a case of NEC

[lvnurs9]

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!

[lvnurs9]

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??

[elizabells, BSN, RN]

Did he have a meconium ileus at any point? Maybe they saw something in his lungs that made them suspicious.

Although since they'll have to wait quite a while to do a sweat test on a baby born at 30wks, that's going to be a loooooong CF workup.

[lvnurs9]

They actually do buccal swabs and test for the genetic marker.

He passed meconium and stooled normally until he got sick when he was 6 days old. I am guessing they are testing him because of the abscess they found...

[wensday, MSN, RN, APN, NP]

NEC's so horrible.

You get that feeling something's not quite right, next day CRP is 200+ and the baby is grey with a belly that looks so painful and you try not to appear hopeless in front of the parents as you aspirates tons of bile.

[elizabells, BSN, RN]

NEC's so horrible.

You get that feeling something's not quite right, next day CRP is 200+ and the baby is grey with a belly that looks so painful and you try not to appear hopeless in front of the parents as you aspirates tons of bile.

What's worse is a baby who looks fine, but you aspirate that bile in front of them for the first time. I hate making phone calls to docs in front of parents, trying not to let my utter panic come through in my voice.

The worst, though, was a little girl we had, I think 32 weeks with a VSD, all repaired, and about to go home. Parents go out to lunch, baby is in an open crib, getting continuous feeds (mom had learned to pass the NGT). Ten minutes after they leave I assess her one more time and her belly is like a gourd. We swing into action, and then the attending tells me (still a student at time!) that she has to go to a meeting, and not to tell the parents anything when they get back, but just page her. So they come back, and the kid is in an isolette, with a replogle to LWS and IVF up. The attending takes over an HOUR to come back after I page her. Parents aren't stupid. They know something's up. Turned out for the best, though, because the baby recovered fine from the NEC without surgery and it turned out she had PHACES syndrome, which only got caught because she had to stick around a while longer.