Diagnosis and Management of Necrotizing Enterocolitis: An International Survey of Neonatologists and Pediatric Surgeons.

BACKGROUND: Necrotizing enterocolitis (NEC) is a serious complication of prematurity. Currently, there is limited evidence to guide investigation and treatment strategies. OBJECTIVES: To evaluate the parameters used to diagnose or exclude NEC, and to identify differences between neonatologists and pediatric surgeons. METHODS: A scenario-based survey was sent to neonatologists and pediatric surgeons. RESULTS: 173 physicians from 26 countries completed the survey (55% neonatologists and 45% pediatric surgeons). Bloody stools, abdominal tenderness, low platelet counts, and increased lactate levels increased the likelihood of NEC for 82, 72, 56, and 45% of respondents, respectively. Intestinal pneumatosis, portal venous gas, and pneumoperitoneum on X-ray increased the likelihood of NEC for 99, 98, and 92% of respondents, respectively. Clinical examination and laboratory tests were insufficient to exclude NEC, but normal intestinal movements and normal gut wall thickness on ultrasonography decreased the likelihood of NEC for 38 and 33% of respondents, respectively. Neonatologists more frequently relied on increased gastric residuals and abdominal distension to diagnose NEC (p = 0.04 and p = 0.03, respectively), whereas pediatric surgeons more frequently reported that absence of bloody stools helped to exclude NEC (p = 0.04). In a deteriorating patient with suspected NEC, 39% of respondents would broaden the antibiotic spectrum, and 42% would recommend a laparotomy. CONCLUSION: Our results indicate a wide variation in the management of NEC, with significant differences between neonatologists and pediatric surgeons. A better appreciation of the relative significance and weighting that should be applied to the clinical features and investigations should reduce the variation in interpretation that appears to exist.

Are Scores Reliable in Predicting the Need for Surgery and Mortality in Necrotizing Enterocolitis?

Background Management of children with necrotizing enterocolitis (NEC) remains challenging. Various scores try to facilitate therapeutic decision-making. We aim to assess the agreement of three scores intending to predict the need for surgery and/or mortality in our patient cohort, and analyze agreement between the different scores. Methods This study is a retrospective analysis of patients with NEC Bell's stage II and III, managed in a single institution (1991-2011). Three existing scores (Metabolic Derangement Acuity score, NEC score, Detroit score) were calculated individually for each patient. The agreement between predicted outcome by scores and real outcome was evaluated with kappa statistic. Results Of 57 children, 46% presented with NEC stage II, 54% with stage III, 46% were treated with surgery, 54% conservatively, and survival was 58%. The kappa indexes for "need for surgery" were 0.41, 0.13, and 0.12 and kappa indexes for "mortality" were 0.27, 0.04, and 0.1 for the Metabolic Derangement Acuity score, the NEC score, and the Detroit score, respectively. Conclusion In our cohort, the agreement between the predicted outcomes by scores and the real need for surgery and/or mortality was poor. There was a lack of clinical usefulness of the tested scores. We must continue to better identify parameters to help guide the management of these patients.

Ketosis After Cardiopulmonary Bypass in Children Is Associated With an Inadequate Balance Between Oxygen Transport and Consumption.

OBJECTIVES: Hyperglycemia after cardiac surgery and cardiopulmonary bypass in children has been associated with worse outcome; however, causality has never been proven. Furthermore, the benefit of tight glycemic control is inconsistent. The purpose of this study was to describe the metabolic constellation of children before, during, and after cardiopulmonary bypass, in order to identify a subset of patients that might benefit from insulin treatment. DESIGN: Prospective observational study, in which insulin treatment was initiated when postoperative blood glucose levels were more than 12 mmol/L (216 mg/dL). SETTING: Tertiary PICU. PATIENTS: Ninety-six patients 6 months to 16 years old undergoing cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Metabolic tests were performed before anesthesia, at the end of cardiopulmonary bypass, at PICU admission, and 4 and 12 hours after PICU admission, as well as 4 hours after initiation of insulin treatment. Ketosis was present in 17.9% patients at the end of cardiopulmonary bypass and in 31.2% at PICU admission. Young age was an independent risk factor for this condition. Ketosis at PICU admission was an independent risk factor for an increased difference between arterial and venous oxygen saturation. Four hours after admission (p = 0.05). Insulin corrected ketosis within 4 hours. CONCLUSIONS: In this study, we found a high prevalence of ketosis at PICU admission, especially in young children. This was independently associated with an imbalance between oxygen transport and consumption and was corrected by insulin. These results set the basis for future randomized controlled trials, to test whether this subgroup of patients might benefit from increased glucose intake and insulin during surgery to avoid ketosis, as improving oxygen transport and consumption might improve patient outcome.

Plasma in the PICU: why and when should we transfuse?

Whereas red blood cell transfusions have been used since the 19th century, plasma has only been available since 1941. It was originally mainly used as volume replacement, mostly during World War II and the Korean War. Over the years, its indication has shifted to correct coagulation factors deficiencies or to prevent bleeding. Currently, it remains a frequent treatment in the intensive care unit, both for critically ill adults and children. However, observational studies have shown that plasma transfusion fail to correct mildly abnormal coagulation tests. Furthermore, recent epidemiological studies have shown that plasma transfusions are associated with an increased morbidity and mortality in critically ill patients. Therefore, plasma, as any other treatment, has to be used when the benefits outweigh the risks. Based on observational data, most experts suggest limiting its use either to massively bleeding patients or bleeding patients who have documented abnormal coagulation tests, and refraining for transfusing plasma to nonbleeding patients whatever their coagulation tests. In this paper, we will review current evidence on plasma transfusions and discuss its indications.

Insufficiency fracture of the calcaneum: Sonographic findings.

We present a case of insufficiency fracture (IF) of the calcaneum diagnosed by sonography (US). An 83-year-old woman consulted because of pain and swelling of the left heel without history of trauma. Standard radiographs showed osteoporosis without fracture. US revealed thickening of the calcaneal periosteum associated with edema of the adjacent soft tissues. Color Doppler imaging showed marked increased vascularity of the periosteum. US changes, together with the clinical and radiographic findings, were consistent with an IF of the calcaneum that was confirmed by MRI. The patient was treated successfully by conservative treatment. In the proper clinical setting, US can suggest the diagnosis of IF of the calcaneum.