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Discussion

a case of NEC

So I have seen my fair share of NEC cases...simple NPO and ABx for 7-14 days to dying in less then 12 hours. But, this patient that I have is just not fitting into one I have seen. I am asking for your opinions, comments, and answers....

This baby is a 30 6/7 week twin who was surfed and on CPAP for 4 days then went to prongs. He was 6 days old when I first took him as a patient, and he hit full feeds (32ml Q3hr) at my first hands on (don't get me started on that!). I thought his belly felt a little firmer then it should, but everything else was normal, so I fed him. He got really fussy an hour later, so I took my gut feelings and talked to the NNP who gave me a glycerin order. I gave that and by my next hands on his girth went up 1cm, he had a 14ml residual and had a nice bloody stool. We made him NPO. By morning they electively intubated him and started ABx...they did all the right things and what we thought was the right time. They didn't hesitate at all. This was Friday. By Sunday at 4am he was perfect. Everything was back to normal, assessment wise, and they were planning to extubate.

At 530, everything changed. He started riding the vent. After 30 minutes, I talked to the NNP and we did a gas...his pH 7.1 and CO2 80! By Tuesday morning at the end of my shift, he had been given blood, platelets, albumin..you name it...his girth went from normal and 24cm to a huge, tight and shiney 31cm!

It's now Thursday night and he isn't getting better. He hasn't gotten worse, but he isn't getting better. He has gained a pound since that Friday, drops his platelets every other day, has band waves (they spike to the 30s then drop to 10), and now has pseudomonas pneumonia to top it off. He is on a PIP of 29 and he doesn't breathe over the vent even when he is awake and his girth is up to 31.5cm.

Why won't he get better? He initially responded, and now is just...not. Do you think he has a chance?? Or do you think he will eventually perf and die? I can't imagine his bowel looks good underneath that skin!

Let me know your thoughts....I hate NEC!

Featured Replies

Hmmm... I'm tired and just off shift, but I'll throw out some ideas:

* The infection is resistant to whatever abx he's on

* Liver involvement - produces ascites and makes it hard to get better and messes with platelets and coags and such

* NEC totalis - hard to come back from, although I've seen it happen once

* Vegetations in his heart from all the infections

Wait wait wait - his PIP is 29??? How big is this child? Do you guys do HFOV? That's a crazy high PIP for a 30 weeker.

Good luck. NEC is the closest thing to pure evil I've ever encountered.

  • Author

Any nurse would believe he should be on the oscillator! I have no idea why he isn't. I even told the Neo that when he was on a PIP of 22 and his CO2 was 90. What do I know. If anything else it would make him feel a little better to not have that much pressure on his belly.

Suddenly I find myself wondering if he has an immune disorder. Those band swings are weird. But maybe I've just been watching too much Mystery Diagnosis...

Have they ruled out an obstruction? Do you have a replogle down, if so what are you getting out? I agree about the vent, he really needs to be on an oscillator. Is he jaundiced? The belly sounds like it could be ascites. I am sure you have thought of all this, sorry if I'm not much help.

  • Experts

A head ultrasound needs to be done to R/O bleeding. How are his fontanelles? Pupils? He could have a mild-moderate case of DIC, or even fungal sepsis, which could explain the platelet destruction.

Is he on Diflucan/fluconazole or AmphoB? Probably needs to be.

What are his LFTs looking like? How about his CRP? CRP is an excellent negative predictor of sepsis.

Ultimately this baby probably needs an ex-lap to r/o perforation, as well as antifungal coverage.

  • Author

He had a repeat head on Wed and it was normal. I am sure he has ascites. They even gave a dose of lasix, but it obviously didn't do anything because all the fluid is in his belly! His direct is 2.4 and he is super yellow. The CRP we did on Friday morning last week when he first got sick was 45 or something, but it hasn't been repeated. Nor have his cultures...so who knows for sure if he has a positive blood cx. I am sure giving at least one dose of AmphotericinB wouldn't be a bad thing.

When he was feeding, he stooled on his own, normally, so an obstruction (besides a stricture now from the NEC) is probably not the case...although his replogle doesnt put out anything. Then again his xrays have been nearly gasless for 5 days now.

I'll see what happens tonight. I guess on Tuesday they were going to give him 48 hours to get better or do an expl. lap but then decided not to. I know his Hct dropped to 28 this am out of nowhere....ugh...

That's NEC for you. We do not know and it's hard for us as caregivers to come to terms with it. Hopefully research will come soon to help us understand better.

NEC is definitely one of the worst things that we as NICU nurses ever have to deal with. Judging by that ABG you mentioned, he probably has some (if not a lot of) necrosis in his gut going on. We had a similar case on our unit not too long ago... 33 week twin who had been room air and almost full feeds - then was being taken off of support less than 36 hours later. (see thread titled "I hate NEC" for more details...)

Any news on this case?

I'm thinking a small perf that is festering? any free air along the diaphragm?

We just had a full termer with nec...treated conservatively, never perfed, started feeds, not a great feeder, went to full feeds and went home. Two weeks later the same kid is on PICU in full blown DIC and septic shock....when they opened him up, sure enough there was a small perf that had gone unnoticed :( He is most like going to die :(

I hate NEC...someone said it right...pure evil personified!

NEC is the closest thing to pure evil I've ever encountered.

I dont think it could be said any better. I have been in the NICU for about a year, and we have hat 3 deaths from NEC. The second was the hardest, and the third came from WAY left field.

  • Author

So this baby did recover...so far from the NEC. They held off on surgery and eventually he jsut got better...amazing.

However...his PDA never closed. So, since they couldn't treat him, they had to ligate him. (I'll remind you now that he had pseudomonas pneumonia during that time as well...the culture was positive 36 hours after being intubated.) So they go in to do the ligation and his lung was adhered to his chest wall. Turns out he had a huge abscess on his LLL. It was full of puss and there was necrotic lung tissue!!!!!! They took out all the dead stuff...then ligated him (they had to use 2 clips bc his PDA was so large!)...then had to place a CT. He was dog sick for 5 days.

That was last week. Now he is hanging out on 1L NP and they started trophic feeds...I guess he is doing pretty well for now.

Anyone know why any of this would make them want to do a CF workup??

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