The hidden mortality in surgically treated necrotizing enterocolitis: fungal sepsis.

From 1979 to 1986, 82 infants underwent surgical treatment for necrotizing enterocolitis (NEC), with 36 deaths. The records of 30 of the 36 infants who died were available for review. Fungal colonization and sepsis, the sites of infection, and timing of diagnosis and therapy were determined. Sixteen of 30 (53%) neonates had no evidence of fungus. Six (20%) were colonized with Candida species. Eight (27%) had fungal sepsis, with two of these eight found only at necropsy. Positive fungal blood cultures were a late finding. In only four of the six patients with positive blood cultures were the results known in time to initiate treatment with amphotericin B. Two of these four babies received less than 2 days of amphotericin B treatment prior to death. Fungal sepsis is a significant lethal factor in the surgical mortality of NEC. Vigorous efforts at earlier diagnosis are mandatory.

Breath hydrogen excretion in the premature neonate.

We measured breath hydrogen excretion in 103 neonates from birth to as late as 2 months of age. The patients weighed less than 2000 g at birth and were part of a study of hydrogen excretion as a screening test for necrotizing enterocolitis. Hydrogen excretion in parts per million was normalized for the quality of the expired air by dividing by the Pco2 of the gas sample The rise in the H2/CO2 ratio was influenced by gestational age, energy intake, and antibiotic usage but not by the daily frequency of feeding. The mean +/- SD peak H2/CO2 ratio was 5.1 +/- 3.6 ppm per millimeter of mercury and occurred at 16.0 +/- 11.0 days of age. The age at which the peak H2/CO2 occurred varied with gestational age. Patients born between 23 and 28 weeks gestational age (n = 34) were 22.9 +/- 13.1 days of age when they experienced their peak H2/CO2 ratio, whereas those born between 29 and 34 weeks gestational age (n = 62) were 12.2 +/- 7.5 days of age. The age at which the peak H2/CO2 ratio occurred did not differ between these two groups when corrected for the age at which oral intake exceeded 420 kJ/kg per day. These results suggest that premature neonates require experience with ingesting more than 420 kJ/kg per day before bacteria and carbohydrates are present in large enough quantities to permit measurable hydrogen production. This information will be useful in future studies of premature gut development and physiology and in studying pathologic processes in which malabsorption may play a role.

Breath hydrogen excretion as a screening test for the early diagnosis of necrotizing enterocolitis.

We measured breath H2 excretion in 122 neonates from birth to 1 month of age. The patients weighed less than 2000 g at birth and thus were at risk for developing necrotizing enterocolitis (NEC). Hydrogen excretion was normalized for the quality of the expired air by dividing by the carbon dioxide pressure of the gas sample. The mean (+/- SD) peak H2/CO2 ratio was significantly different between the seven patients who subsequently developed NEC (9.4 +/- 2.7 ppm/mm Hg) and the 115 patients who did not (5.0 +/- 3.5 ppm/mm Hg). The prevalence of NEC was 5.7% in the present study. Defining a positive test as one with a ratio value of greater than or equal to 8.0 ppm/mm Hg, the resulting screening test had a sensitivity of 86% and a specificity of 90%. The screening test yielded a 33% predictive value of a positive test and a 99% predictive value of a negative test. High H2 excretion occurred eight to 28 hours before the earliest clinical signs of NEC. Breath H2 excretion is a simple noninvasive test that may be useful in the management of the premature neonate at risk for the development of NEC.

Inappropriate fluid response in congenital diaphragmatic hernia: first report of a frequent occurrence.

Safe management of the newborn infant with congenital diaphragmatic hernia (CDH) requires precise fluid administration to avoid hypovolemia or fluid overload. Twenty-two CDH patients and 12 infants who underwent abdominal operations were studied for three postoperative days to determine whether the postoperative neonatal renal response to fluid administration was appropriate or inappropriate. Each response was categorized, on the basis of urine and blood measurements, as: (1) appropriate urine output and concentration, (2) inappropriate urine output and concentration with fluid retention or (3) renal failure. Fluid intake was similar in all groups. The CDH group had a significantly lower urine output, higher urine osmolarity, and lower serum osmolarity. All of the control group (100%) responded appropriately to intake. Sixty-four percent of the CDH group inappropriately retained water during the first 16 hours (appropriate, 27%; renal failure, 9%). By 24 hours, 34% still had inappropriate urine output and fluid retention. The majority of patients with CDH initially responded inappropriately to postoperative fluid intake. If this response is not recognized and fluid intake is not adjusted, serious fluid overload will result.

Peritoneal drainage for necrotizing enterocolitis.

This study evaluates the role of primary peritoneal drainage (PPD) in the management of neonatal necrotizing enterocolitis (NEC). Of 169 patients with definite NEC, 92 (55%) underwent operation: primary laparotomy, 41 patients (45%); and PPD, 51 patients (55%). Seventeen (33%) of the PPD infants had subsequent laparotomy within seven days. Pneumoperitoneum was the indication for operation in 37% of the primary laparotomy and 67% of the PPD infants. Following PPD, 34 patients (67%) showed clinical improvement. Operative survivals were as follows: primary laparotomy, 83%; PPD, 53%. Infants who had PPD had a significantly lower mean birth weight, gestational age, preoperative pH and platelet count, and a significantly higher incidence of intraventricular hemorrhage and patent ductus arteriosus. For infants weighing less than 1,000 g at birth, the survival was similar following primary laparotomy (57%) and PPD (52%); this occurred in spite of the higher incidence of adverse risk factors in the PPD infants. For infants weighing greater than 1,000 g, the survival was 86% following primary laparotomy and 62% after PPD; in this group, all the early deaths following PPD occurred in critically ill infants who died within 48 hours of drainage. The late survival rates were as follows: primary laparotomy, 76%; PPD, 35%. More than half of the late deaths following PPD were not related to NEC, reflecting the difference between the two patient populations. Primary peritoneal drainage is a useful adjunct to resuscitation of the critically ill infant with complicated NEC, particularly prematures less than 1,000 g birth weight with intestinal perforation. Primary peritoneal drainage is not an alternative to laparotomy, which is recommended when an optimal clinical response has been achieved.