Development of NEC- questions for you!Register Today!
- by NICU_Nurse Apr 26, '03Hey, guys, I have some questions. Do any of you have any experience with babies who've developed NEC and/or perfed on your shift? I figured you do , but would you mind sharing your experiences? What kinds of things did you start to see happen with the baby? Did the doctors know about it as it was happening? What sort of orders were made as this occurred, etc.? What are early signs of a baby developing NEC, as you've seen them? I have a lot to look up in my texts, but figured that some of you may have some firsthand experience that you'd be willing to share? I'd like to hear anything you have to say about it. Thanks! :>)
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- NEC in a nutshell eh?
Well, we routinelly measure girth and heme check all stools. Let's say a a girth is up 1cm and bowel signs decreased and baby is regurging. Suspest NEC and make NPO get an abd xray and draw a CBC and start abx.
If baby has increased residuals and they look green, ditto and drop a...uh oh, brain freeeze!!!! Ya know! And hook it up to intermittent suction.
Maybe he stool is heme + and baby's hr is up, MAP is down. Same thing. Now based on the x ray it depends what we do next. If loops are dialated we keep an eye on them and continue previous interventions.
Worst I saw was at the beggining of shift. Baby had resiuals and girth was up in the am. Made NPO and got a film that showed dialated lops. Well by the time I got there this kid had visable loops and belly was looking ecchymotic! Grabbed the fellow walking by and got a stat abd xray. Full of air! KId was intubated, started Vanco, hooked to suction, (damn what's it called!) and shiped out as we don't do surgery. I don't know what the outcome was. The nurse (new grad) had been telling the resident for a couple of hours about this kids belly and thy blew her off!
So(as this get's longer!) all babies are different so you want to put your critical thinking cap on and look at all these things:
Are feeds being tolerated? Residuals, vomiting, regurge? Last BM? Are BMs heme+? Funky color? Girth up? Any bowel sounds?
VS? HR up? MAP down ? Does the baby have an increase need for O2?
Look at the baby. Does he "look sick"? How's his color? Does the belly look loopy and a bad color? Is he lethargic?
Of course these could be anything, but put them together in the right way and it could be NEC.
That got long! HTH!!!
BTW, just lost a really sweet feeder/grower to NEC, so don't rule it out until the kid is out the door!
- Apr 26, '03 by NICU_NurseWow! Thanks. ;>) That was fast. Okay, here's what I'm wondering, after re-reading up on it (thank you, E-medicine...now my 2nd favorite web site!). We were talking about this for a while last night and I had lots of questions!
Here's a scenario. I had to fill in the blanks here a bit, so forgive me if it's not completely right.
A 35 weeker is admitted to intermediate care. Seems stable. Feeds started, quickly advanced after tolerance is 'proven.' Orders to continue advancing q3 by 3cc until you hit the max (say, 30cc or so). At 2 days old, infant is up to the max feeds but starting to show signs of intolerance. MD's aware, watching closely, eval. for GER. Infant spits up regularly, amounts increasing over 24 hours or so (before max is hit on that second day of feeds). First 1-2cc, then 5-6cc, then rapidly (within hours) to almost the entire volume of feed (25+cc spit up over a 3 hour period). MD's called multiple times to consult during this time and orders given: Reflux precautions (HOB to 45 degrees, etc.), feed on syringe pump over 20, then 30, then 45 minutes, then 1 hour). When infant reaches 25+cc regurg, order given to hold next feed and reevaluate at next regularly scheduled feed time. Feed held per order. At the next scheduled feeding time, infant is assessed and upon stimulation regurges 15+cc of mucousy, bloody fluid. During assessment, diaper is checked and reveals mucousy, bloody stool along with a small amount of seedy, yellow stool. Urine appears to be brown-tinged. All previous diapers have been normal. MD's on unit STAT, and within a very short period the following things occur:
1) Infant becomes completely lethargic and unresponsive to visual stimulation.
2) Vital signs remain the same with no visible changes in BP, MAP, HR, Resp, or temp. Infant is on room air with no supplemental O2.
3) Abdomen begins to distend. Abdominal girth is taken at first sign of distention and shows a 2cm increase from the previous girth, which was taken at birth.
4) General skin color begins to change, first pale, then yellowish, then greenish color. Color is generalized and not confined to one area (i.e, not just abdominal discoloration), and never erythematous- more of a jaundiced appearance.
5) Air/residuals are checked and there is minimal result- little to no withdrawable air, and no residual (presumably because of frequent regurgitation- nothing left in stomach?).
6) Last labs were drawn at birth and 12 hrs after first set drawn. No significant issues with lab results or cultures.
So, keeping these things in mind: For at least 12 hours infant has been regurg-ing. For the last 2 hours infant has been lethargic and other signs mentioned above begin to present themselves. Within 1 hour infant has changed color, abd is distended and becoming firm (no bowel loops visible, but superficial veins are beginning to become pronounced; no palpable abd masses, no apparant tenderness upon palpation, but bowel sounds go from hypo to absent or inaudible within one hour), becomes completely lethargic and responsive only to major stimulation/pain/agitation.
Stat abd series ordered shows what looks like pneumotosis and a dilated bowel loop, but is unconfirmed. Infant remains on RA, VS remain mostly stable, MAP is only visible thing that is changing (MAP is dropping VERY slowly). Gomco sx getting fairly large amount of bloody, mucousy residual from stomach.
What do you think? Ever seen anything like this before? Sounds like NEC, but is it really possible for it to come on this quickly? I'm also wondering about SIP. Are any of these things signs you would see in a baby who has perfed, or is this just typical of NEC in general? I've never had a baby who's had NEC; I've always gotten them post-NEC or post-resection, so I'm really not sure what these things mean. Help me put these clues together!! Is this typical? Does it usually happen this quickly? We're talking max, two days after birth. I've got some more research to do, but if any of this clicks into place for you, let me know. ;>)
Kristi, who is tired of reading.Last edit by NICU_Nurse on Apr 26, '03
- Apr 26, '03 by nicudaynurseExcellent thread and I am so impressed with the critical thinking.
I have seen healthy feeder growers who appear to be doing great one day and then I would come in the next day and they are intubated, on multiple drips, etc... due to NEC. It can happen very fast. Sometimes the initial signs and symptoms can be very subtle.
- Sounds like it could be NEC or some sort of formula intolarence. It can come on like that. How are his labs? Wondering if it's the liver. Sounds like everything was done par for the course to me. Let me know how it goes for the little one!
- Apr 26, '03 by NICU_NurseThanks to both of you. I guess the presenting symptoms seemed so sudden that I couldn't help asking/wondering if everything possible was done, or if some major factor was overlooked or something. I admit I've got limited experience here, but this whole scenario just shocks me a bit. Never seen anything like it in my whopping 16.5 months as a nurse.
- Apr 26, '03 by prmenrsWas a surgeon consulted? And when? The only thing I can suggest is that girths need to be checked q feed on any premie, esp one that's upchucking.
Remember my old signature line? Let me repeat:
NEVER, EVER TRUST A 35 WEEKER!
NEC can present in a catastrophic fashion, complete w/overwhelming sepsis. This baby gave you little, tiny hints, then just crashed.
Sometimes, you'll have a baby that just doesn't "feel right" to you. ALWAYS pay attention to that intuition. If the docs won't listen, document the details--girths, hemacults, ask a more experienced nurse to assess w/you. With all the details you remember, something was telling you the baby was not OK. I think you are developing that sixth sense--which is a MAJOR step toward expertise. You're not just dong a series of tasks, you're evaluating at some interior level [that you may not be aware of] the data you are collecting and documenting.
No matter how long you are doing this, the kids can always pull a fast one on you!! Just less of them as time goes on.
- Apr 27, '03 by NicuGalThat sounds like a nice case of NEC to me! Usually those kids start looking icky and then it is downhill from there.
We have had alot of full termers lately with NEC....perfed NEC.
And you can have a kid that has been feeding for a while, even up to full feeds and they can develop NEC...sometimes those are the kids with the insidious abd. problems...puking here and there, had feeds held a few times. After a while you'll be able to peg those kids and say "Yup that one is a big ole setup for NEC!"
- Apr 27, '03 by MiraWhen I just started working with the neonates,I was told that those formula fed babies are more prone to NEC & it was proven when I`ve seen babies developing NEC so slowly,puking for 24hours or so,visible veins on abdomen,not passing stool >24h etc. it was when I was in the countryside,but when I moved to a city,the scenario was so different most of the babies who had NEC actually were on breastmilk,and the effect of NEC was so quick,I just handed over to the night staff that the baby was fine,stable vital signs apart from resps of 80-100br/min,tolerating feeds,opening bowels to a soft yellow stool every diaper change(4-6h).Then the following day(<12h) this baby was intubated,abdomen very shiny w visible veins,baby needs resection etc.I feel guilty for whatever I`ve missed.It was not the only baby who had NEC in our unit,within a month we had 3 cases,and one died( the one who is actually a feeder and grower baby).Thankfully,I`ve never handled the other 2(or else I would hang myself).It is common in our unit to see babies with distended abdomen and puking,but the most significant signs of NEC I`ve seen/heared is changes in the V/S,like tachycardia/tachypnea,and rigid distended abdomen.We have noticed as well that babies who had a top up transfusions are most likely candidate(I need to find out the rel.coz most of the preemies had it).Apparently in our unit the cause of the rapid changes in the baby with NEC was Group B strep(I wonder how did they picked up that bug?).