” Fluid +/- inotrops Invasive monitoring Maintain Sat. higher than acceptable for
GA. NPO, NG (IMS)
CBC Coags Lytes & BG SWU Antibiotics Maintain Hg > 12 Maintain BS
CBC Coags Lytes & BG SWU 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
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
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???Surgical approach???
Free air remain the strongest indication??
Newer trend to use peritoneal drain initially!!
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 Complication
Death 20-40% (early/late) Bleeding Stricture Short bowel syndrome (27%) Abscess Neurodevelopmental delay
Death 20-40% (early/late) Bleeding Stricture Short bowel syndrome (27%) Abscess Neurodevelopmental delay
Breast Milk
Immuno-globulin
Antibiotics
Probiotics
Slow feeding
StandardizedFeedingprotocols
PreventionOf NEC
Prevention 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
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, 1990Schanler, 1999McGuire, 2003
Contin…Contin… Feeding strategies: One large trial showed benefit of slow
rate @ 20 cc/kg/d, stopped early.
Many other trials & meta-analyses; showed no difference
Kennedy,2003 Kamitsuka, 2000
Feeding strategies: One large trial showed benefit of slow
rate @ 20 cc/kg/d, stopped early.
Many other trials & meta-analyses; showed no difference
Kennedy,2003 Kamitsuka, 2000
Berseth et al, 2003
Feeding protocol: Modest evidence that protocol for
feeding may reduce the risk of NEC
Trophic feeds:
Feeding protocol: Modest evidence that protocol for
feeding may reduce the risk of NEC
Trophic feeds:
Schurr & Perkins, Cochrane review
Tyson & Kennedy
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 6.5 6.5 7 7 7 7 7.5 7.5 7.5
Example of guidelines
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?
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?
Probiotics
Amino acid supp: Arginine supp, Amin, 2002 Enteral glutamine, Vaughn, 2003
Immunoglobulin: IgG/IgA po, no difference, Foster, 2004 IVIG, Faranoff, 1994
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 PO/IV; Ng et al
Antibiotics: Oral Gentamicin: Meta-analysis of 5 studies showed
efficacy in reduction of NEC (Bury, 2004)
Erythromycin PO/IV; Ng et al
H2 hitamine blocker: Usage of H2 blocker ass’ NEC Guillet 2006
• Indomethacin****
H2 hitamine blocker: Usage of H2 blocker ass’ NEC Guillet 2006
• Indomethacin****
Conclusion Conclusion A disease of medical progress Encourage EBM Control multiple pregnancy
“induced” Standardized feeding protocol Probiotics looming around Medical care 1st & scalpel
A disease of medical progress Encourage EBM Control multiple pregnancy
“induced” Standardized feeding protocol Probiotics looming around Medical care 1st & scalpel