SIP typically presents in the first week of life with abdominal distension and discoloration, hypotension, and pneumoperitoneum. It involves an isolated perforation of the terminal ileum. In contrast, NEC usually presents after the first week with abdominal distension and erythema, crepitus, induration, and radiological findings like pneumatosis intestinalis. NEC involves ischemic necrosis of the intestinal mucosa and is associated with various systemic signs. Both require supportive care but NEC may additionally require surgical intervention for perforation or deterioration.
Neonatal necrotizing enterocolitis
NEC is the most common life-threatening emergency of the gastrointestinal tract in the newborn period. The disease is characterized by various degrees of mucosal or transmural necrosis of the intestine. The cause of NEC remains unclear but is most likely multifactorial. The incidence of NEC is 1-5% of infants in neonatal intensive care units (NICUs). Both incidence and case fatality rates increase with decreasing birthweight and gestational age. Because very small, ill preterm infants are particularly susceptible to NEC, a rising incidence may reflect improved survival of this high-risk group of patients.
Clinical Manifestations
Infants with NEC have a variety of signs and symptoms and may have an insidious or sudden catastrophic onset (Table 96-1). The onset of NEC is usually in the 2nd or 3rd week of life but can be as late as 3 mo in VLBW infants. Age of onset is inversely related to gestational age. The 1st signs of impending disease may be nonspecific, including lethargy and temperature instability, or related to gastrointestinal pathology, such as abdominal distention and gastric retention. Obvious bloody stools are seen in 25% of patients. Because of nonspecific signs, sepsis may be suspected before NEC. The spectrum of illness is broad, ranging from mild disease with only guaiac-positive stools to severe illness with bowel perforation, peritonitis, systemic inflammatory response syndrome, shock, and death. Progression may be rapid, but it is unusual for the disease to progress from mild to severe after 72 hr.
Diagnosis
A very high index of suspicion in treating preterm at-risk infants is crucial. Plain abdominal radiographs are essential to make a diagnosis of NEC. The finding of pneumatosis intestinalis (air in the bowel wall) confirms the clinical suspicion of NEC and is diagnostic; 50-75% of patients have pneumatosis when treatment is started (Fig. 96-4). Portal venous gas is a sign of severe disease, and pneumoperitoneum indicates a perforation (Figs. 96-4 and 96-5). Hepatic ultrasonography may detect portal venous gas despite normal abdominal roentgenograms .
Neonatal necrotizing enterocolitis
NEC is the most common life-threatening emergency of the gastrointestinal tract in the newborn period. The disease is characterized by various degrees of mucosal or transmural necrosis of the intestine. The cause of NEC remains unclear but is most likely multifactorial. The incidence of NEC is 1-5% of infants in neonatal intensive care units (NICUs). Both incidence and case fatality rates increase with decreasing birthweight and gestational age. Because very small, ill preterm infants are particularly susceptible to NEC, a rising incidence may reflect improved survival of this high-risk group of patients.
Clinical Manifestations
Infants with NEC have a variety of signs and symptoms and may have an insidious or sudden catastrophic onset (Table 96-1). The onset of NEC is usually in the 2nd or 3rd week of life but can be as late as 3 mo in VLBW infants. Age of onset is inversely related to gestational age. The 1st signs of impending disease may be nonspecific, including lethargy and temperature instability, or related to gastrointestinal pathology, such as abdominal distention and gastric retention. Obvious bloody stools are seen in 25% of patients. Because of nonspecific signs, sepsis may be suspected before NEC. The spectrum of illness is broad, ranging from mild disease with only guaiac-positive stools to severe illness with bowel perforation, peritonitis, systemic inflammatory response syndrome, shock, and death. Progression may be rapid, but it is unusual for the disease to progress from mild to severe after 72 hr.
Diagnosis
A very high index of suspicion in treating preterm at-risk infants is crucial. Plain abdominal radiographs are essential to make a diagnosis of NEC. The finding of pneumatosis intestinalis (air in the bowel wall) confirms the clinical suspicion of NEC and is diagnostic; 50-75% of patients have pneumatosis when treatment is started (Fig. 96-4). Portal venous gas is a sign of severe disease, and pneumoperitoneum indicates a perforation (Figs. 96-4 and 96-5). Hepatic ultrasonography may detect portal venous gas despite normal abdominal roentgenograms .
Necrotizing enterocolitis (NEC) is a life-threatening emergency of the gastrointestinal tract in the newborn period.
The most common gastrointestinal condition in premature neonates.
It is characterized by inflammation, ischemia, and permeability of the neonatal bowel wall to bacteria.
It is potentially life-threatening with significant associated morbidity.
The disease is characterized by various degrees of mucosal or transmural necrosis of the intestine.
Pediatric GI problems
Abdominal pain in children
DDx: Acute abdominal pain
Inflammatory:
• Abdominal infection: appendicitis, gastroenteritis, UTI, mesenteric adenitis (post URTI), mumps pancreatitis, hepatitis.
• Lower lobe pneumonia.
• Autoimmune: IBD, HSP, DKA.
Anatomical:
• GI obstruction, constipation.
• Meckel's complication e.g. obstruction, inflammation. However, Meckel's is usually asymptomatic.
• Renal and genitourinary: hydronephrosis, menstruation.
• Compressed anatomy: strangulated inguinal hernia, testis torsion.
Acute abdominal pain in children often has no specific cause ('non-specific abdominal pain'), and resolves in 24h.
Students can also use this service to download free books and upload slides. For more information, Visit on https://bookapp.page.link/tele.
Approach to cardiac murmurs and cardiac examination in childrenVarsha Shah
Cardiovascular examination in children for MBBS undergraduate, Residents, Trainees, pediatricians, GP, family physicians, nursing , dental, allied health students
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. Spontaneous intestinal perforation
Isolated perforation of newborn
Typically at terminal ileum
Separate clinical entity from NEC*
Differentiation is important as there are
management considerations
*J Am Coll Surg. 2002 Dec;195(6):796-803.
Spontaneous localized intestinal perforation in very-low-birth weight infants: a distinct clinical entity different from necrotizing
enterocolitis
3. epidemiology
Commonly found in VLBW, ELBW
Risk~2-3 % in VLBW, 5% in ELBW
Median gestational age 25-27 weeks
Median BW 670-973g
More frequent in male infants
4. Risk factors
Prematurity
Antenatal
3. Severe placental chorioamnionitis*
4. ? Glucocorticoids/NSAIDS
Postnatal
6. Early postnatal glucocorticoids@
7. ? Indocid
* Maternal factors in extremely low birth weight infants who develop spontaneous intestinal perforation.
Ragouilliaux CJ; Keeney SE; Hawkins HK; Rowen JL Pediatrics 2007.
@Focal small bowel perforation: an adverse effect of early postnatal dexamethasone therapy in extremely low birthweight infants.
Gordon PV; Young ML; Marshall DD J Perinatol. 2001 Apr-May;21(3)
New insights into spontaneous intestinal perforation using a national data set
Attridge JT; Clark R; Gordon PV J Perinatol. 2006 Nov;26(11):667-70. Epub 2006 Oct 5.
5. Pathology and pathogenesis
Single isolated perforation
Typically in terminal iluem, but also reported
in jejunum, colon
Focal hemorrhagic necrosis with well defined
margins seen(in contrast to ischemic,
coagulative necrosis in NEC)
Bowel proximal and distal to perforation
normal
6. Clinical presentation
SIP NEC
First week of life, median age After first week,
7(0-15) Median age 15
Abdominal distension, bluish Abdominal distension
discoloration(groin, scrotum) Abdominal erythema
Hypotension Crepitus, induration
Pneumoperitoneum, gasless Pneumatosis intestinalis, portal
abdomen venous gas, transient thickening of
intestinal wall, fixed dilated SB
loops, pneumoperitoneum
Associated sepsis due to CONS,
fungemia
Leukocytosis, raised ALP,
bilirubin, decreased platelet, hct
7. Clinical diagnosis based upon:
Clinical presentation
Physical examination
Abdominal radiographs support diagnosis
Definitive diagnosis :
Direct visualization of intestinal perforation in setting of
otherwise healthy appearing small bowel
10. Primary peritoneal drainage
Avoids laparotomy, need for GA and transport
Many do recover without any further surgical
intervention
Laparotomy indicated if:
4. Reaccumulation of free air after drain removed,
indicating perforated bowel did not seal
5. Fistula with intestinal drainage that fails to close
6. Bowel obstruction secondary to adhesions or
stricture at site of perforation
11. Long term outcome
Survival rates of 64-90%
Neurodevelopmental outcome better than those with
NEC*
Increased risk to develop ROP and PVL compared
to controls
*Intestinal perforation in very low birth weight infants: growth and neurodevelopment at 1 year of age.
Adesanya OA; O'Shea TM; Turner CS; Amoroso RM; Morgan TM; Aschner JL J Perinatol. 2005 Sep;25(9):583-9.
12. NEC
Ischaemic necrosis of intestinal mucosa,
associated with inflammation, invasion of
enteric gas forming organisms and dissection
of gas into muscularis and portal venous
system.
13. NEC
1-3 per 1000 live births
Predominently in prems, up to 6-7% in VLBW
Incidence decreases with increasing GA, BW
Males and females equally affected
Sometimes occurs in clusters, associated with
epidermics
Reported mortality of 15-30%
13% occur in term infants
14. Pathogenesis
Terminal ileum and colon
Entire GIT in severe cases
Pathogenesis remains unknown
Heterogeneous disease
results from multiple factors that result in mucosal injury in
susceptible host
6. Prematurity
7. Microbial bowel overgrowth
8. Milk feeding
9. Impaired mucosal defense
10. Circulatory instability of intestinal tract
11. Medications
12. CHD, perinatal asphyxia, polycythemia, sepsis, respiratory
disease
13. Inflammation
15.
16. Clinical presentation
Timing of onset of symptoms varies, inversely
related to GA
Systemic signs
3. Nonspecific (apnea, resp failure, lethargy, poor
feeding, temp instability)
4. Hypotension
Abdominal signs
- distension, gastric retention, tenderness, vomiting,
diarrhoea, rectal bleeding, bilious aspirates
17. Bells staging
Classifies severity of NEC based on severity
of systemic, intestinal, radiographic findings
Treatment directed at clinical signs rather
than particular stage of NEC
28. Management
Depends on severity of illness
Medical management
Surgical management
29. Medical management
Supportive care-NBM, drip and suck, TPN,
fluid replacement, correction of hematological
and metabolic abnormalities,
cardiorespiratory support
Antibiotic therapy
Close monitering and radiologic
monitering(6-8 hrly)
30. Surgical intervention
Perforation/severe peritonitis
unremitting clinical deterioration despite
medical management suggesting extensive
necrosis
presence of abdo mass, ascites or intestinal
obstruction
Primary peritoneal drainage
Laparotomy with bowel excision
32. Clinical presentation
SIP NEC
First week of life, median age 7(0-15) After first week,
Median age 15
Abdominal distension, bluish Abdominal distension
discoloration (groin, scrotum) Abdominal erythema
Hypotension Crepitus, induration
Pneumoperitoneum, gasless abdomen Pneumatosis intestinalis, portal venous
gas, transient thickening of intestinal
wall, fixed dilated SB loops,
pneumoperitoneum
Associated sepsis due to CONS, Concomitant bacteremia
fungemia
Leukocytosis, raised ALP, bilirubin, Thrombocytopenia,neutropenia, hypoNa,
decreased platelet, hct hyperglycaemia, metabolic acidosis
Editor's Notes
J Am Coll Surg. 2002 Dec;195(6):796-803. Spontaneous localized intestinal perforation in very-low-birth-weight infants: a distinct clinical entity different from necrotizing enterocolitis. Pumberger W , Mayr M , Kohlhauser C , Weninger M . Division of Pediatric Surgery, Department of Surgery, University of Vienna, Vienna, Austria. Abstract BACKGROUND: Idiopathic spontaneous intestinal perforation (SIP), a distinct clinical entity different from necrotizing enterocolitis (NEC), has an increasing prevalence in very-low-birth-weight infants. The aims of our study were to define patient characteristics and potential risk factors for premature infants with SIP compared with infants subjected to surgical treatment for NEC. STUDY DESIGN: The medical records of 29 premature infants with either SIP (n = 13) or NEC (n = 16) were reviewed retrospectively. RESULTS: Infants who experienced SIP were smaller at birth, had lower Apgar scores, and required more intensive neonatal resuscitation. An increased rate of premature rupture of membranes in infants with SIP (8/13 versus 6/16) was not associated with a higher rate of infection in mothers or infants. The onset of illness in SIP was significantly earlier than in NEC (p = 0.022). In contrast to patients with NEC (7/16), 11 of 13 patients in the SIP group had received indomethacin (p = 0.02). Bluish discoloration of the abdomen (8/13), a gasless abdomen (8/13), and the absence of pneumatosis intestinalis (0/13) were further significant markers in infants with SIP. At operation, SIP was always located in the terminal ileum in an antimesenteric position (13/13), and the remaining bowel appeared grossly normal. In most cases of SIP (10/13), the histologic investigation revealed an area of hemorrhagic necrosis without the typical coagulation necrosis seen predominantly in NEC. CONCLUSIONS: Based on clinical presentation and radiologic and intraoperative findings, SIP is a distinct pathologic entity in very-low-birth-weight infants and can be differentiated from classic NEC. Detected early, SIP can be treated by simple procedures (sutures, or resection and primary anastomosis) with a low rate of morbidity and mortality.
Focal small bowel perforation: an adverse effect of early postnatal dexamethasone therapy in extremely low birth weight infants. Gordon PV; Young ML; Marshall DD J Perinatol. 2001 Apr-May;21(3): OBJECTIVE: We tested the hypothesis that early postnatal dexamethasone (EPD) increases the risk of focal small bowel perforation (FSBP) in extremely low birth weight (ELBW) infants. STUDY DESIGN: The techniques of meta-analysis were applied to studies evaluating EPD, which we identified through a systematic literature search. Studies were included if they were randomized, placebo-controlled trials of EPD, enrolled infants with birth weights<or =1000 g, and reported FSBP as an outcome variable. The Breslow-Day test was used to assess for homogeneity and a summary odds ratio was calculated using the Mantel-Haenszel exact method. RESULTS: Four studies, with a pooled sample of 1383 infants, were included in the primary analysis. The Breslow-Day test showed a p-value of 0.61, indicating homogeneity among the studies. FSBP was significantly higher in EPD treated infants [odds ratio 1.91, 95% confidence interval (CI) 1.21, 3.07; p=0.004]. CONCLUSION: EPD increases the risk of FSBP in ELBW infants. New insights into spontaneous intestinal perforation using a national data set Attridge JT; Clark R; Gordon PV J Perinatol. 2006 Nov;26(11):667-70. Epub 2006 Oct 5. OBJECTIVE: To examine whether antenatal steroids (ANS), alone or with early indomethacin, are associated with spontaneous intestinal perforation (SIP). SIP is a known complication of concurrent post-natal administration of glucocorticoid and indomethacin in extremely low birth weight (ELBW) infants. STUDY DESIGN: A large de-identified national data set was retrospectively examined for infants with SIP without any report of other malformation or necrotizing entrocolitis. A control group was then derived matching for gender and birth weight (+/- 20 g). Pre- and post-natal variables were tested by both univariate and multivariate analysis to identify associations with SIP. RESULTS: From January 1996 to June 2004, there were 2 27 711 discharges from Pediatrix neonatal intensive care unit sites. From this population 388 infants with SIP associated with ELBW were compared to matched controls. Infants with SIP were more likely to have received early indomethacin and to have received a combination of early indomethacin with post-natal glucocorticoids (P<0.05 for both). When used alone (without subsequent indomethacin), ANS showed no association with SIP. When used in conjunction with indomethacin, ANS did not increase the rate of SIP beyond indomethacin alone. CONCLUSION: ELBW Infants that acquire SIP were more likely to have been exposed to early indomethacin and post-natal glucocorticoids. However, no association was found between SIP and ANS within a well-powered cohort. Spontaneous intestinal perforation (SIP) has emerged as a disease of extremely low-birth-weight (ELBW) infants over the last two decades. Several risk factors have been associated with this disease including early postnatal steroids (EPS; use within the first week of life), early use of indomethacin (EUI; use within the first 3 postnatal days), and the synergistic combination of the two. These two risk factors are thought to play a causal role in the etiology of SIP through their effects on ileal trophism and motility. Two infectious agents ( Candida and Staphylococcus epidermidis) are commonly grown from peritoneal cultures of patients with SIP. It is less clear whether these infections play a causal role or if they represent comorbidities of perforation. Chorioamnionitis is thought to be a risk factor for SIP, as is the stress and elevated cortisol that accompanies it. Recent analyses suggest that antenatal indomethacin may also be a risk factor for SIP, particularly when given close to birth. These latter variables are more challenging to rank in importance compared with EPS and EUI, which have been repeatedly associated with SIP in both retrospective cohorts and randomized controlled trials. Because neonatal care of the ELBW infant is commonly standardized, the habitual combination of any of these risk factors potentially amplifies the risk of SIP. Many of these factors are medicines, thus SIP risk is exacerbated by select forms of polypharmacy. Our challenge lies in understanding how these drug interactions lead to harm.
Infants who experienced SIP were smaller at birth, had lower Apgar scores, and required more intensive neonatal resuscitation. An increased rate of premature rupture of membranes in infants with SIP (8/13 versus 6/16) was not associated with a higher rate of infection in mothers or infants. The onset of illness in SIP was significantly earlier than in NEC (p = 0.022). In contrast to patients with NEC (7/16), 11 of 13 patients in the SIP group had received indomethacin (p = 0.02). Bluish discoloration of the abdomen (8/13), a gasless abdomen (8/13), and the absence of pneumatosis intestinalis (0/13) were further significant markers in infants with SIP. At operation, SIP was always located in the terminal ileum in an antimesenteric position (13/13), and the remaining bowel appeared grossly normal. In most cases of SIP (10/13), the histologic investigation revealed an area of hemorrhagic necrosis without the typical coagulation necrosis seen predominantly in NEC. CONCLUSIONS: Based on clinical presentation and radiologic and intraoperative findings, SIP is a distinct pathologic entity in very-low-birth-weight infants and can be differentiated from classic NEC. Detected early, SIP can be treated by simple procedures (sutures, or resection and primary anastomosis) with a low rate of morbidity and mortality.
Two infectious agents ( Candida and Staphylococcus epidermidis) are commonly grown from peritoneal cultures of patients with SIP. It is less clear whether these infections play a causal role or if they represent comorbidities of perforation.
The role of laparotomy for intestinal perforation in very low birth weight infants. AU Baird R; Puligandla PS; St Vil D; Dube S; Laberge JM SO J Pediatr Surg. 2006 Sep;41(9):1522-5. BACKGROUND/PURPOSE: The management of intestinal perforation in very low birth weight (VLBW) infants (less than 1500 g) is controversial. Current practice favors peritoneal drainage (PD) with or without a delayed laparotomy over primary laparotomy (PL). We compared the outcomes of PD +/- delayed laparotomy vs PL in VLBW infants using the Score for Neonatal Acute Physiology with Perinatal Extension (SNAPPE-II) as a validated predictor of mortality. METHODS: A retrospective analysis (1998-2003) of VLBW infants with intestinal perforation at 2 pediatric centers was undertaken. Data retrieval included neonatal demographics and parameters for SNAPPE-II calculation. The primary end point was 30-day mortality. Other outcome measures included in-hospital mortality, days fasting, days to extubation, and length of stay. Statistical analysis was performed with either Student's t test or chi2 analysis. Subgroup and multivariate analyses were also performed. P values<.05 were considered significant. RESULTS: Fifty-two neonates (25 PD, 27 PL) were reviewed. Overall, 10 (19.2%) infants died. Observed 30-day mortality rates in PD and PL groups were 32% and 7.4% (P = .028), respectively. Average SNAPPE-II scores for PD (42.5 +/- 20.8) and PL (25.1 +/- 14.6) groups yielded predicted mortality rates of 15.7% and 4.9% (P = .001), respectively. PD group 30-day mortality far exceeded the rate predicted by the SNAPPE-II score. Days fasting (13.7 vs 20.4; P = .0001), days to extubation (26.7 vs 51.5; P = .014), and length of stay (56.1 vs 83.6; P = .031) all favored the PL group despite incorporating SNAPPE-II score as a covariate into the multivariate analysis. Of the 25 patients receiving drainage, 9 underwent PD alone (SNAPPE-II = 46.6 +/- 27.9), whereas 16 patients underwent delayed laparotomy (SNAPPE-II = 37.8 +/- 17.6). The PD-only group had a greatly elevated mortality rate (77.8% vs 15.7% predicted), whereas the delayed laparotomy group had a reduced mortality rate (6.3% vs 9.3% predicted). CONCLUSION: Our data suggest that laparotomy, either alone or after PD, provides an improved outcome in VLBW infants with intestinal perforation. PD should be used as a temporizing measure until laparotomy can be performed. No RCT comparing two interventions in infants with SIP
Intestinal perforation in very low birth weight infants: growth and neurodevelopment at 1 year of age. Adesanya OA; O'Shea TM; Turner CS; Amoroso RM; Morgan TM; Aschner JL J Perinatol. 2005 Sep;25(9):583-9. OBJECTIVE: To compare growth and neurodevelopment in surviving very low birth weight (VLBW) infants with an intestinal perforation (IP) caused by necrotizing enterocolitis (NEC) versus spontaneous intestinal perforation (SIP). STUDY DESIGN: Retrospective, observational cohort study. Infants born between January 1996 and December 1999 with birth weight<1500 g and a diagnosis of intestinal perforation were identified and data extracted from NICU, surgical and hospital databases. RESULTS: IP was identified in 62 of 1357 VLBW infants (5%); 39 infants (63%) had surgical NEC and 23 (37%) had SIP. Among survivors, 21/28 with surgical NEC (75%) and 13/18 with SIP (72%) returned for follow-up. At 1-year adjusted age, there were no differences in growth parameters but the Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) were lower in survivors with NEC versus SIP (mean difference in MDI=15; 95% confidence limits=3, 28; p=0.02; mean difference in PDI=14; 95% confidence limits=0.4, 28; p=0.04 ). CONCLUSIONS: Intestinal perforation caused by NEC, as compared to SIP, is associated with worse neurodevelopmental outcome at 1 year. Discharge outcomes of extremely low birth weight infants with spontaneous intestinal perforations. Attridge JT; Herman AC; Gurka MJ; Griffin MP; McGahren ED; Gordon PV J Perinatol. 2006 Jan 1;26(1):49-54. OBJECTIVE: To examine discharge outcomes of extremely low birth weight infants (ELBW) with spontaneous intestinal perforation (SIP). STUDY DESIGN: A single-center retrospective cohort study of all ELBW infants admitted to the University of Virginia neonatal intensive care unit between July 1996 and June 2004. RESULTS: We found 35 patients with SIP (incidence 8.4%). The median gestational age was 25 weeks, median birth weight was 722 g, and 71% of the infants were male. Most infants (n=28) with SIP were diagnosed secondary to pneumoperitoneum; however, one-third (7) of infants<25 weeks had occult presentations without pneumoperitoneum. When controlled for gestational age, gender, multiple gestation, indomethacin, and glucocorticoid exposure, infants with SIP have a higher risk of PVL and death than infants without perforation . SUMMARY: Periventricular leukomalacia and death are significantly associated with SIP in ELBW after adjusting for gestational age, multiple gestation, indomethacin, and glucocorticoid exposure.
Journal of Surgical Research Volume 161, Issue 1 , 1 June 2010, Pages 95-100 Peritoneal Drainage versus Laparotomy for Necrotizing Enterocolitis and Intestinal Perforation: A Meta-Analysis Background To determine whether peritoneal drain (PD) or laparotomy (LAP) is the most effective intervention in premature neonates with necrotizing enterocolitis (NEC) or intestinal perforation (IP). Methods A systematic review of the published literature between January 2000 and December 2008 was undertaken. Prospective studies with at least 25 patients in each of the PD and LAP arms were selected. Gestational age, birth weight, operation, and mortality data were extracted. Results Five prospective studies (two level I, three level II) with 523 (273 PD, 250 LAP) participants followed for mortality met selection criteria. Using a fixed effect model, the combined estimate indicates an increased mortality of 55% with PD (OR 1.55, 95% CI: 1.08–2.22, P = 0.02) without statistical heterogeneity (χ2 = 5.88, P = 0.21). PD patients were 0.78 wk younger ( P = 0.0002) and 67g smaller ( P = 0.0006). Analysis of the three level II trials yielded a combined estimate indicating an excess mortality of 89% with PD patients (95% CI: 1.20–2.98, P = 0.006) without statistical heterogeneity (χ2 = 3.74, P = 0.15). Conclusions PD is associated with 55% excess mortality compared with LAP. Pediatric surgeons must individually assess and select patients with NEC and IP for optimal surgical therapy.