Interval between clinical presentation of necrotizing enterocolitis and bowel perforation in neonates.
ABSTRACT To define the interval between clinical presentation of necrotizing enterocolitis (NEC) and bowel perforation in neonates.
Charts of neonates with discharge diagnosis of NEC (n = 124) from our NICU during 2004-2008 were retrospectively reviewed. Demographic data were collected. Acute episode of NEC was defined as the interval between clinical presentations to resumption of enteral feeds. Neonates are followed, as a standard of care, clinically and radiologically until resumption of enteral feeds at the discretion of the attending clinician. Abdominal radiograph results were reviewed serially to determine the interval between clinical presentation and bowel perforation using pneumoperitoneum as the surrogate radiological marker. Histological report of resected bowel specimens was reviewed for coagulative necrosis as evidence of NEC and to exclude spontaneous intestinal perforation (SIP). Neonates with stage 1 NEC and SIP were excluded from the results.
105 neonates with stage 2 NEC were included in the study. Forty-six needed surgical treatment (group 2) and 59 did not need surgery (group 1). Twenty-six (26/46, 56%) group 2 neonates had bowel perforation and hence required surgery. Pneumoperitoneum was noted at a median interval of 1 day after presentation of symptoms. Twenty neonates in group 2 needed surgery for clinical indications including worsening clinical examination, thrombocytopenia or persistent metabolic acidosis. Fifty-nine neonates (group 1) were treated with bowel rest, antibiotics and parenteral nutrition. Group 2 neonates were significantly more premature, weighed less and had less radiographs than group 1 neonates. Mortality was significantly higher in group 2 compared to group 1.
Bowel perforation occurs at a median interval of 1 day after clinical presentation of NEC. Neonates not needing surgery for their disease are exposed to significantly more radiographs than those needing surgery. Radiological evaluation can be safely minimized or eliminated after 2 days of presentation.
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ABSTRACT: Purpose Abdominal radiographs are frequently employed in the surveillance of patients with necrotizing enterocolitis (NEC), with typical findings well described. Clinicians interpret and act upon these films at different intervals, however, and inter-rater agreement has not been evaluated to date. Methods Thirty abdominal radiographs of premature infants were distributed to attending radiologists(4), pediatric surgeons(4), and trainees(4), who evaluated for findings of NEC from a list of eight potential choices (1 = normal, 8 = perforation). Fleiss’s Kappa (FK) was used to evaluate concordance between multiple raters with 0–0.2 = slight association and 0.8-1 = almost perfect agreement. Results Practicing surgeons had an FK of 0.77 overall (95%CI: 0.67-0.87), but demonstrated poor agreement when evaluating decubitus films (FK:0.39, 95%CI:0.12-0.65). Radiologists had excellent inter-rater agreement (FK:0.81, 95%CI: 0.74-0.88), but had only modest agreement with surgeons (FK:0.59, 95%CI: 0.56-0.63) and poor agreement for decubitus films (FK:0.15, 95%CI: 0.47-0.26). Surgical and radiology trainees had fair agreement with their respective attendings (0.60, 95%CI: 0.55-0.65 and 0.64, 95%CI: 0.60-0.69, respectively). Conclusions While inter-rater agreement was good-excellent among attending staff, it was only moderate between radiologists and surgeons and between trainees and their attendings. This highlights the importance of inter-disciplinary and hierarchical communication to optimize clinical decision-making. Decubitus films may be of limited value in evaluating patients with NEC.Journal of Pediatric Surgery 05/2014; DOI:10.1016/j.jpedsurg.2014.02.058 · 1.31 Impact Factor
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ABSTRACT: Necrotizing enterocolitis (NEC) is a leading cause of infant mortality, and the most common reason for emergent surgery in very low birth weight (VLBW, < 1,500 g) infants. We investigated whether transfer for higher level of surgical care affects mortality in this population. VLBW infants who underwent NEC surgery were reviewed retrospectively from the California Patient Discharge Linked Birth Cohort Database (1999-2007). Transfer for emergent operation was defined as surgery ≤2 days after transfer. Mortality was analyzed with multivariate logistic regression. Overall, 1,272 VLBW infants with surgical NEC were identified, with a 39% mortality. Transfer for operative care occurred in 406 (32%) infants. Unadjusted mortality was not increased for infants who were transferred compared with not transferred (37% vs. 40%; P = .25). Adjusted mortality for infants transferred for operative care did not differ from those who received operative care at their primary neonatal intensive care unit (odds ratio 0.75, 95% confidence interval 0.42-1.32). Lower birth weight, lack of prenatal care, peritoneal drainage as sole surgical intervention, and pulmonary interstitial emphysema/pulmonary hemorrhage were associated with increased odds of mortality (P < .05). VLBW infants with surgical NEC do not demonstrate increased risk of mortality when transferred emergently for operative care. Future efforts must engage health professionals caring for this vulnerable population to maximize resource allocation and safety.Surgery 07/2012; 152(3):337-43. DOI:10.1016/j.surg.2012.05.036 · 3.11 Impact Factor
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ABSTRACT: NEC remains a major concern for neonatologists, surgeons, and gastroenterologists due to its high morbidity and mortality. These infants often have poor developmental outcome, and contribute to significant economic burden resulting in marked stress in these families. By developing and adhering to strict feeding protocols, encouraging human milk feeding preferably from the infant's mother, use of probiotics, judicious antibiotic use, instituting blood transfusion protocols, the occurrence of NEC may possibly be reduced. However, because of its multifactorial etiology, it cannot be completely eradicated in the NICUs, particularly in the extremely premature infants. Ongoing surveillance of NEC and quality improvement projects may be beneficial.Pathophysiology 02/2014; DOI:10.1016/j.pathophys.2013.11.009