Understanding Necrotising Enterocolitis and administration of Anesthesia

1. NECROTISING ENTEROCOLITIS
Speaker: Dr Bhagirath.S.N
Moderator: Dr Sarika

2. Necrotising Enterocolitis
• Incidence in low birth weight babies (<1500g): 10% - 15%
• predominantly seen in
 premature babies (gestational age less than 32 weeks)-80%
 rapid feeding increases the risk
• gastrointestinal pathology with systemic ramifications
secondary to sepsis.
• Exact etiology is unknown. May be multifactorial.
• Most common site is the ileocolic region
• The triggering event in the cascade is a decreased
ability to absorb substrate.

3. Necrotising Enterocolitis-aetiopathogenesis cascade
• decreased ability to absorb
• Stasis of bowel
contents
• Bacterial proliferation
• Infection
+ Ischemia
• Necrosis of the
intestinal mucosa
• perforation of the
intestinal mucosa
Fluid loss
Gangrene of the gut wall
Peritoniti
s
Septicemi
a
Disseminated Intravascular
Coagulation
Increasing
gastric
aspirates
Abdomin
al
distensio
n
Irritability
Pneumatosis
intestinalis
hypovolemia
Metabolic
acidosis
Bloody diarrhea
Thrombocytopenia,
anemia,
coagulopathy

4. Necrotising Enterocolitis-approach to the problem
•Essentially a medical disease rather than a surgical problem
 fluid resuscitation
 stopping enteral nutrition
 decompressing the stomach with
a nasogastric tube
 antibiotics.
If condition worsens and the neonate becomes more septic
• Exploratory laparotomy-removal of the gangrenous bowel
• Ileostomy
• Peritoneal drain

5. Necrotising Enterocolitis-Pre-operative approach
• Debilitated condition warrants intubation and elective ventilation
• fluid replacement to replenish the losses (third space & surgical losses)
• Investigations:
 coagulation profile
 serum electrolytes
 arterial blood gas analysis
 Hematocrit
 glycemic status
• Vascular access-arterial line, central venous line
• Blood must be cross matched.
• Keep platelet and packed red cells ready for transfusion

6. Necrotising Enterocolitis-Anesthetic considerations
• Continue resuscitation
• adequate relaxation for surgery
• careful titration of anesthetic drugs (increased sensitivity)
• Rapid sequence intubation with Ketamine and succinylcholine
(dead bowel-high K+ levels-may warrant rocuronium usage)
• Maintenance of anesthesia
 use of opioid
 supplementation with Ketamine
 low dose inhalation agent, oxygen and air.
• Avoid nitrous oxide for fear of causing gas pockets in abdomen
• Continue IPPV by a T-Piece rather than a ventilator
• Ventilatory requirements increase during surgery as handling of bowel reduces
lung compliance.

7. Necrotising Enterocolitis-Anesthetic considerations
• prevent hypothermia by using increasing ambient temperature, warmed fluids,
warming mattress, warm air blanket.
•Surgery-bowel resection, primary anastamoses, enterostomies
• better not to extubate

8. Necrotising Enterocolitis-Prognosis
• long term survival depends on
 degree of prematurity
 associated congenital anomalies
 degree of surviving bowel
 total length of affected bowel
• Mortality rate (especially in < 1500g) – 25% - 50% mortality