Necrotizing Enterocolitis Laparotomy (Neonatal)
Patient phenotype
Premature neonate (24-32 weeks gestation), VLBW (< 1500 g), in NICU. Septic, acidotic, coagulopathic. Often intubated already with chronic lung disease. Highest-acuity pediatric anesthetic.
Procedure
Open laparotomy: identify dead bowel, resect, primary anastomosis vs. ostomy creation, abdominal washout, may leave open. ~60-180 min. Bedside in NICU sometimes vs. OR transport.
Anesthetic plan
Continue ventilator/sedation already running. Add fentanyl + NMB for surgical conditions. Aggressive volume + blood resuscitation. Vasopressors. Calcium replacement. ICU intubated post-op (ALWAYS).
Setup
- ·Pediatric monitors + temp + Foley (if not already)
- ·Existing NICU lines (UVC, UAC, PICC) used + augmented if needed
- ·Two PIVs (small gauge — 24g acceptable)
- ·Type O blood ready (not always type-specific time)
- ·Calcium gluconate (not chloride in neonate — PIV)
- ·Dopamine + epi + bicarb drawn at neonatal concentrations
- ·Servocontrolled radiant warmer + warm fluids + fluid warmer
- ·Anesthesia machine pediatric circuit + smallest tubing
Biggest concerns by phase
Resuscitate first — acidosis + sepsis + coagulopathy
Pre-op: 10-20 mL/kg crystalloid bolus, blood if Hb low, FFP for coagulopathy, calcium for ionized hypocalcemia, pressors started. Don't take to OR if shocked + uncorrected. Surgical urgency vs. resuscitation balance.
Drug doses + NMB choice in neonate
Fentanyl 1-2 mcg/kg + rocuronium 0.6-1 mg/kg + glycopyrrolate 0.01 mg/kg. Avoid sux in neonate routinely (no significant indication). Volatile usually too dropping (BP) — use propofol 1-2 mg/kg if needed for additional depth.
Hypothermia — neonates don't thermoregulate
Critical in neonate. Servocontrolled warmer overhead, warm room, warm fluids, plastic wrap on extremities, cap on head. Hypothermia in neonate → coagulopathy + acidosis + cardiac depression worsens dramatically.
Glucose monitoring — infants depend on glucose
Check glucose q30 min. Run D10 0.1-0.2 mL/kg/hr (or D5 + electrolytes per NICU protocol). Hypoglycemia → seizures + brain injury. Hyperglycemia → osmotic diuresis + worsened outcome.
Massive transfusion + 1:1:1 + calcium
Lose any blood = significant percentage of TBV. Transfuse 10 mL/kg PRBC for any sustained loss. FFP + platelets in 1:1:1 if bleeding. Calcium 30 mg/kg gluconate (PIV-safe) per 10 mL/kg blood.
Direct to NICU intubated — never extubate
Acidotic, septic, fluid-overloaded neonate stays intubated. Hand off to NICU with detailed report. Watch for: ongoing bleeding, abdominal compartment syndrome, ostomy output, electrolytes.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
28-week premature, day 12 of life, weighs 950g. Found with pneumatosis on KUB + lactate 6 + falling BP. NICU has resuscitated with 20 mL/kg NS + pressor, BP now 50/30 on dopamine 10. They want surgery now. What's your plan?
What an examiner probes for
- ▹Continue resuscitation, blood + calcium ready
- ▹Transport to OR carefully (don't extubate, maintain pressors)
- ▹Drug doses: micro-doses, fentanyl 1 mcg/kg, roc 0.6 mg/kg
- ▹Plan for likely massive transfusion + ICU return intubated
- ▹Communicate with NICU + surgical team about realistic outcome
Sources
- Coté Pediatric Anesthesia 7e (NICU chapter)
- ACS NSQIP Pediatric
Anatomy reference
Sourced reference images. 4 matches for "abdomen bowel intestine neonatal".
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