2020 FSA Posters

P087: EMERGENT BEDSIDE LAPAROTOMY IN NEONATAL NECROTIZING ENTEROCOLITIS; THE ANESTHESIA PROVIDER'S ROLE.
Parneet Parekh; Kendall regional Hospital

Introduction/Background: A 5-day old, 1760g, 33-week premature infant intubated with a HR of 208 and BP of 40s/20s on dobutamine presented with distended abdomen, hyperglycemia, fevers, and hyperkalemia for Ex-Lap for suspected Necrotizing enterocolitis (NEC). If recognized early it may be managed medically by withholding feeds and broad-spectrum antibiotics [1]. Delay in diagnosis could quickly result in sepsis and/or intestinal perforation requiring emergent surgery. Efficient communication between healthcare providers is critical in ensuring optimal outcomes. The purpose of this article is to discuss the anesthesia provider’s role in mmanagementt. Can cut out and compress above focus on stuff most relevant to us meaning pt initially medically managed however continued to rapidly deteriorate. Developed sepsis with concerns of bowel perforation.

Methods: A hemodynamically unstable 5-day old 32-week premature infant presented with distended abdomen, hyperglycemia, fevers, and hyperkalemia.  The patient underwent emergent bedside exploratory laparotomy and was found to have NEC.  Rapid sequence induction with low-dose midazolam due to instability and paralyzed w/ rocuronium. Pt starting hgb 5.1,  Patient was resuscitated with 90 ml blood, 40 ml ffp, and crystalloid. The patient remained hemodynamically stable during the procedure and remained intubated postoperatively.

Results: Unfortunately two small perforations were noted and bowel resection performed. After Intraoperative resuscitation patient HR 180s BP he infant became hemodynamically unstable while in the neonatal ICU and died the following day.

Discussion: NEC is commonly seen in premature infants, (gestational age less than 32 weeks) and low birth weight (less than 2 kg) [2].  Infants with NEC are critically ill and present with sepsis, hypotension, coagulopathy, dehydration and electrolyte imbalances. These neonates are generally intubated prior to coming to the operating room. In our case the infant had been intubated but was too unstable for transport to the operating room and the decision was made to perform the procedure bedside in the Neonatal Intensive Care Unit.  If the patient is not already intubated, rapid sequence induction should be performed. Ketamine 4 mg/kg/hr with fentanyl 10-30 μg/kg and a muscle relaxant can be administered. [2] Inhalational agents can be used in the operating room, although nitrous oxide is contraindicated. Maintenance of mean arterial pressure and aggressive fluid management (70 mL/kg) is critical in combatting intravascular volume depletion due to third spacing.  Nasogastric tube placement is important for gastric decompression and should be performed prior to induction.  The tube should remain on suction to decrease the amount of gastric contents in the oropharynx. Blood, fresh frozen plasma, platelets, dopamine, and vasopressors may be necessary.  Regional analgesia is contraindicated due to coagulopathy in NEC.  Arterial line access is recommended as hypotension and frequent arterial blood gas assessment may be necessary. Resuscitation may result in significant electrolyte imbalances and should be promptly addressed.  Cardiovascular instability in pediatric patients can be a sign of impending decompensation. Bicarbonate administration may be necessary if base deficit is significant. Post-operative management should include fluid resuscitation, inotropes, ventilator support, and antibiotics until patient is hemodynamically stable.