My first case of NEC

Bortaz, MSN, RN · Jun 11, 2013

Hang in there. NEC sucks.

UTVOL3 · Jun 13, 2013

NEC really does suck.

twinkletoes53 · Jun 13, 2013

NEC is one of the most dreaded complications that a premature infant can develop. I hate it with a passion. And you can do everything that you are supposed to do---monitor the infant closely, notify the doctor at the first sign of feeding intolerance, abdominal distention, guaiac positive stools, etc. And still lose that baby.

I cared for an infant once who was po feeding, room air, no pre-existing factors for sepsis, doing "well". Three hours into my shift, at 0200, he had his first guaiac + stool. I notified the on-call doctor, who came and examined him. He had no other symptoms, was still active, responsive, vital signs stable. Abdominal X Ray was negative. Doc said to continue to feed & monitor. Within 12 hours he had died from what his doctors described as "fulminating NEC". I was shocked. So many "what ifs". Should we have placed him NPO immediately? Should we have done blood work? Started serial abdominal films? Started antibiotics? Would it have made a difference? He went from being asymptomatic to being in full blown septic shock from NEC within a few hours.

Another patient in our NICU was an ex-preemie was in an open crib, po feeding, slated for discharge within a couple of days. The nursing staff went home that morning, only to return 16 hours later to find him with a severe case of NEC, with pneumatosis on X ray, followed by bowel perforation within another couple of hours. He too did not survive. How do you tell a parent that their son, who had battled months of complications related to prematurity, and overcome one obstacle after another, was not going to be going home? It breaks my heart.

Bortaz, MSN, RN · Jun 13, 2013

The 24 weeker that I oriented on as a new NICU nurse...man, I loved that little girl...she was my first premie, my first time falling in love in the NICU, my first NEC case and my first baby death. It devastated me. We actually lost 2 to NEC that day. Both out of the blue as twinkletoes described. I will never forget that day if I live 1000 years.

boardchic · Jun 13, 2013

Thanks for the stories. As awful as it is, it does help to know it happens even under close monitoring. We have a lot of grower feeders and all are over 31 weeks, so it was shocking. Especially that she was pink and normal on my shift and the next day she was grey and septic. She was going for an exploratory laparotomy yesterday last I heard, so maybe I'll get an update on my next set.

boardchic · Jun 13, 2013

That so sucks, Bortaz. My first NICU death was a hemopericardium/cardiac tamponade. We tried so hard to save that little girl, but she wouldn't respond to anything. I'll never forget watching helplessly until it was called - by then the transport neo had taken over. Still makes me cry thinking about it.

Jory, MSN, APRN, CNM · Jun 15, 2013

Thanks for the stories. As awful as it is, it does help to know it happens even under close monitoring. We have a lot of grower feeders and all are over 31 weeks, so it was shocking. Especially that she was pink and normal on my shift and the next day she was grey and septic. She was going for an exploratory laparotomy yesterday last I heard, so maybe I'll get an update on my next set.

Have heart..it may not have been obvious when you had the baby.

One of the two things that I have noticed a baby will start doing, before other symptoms show up, is that they will fail to wake up for feeds (as much) as get really floppy or have less of reaction to pain stimuli from lab draws.

At our facility, we also tell each other in report if a baby was "early" or a "late" feeder (for a round) and we have a very, very strict protocol on how long to infuse gavage feeds. If a baby is NG fed, we check for residuals at every feeding...which is something some NICU's don't do.

TiffyRN, BSN, PhD · Jun 21, 2013

Everyone with any time in the NICU has a NEC story, one that happened to their baby, not just some kid you heard about, it's that common. With the kid I cared for, she wasn't right at the 8pm feed, but nothing you could say for sure, green residual at 11pm, receiving PPV at MN while we set up an oscillator. 18hrs later we were withdrawing support, no viable bowel left.

NEC is evil.

Some of the more experienced nurses tell me of the pre-surfactant days and how they watched so many babies die of RDS and what a miracle surfactant was. I want to tell outdated stories about NEC like that one day before I finish my career, how it used to get so many of our kids. :cry:

twinkletoes53 · Jun 27, 2013

Have heart..it may not have been obvious when you had the baby.

"One of the two things that I have noticed a baby will start doing, before other symptoms show up, is that they will fail to wake up for feeds (as much) as get really floppy or have less of reaction to pain stimuli from lab draws.
...and we have a very, very strict protocol on how long to infuse gavage feeds. If a baby is NG fed, we check for residuals at every feeding...which is something some NICU's don't do.

"

One of the early signs of sepsis is lethargy, as Jory described. You may also note a change from baseline v/s: infant hypo or hyperthermic. Usually hypothermic. If the baby is in an Isolette, you may see a change in his baseline ambient temperature. e.g. he was able to previously maintain a temp. WNL with an Isolette temp. of 29 degree Celsius. As the hours pass, you note that he now requires an Isolette temp of 32-36 degrees Celsius to maintain his temp.WNL. Other v/s will change, too. Hypotension, tachycardia, increased WOB, increase in apneas, bradys, and desats., abdominal distention, visible dilated loops of bowel, etc.

As in Jory's hospital, we also had a strict protocol for NG feeds, and measured residuals before each feeding. A residual of up to 20% of the previous feed was considered acceptable. Anything over that amount was reported to the resident on duty.

krenee · Jun 27, 2013

My first NEC case was recently as well . . . ex 26 weeker who was 40 days old, on full feeds and had never had any problems tolerating the feeds. I'd had her many times before. First hands on she was fine. Second hands on she had had some emesis, fairly large residual (about half her feed), and increased girth and questionably firm abdomen. I called the Dr, she was made NPO and we drew labs & got a KUB, which the Dr. thought looked OK. Her CRP came back 14 so we started triple antibiotics. Her H&H were low, her platelets were 26. Next hands on her girth was increased and abdomen definitely firm, I got about a 9 cc residual of brown yuckiness, and there was stool with blood. Drew more labs, and her K+ was high, her Sodium was low. Her output was about nothing. She was a sick little baby . . . She got platelets & then rbcs, follow up KUB and shipped out to a higher level NICU because we don't do surgery. It was amazing to me how she went from "fine" to critical over a 12 hr shift. I did, however, felt like I did everything right . . . let the Dr. know as soon as she was questionable. Word is she's doing OK. NEC is scary!

boardchic · Jun 27, 2013

Man, it just moves so fast once signs start to show. I don't feel like I did anything wrong - she was fine on my shift - her usual sweet self, residuals fine, stool fine, tummy fine. And absolutely not septic - i know what septic looks like. It's just at first i was thinking back and questioning if we should have advanced her feeds slower, but we treated her as we do other new 35 weekers and she's the only one that developed NEC. It sucks. Now I understand why people call it evil.