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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.

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NEC

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  1. NEC Nawaf Al-Dajani

  2. Disclosure

  3. NEC • Definition • Early history • Epidemiology • Pathophysiology • Presentation • Prevention • Treatment

  4. Definition • Acute inflammatory disease process affecting GI tract of neonates. • Usually ass’ necrosis of affected part. • Unpredictable course.

  5. History • Not known prior 1950’s • First described by Schmid & Quaiser. • Well recognized entity 1960-1970. • High MR • Idiopathic GI perforations.

  6. 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.

  7. Pathophysiology

  8. NECROTIZING ENTEROCOLITIS • Pathophysiology: UNKNOWN CAUSE…….

  9. 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

  10. CIRCULATORY INSTABILITY Hypoxic-ischemic event Polycythemia PRIMARY INFECTIOUS AGENTS Bacteria, Bacterial toxin, Fungus MUCOSALINJURY 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

  11. Preemies gut Luminal flow Mucin Inflammation PMN M0 Immune cells PAFTNF Vasoconstriction Tissuepermeability

  12. Risk factors • IUGR • RDS • Cyanotic heart disease • Blood Tx • Gastroschisis

  13. 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

  14. 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)

  15. Radiographs

  16. Management “same same” • Medical emergency: • Cardiorespiratory support: • Ventilation “avoid CPAP” • Fluid +/- inotrops • Invasive monitoring • Maintain Sat. higher than acceptable for GA. • NPO, NG (IMS)

  17. CBC • Coags • Lytes & BG • SWU • Antibiotics • Maintain Hg > 12 • Maintain BS

  18. 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

  19. 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

  20. 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

  21. Complication • Death 20-40% (early/late) • Bleeding • Stricture • Short bowel syndrome (27%) • Abscess • Neurodevelopmental delay

  22. Breast Milk Probiotics Slow feeding Prevention OfNEC Standardized Feeding protocols Antibiotics Immuno- globulin

  23. 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

  24. 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 Berseth et al, 2003

  25. Feeding protocol: • Modest evidence that protocol for feeding may reduce the risk of NEC • Trophic feeds: Schurr & Perkins, Cochrane review Tyson & Kennedy

  26. Exampleof guidelines

  27. 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?

  28. Amino acid supp: • Arginine supp, Amin, 2002 • Enteral glutamine, Vaughn, 2003 • Immunoglobulin: • IgG/IgA po, no difference, Foster, 2004 • IVIG, Faranoff, 1994

  29. Antibiotics: • Oral Gentamicin: • Meta-analysis of 5 studies showed efficacy in reduction of NEC (Bury, 2004) • Erythromycin PO/IV; • Ng et al

  30. H2 hitamine blocker: • Usage of H2 blocker ass’ NEC Guillet 2006 • Indomethacin****

  31. Conclusion • A disease of medical progress • Encourage EBM • Control multiple pregnancy “induced” • Standardized feeding protocol • Probiotics looming around • Medical care 1st & scalpel

  32. Thank you

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