Wow! 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.