You've diagnosed NEC- NOW what do you do???- Tala Talks NICU

NPO? Replogle to suction? Serial KUBs? Which antibiotics? When does a patient need surgery? Learn all this in part 3 of the series on NEC. Management and Treatment of NEC - Tala Talks NICU
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Dr. Tala is a board-certified neonatologist, and has worked in busy level III and IV units for the past 15 years. She has won multiple teaching awards throughout her time as a neonatologist.
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References:
Acute Necrotizing Enterocolitis in infancy: A review of 64 cases. Santulli et al. Pediatrics vol. 55 No. 3 March 1975
Antibiotic Treatment and Patient Outcomes in Necrotizing Enterocolitis. Murphy et al. Am J Perinatol 2020 Oct;37 (12) 1250-1257
Initial Laparotomy versus Peritoneal Drainage in Extremely Low Birthweight Infants with Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation. Blakeley et. al. Annals of Surgery. Volume 274. Number 4. Oct 2021.
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Timstamps:
0:55 Management of NEC
2:00 Treatment of NEC
7:31 When is surgery required for NEC?
9:30 Which surgical intervention should be chosen?
13:07 Second look
13:42 Supporting other systems while an infant has NEC
15:14 When do we stop treatment?
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Music: www.bensound.com (royalty free with credit)
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*Disclaimer*: This video is intended for educational purposes only and while
we strive to give the most accurate information, errors may occur. Subsequently,
this video should not be a replacement for medical advice.

[@anneshields8188]

I have worked with many neonatogists in my career. All have the gift of healing. Not all have the gift of explaining. You have both. Thank you for all your teaching.

[@TalaTalksNICU]

Dearest Anne- I have been enjoying your comment for two days now. It may be the nicest compliment I have ever received- and it's been a rough couple of days in the unit so even more needed! I will say that- all of it is training and learning and experience- and being surrounded by brilliant people who have given you their blood, sweat and tears to make you better. Not sure anybody's healing powers are a gift- but rather thanks to all the people before them and with them now- that supported them and taught them and allow them to do something they love! But thank you!!! And as an aside- we put your question on a Facebook page- asking for tips. Loving the ones we've received- and all the little tips we've been given at work- so that video will come out eventually! Thanks again so much for being here :)

[@inalumieresonia9677]

I am a general pratictionner but your videos inspire me to become one day a neonatologist!

[@TalaTalksNICU]

That's fantastic!! Go for it! best field ever!

[@freedaboyoung3722]

Thank you so much, Dr Tala! Wonderful video as always

[@TalaTalksNICU]

So glad you liked it- thanks so much Freeda :)

[@stillbreathing100]

Absolutely brilliant..

[@TalaTalksNICU]

Thank you so much Awais for your loyalty!

[@naitramsingh6942]

Amazing video as always, very informative and you are an awesome teacher, do continue the amazing work, thank you and your team

[@TalaTalksNICU]

Thank you so much Naitram, for your continued support and positivity!

[@baghdai9282]

Excellent video

[@MoHa-dp3wd]

I would add that you should make sure you have a negative blood culture for 24-48 hrs prior to placing a central line. Recently, on a baby we had with NEC we did 10days of Amo/Gent/Clinda, due to a nasty X-ray and concern for a perf. We could have considered stopping the Clinda once the baby was stable and X-ray cleared, but didn’t. We did start feeding on day 7 of treatment and was able to pull the central line out the day we stopped abx.

[@TalaTalksNICU]

You're right- that is an important point. Always nice to have a clear blood culture before putting in a line- if at all possible! Your management plans sound very similar to ours. Thanks so much for sharing and adding that important comment :)

[@asmamajeed7551]

Very informative video 👍

[@TalaTalksNICU]

We're so glad you think so- thank you for taking the time to write!

[@shellyshahaf4047]

really love your videos i work in a hospital in tel aviv - Israel. we use tazocin for 5-7 days. i never knew about the drainage you were talking about. in some cases babies get surgery with stoma. thank you very much! glad i discovered your channel

[@TalaTalksNICU]

We're so glad you're here too. Yes- sometimes the tiny ones get a drain if they're too sick for surgery (or if there was a SIP and not NEC). So glad you're watching from Isael. We hope your family and friends are safe.

[@shellyshahaf4047]

@@TalaTalksNICU thank you very much for your thoughtful response. it's not an easy time but we are hanging in there.

[@user-wj8ec7mf1c]

You are awsome

[@TalaTalksNICU]

Ha! Definitely not- but we appreciate the sentiment!!!! Thank you :)

[@lvillarreal8865]

Thank you, Dr Tala! Do you think you can discuss and elaborate lab results (computations) in identifying infection in newborns. Such as bands/segs etc. If possible.

[@TalaTalksNICU]

Hello! We haven't done an official video on infections yet, but we shot a video on WBC calculations and we go over the important values to consider in sepsis. They hold pretty true for NEC too. Hope this helps!

[@osamaalagamawy3891]

ما شاء الله. بارك اللة فيكى.

[@TalaTalksNICU]

Shukran!

[@osamaalagamawy3891]

@@TalaTalksNICU you got it. Marvelous

[@osamaalagamawy3891]

💯❤🏅🌷⚘💐

[@docNICU]

in our unit the peritoneal drain used only for those babies with surgical NEC who are very very sick like shock, on multiple ionotropic support and are otherwise not fit for exp lap and will ultimately go for exploration if they survive. the main question always is regarding how many days the patient has to be kept without feed and free drainage OGT because majority of the cases are ?NEC or and no one is sure weather this is stage 1 NEC or somthing else and unfortunately we dont have any clear guidelines for that.

[@TalaTalksNICU]

Hello! Thank you for such a thorough comment. Most units seem to be practicing similarly- with the tiniest sickest infants still having a drain placed (out of desperation often). I agree- we really don't have the studies to show how long we should treat for. Like you said, part of that reason is that so many instances of NEC may not really be NEC. The good thing is- this is a field of AMPLE research- so hopefully we'll get more answers soon.

[@goecmj]

Can you highlight the difference btwn a mucous fistula and an ostomy?

[@TalaTalksNICU]

Yes JH! So imagine the intestine as a tube from the duodenum to the recriminations. Let’s say there is an obstruction at the level of the ileum. The surgeon goes in and decides she can’t repair it immediately (ie cut out obstruction and bring upper and lower portion of intestine together). So she brings up the proximal portion to be an ileostomy (ie this is continuous with upper part of gut. Infant can eat and will “stool” out of this into a bag). The distal portion, the surgeon could see it up and keep it in the belly OR she could also bring the distal intestine up to the skin- this would be a mucus fistula. Sometimes we take the “stool” from the ostomy and “feed” it with a syringe into the mucous fistula to help with nutrition and to prepare that distal portion of the gut for repair in the future. Does that make sense?

[@baghdai9282]

I am a plastic surgeon. My daughter in law gave birth at 27 weeks to twins aboy and girl. 700gm and 1kg weight. Both Wer Suspdcted to have NEC. the girl was opemn and shut case . No finding of necrosis. The boy had NEC. 2cm removed and stoma closed few days ago. The girl is growing up but the boy is noing as good. What are the chaces that he will be disabled

[@TalaTalksNICU]

I’m so sorry. So difficult when you know more details and everything falling on you to make predictions and help in care. They are a good weight and it is encouraging that he has nearly all of his gut left. Obviously I don’t know any of the details but I have seen great outcomes with infants with surgical NEC even- who feed again and get reanastomosed without issues. Encourage them to take one day at a time. It is a relief the NEC didn’t do more damage. Wishing your family health and love xx

[@baghdai9282]

@@TalaTalksNICU God bless you

[@user-wj8ec7mf1c]

When to start vancomycin ornafacilin it wasnt clear for me

[@TalaTalksNICU]

This is a great question- and the real answer is it should probably be unit dependent (based on the bugs your NICU generally sees). Generally if an infant has a central line in (i.e. a PICC or broviac- or even an umbilical catheter), then you are more worried about getting seeding from the skin Staphylococcus into the blood-stream. So generally if an infant has a line, then you'd be more likely to start Nafcillin or Oxacillin, to cover for MSSA (Methicillin Sensitive Staph Aureus). If your unit has a bunch of MRSA (or you test weekly and you know the patient has an MRSA), then would be wise to start on vancomycin initially. Sometimes infants with lines also have a Staph Coag negative infection- like a Staph Epi. (PS if not a contaminant). In these cases , infants need to be put on Vancomycin to treat that. The good thing about this bug, is that it's not super-aggressive, so the infant is unlikely to get really really sick from Staph. Epi even if the baby is not on Vanc. Does this all make sense??

[@user-wj8ec7mf1c]

@@TalaTalksNICU sure thanks