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A CASE SERIES OF EXTREMELY PREMATURE NEONATES WITH SUSPECTED NECROTISING ENTEROCOLITIS:  CHARACTERISTICS OF ANAESTHESIA AND OUTCOMES IN NEONATAL LAPAROTOMY

R. Anandanadesan¹, A. Selman², B. Blaise²

¹Barts Health NHS Trust, London, UK

²Evelina London Children's Hospital, London, UK

Background:

Extremely preterm neonates are prone to developing intestinal complications as necrotising enterocolitis (NEC), which is associated with significant morbidity and mortality.1,2 However, there is a lack of literature looking at the perioperative management and outcomes in these patients.  We undertook a case series that looked at pre-term neonates who had an emergency laparotomy for suspected NEC.  The objectives of this study were to describe the characteristics of this population, risk factors, types of anaesthesia and support received by these neonates intraoperatively, and to look at postoperative outcomes.

Methods:

We performed a retrospective case review of all neonates born at <24 weeks gestation who had emergency laparotomy for suspected necrotising enterocolitis between January 2015-December 2021 in a single tertiary centre.   We looked at information regarding patient demographics, indications for laparotomy, operative location and intraoperative support received.  Outcomes investigated included:  survival rates at discharge from NICU and at 1-year, post-operative complications, and functional status at >15 months.

Results:

A total of 18 neonates were identified who had emergency laparotomy for suspected NEC.  Median gestation age was 23 weeks and the median birth weight was 577.5 grams (range 450 grams-790 grams).  Forty percent of patients had >3 co-morbidities, the most common included intraventricular haemorrhage and patent ductus arteriosus.  All patients developed respiratory failure requiring ventilatory support, with 50% progressing to chronic respiratory failure.

The most common indication for laparotomy was NEC (94%).  There was one case of spontaneous intestinal perforation.  In 67% of patients, surgery was performed in theatres.  Of those who had surgery on the NICU, 67% were on high frequency oscillatory ventilation.  Intraoperatively, 61% of neonates were on pressure control ventilation.  Fifty percent of patients were anaesthetised with an intravenous morphine infusion.  Other combinations were sevoflurane or a combination of morphine infusion and sevoflurane. All neonates received paralysing agents.  Sixty-one percent of patients required at least 1 vasopressor or inotrope intraoperatively, with 28% requiring multiple vasopressors/inotropes.

Perioperative complications occurred in 72% of neonates, the most common being bleeding (33%).  Forty-four percent of patients required a repeat laparotomy.

Overall, 50% of patients were discharged home from NICU, and 44% were alive at 1 year.    Of the neonates operated in the NICU, 33% survived to NICU discharge and were alive at 1 year compared with 58% of those operated in theatre.  Of those neonates who remained alive after 1 year, 50% were meeting developmental milestones.

Conclusion:  

This case series shows that emergency laparotomy can be successfully performed in extremely pre-term neonates in theatres and on the NICU, with overall survival of 44% at 1 year.  However, mortality rates are higher in those operated on NICU, and these children tend to be sicker and require a greater degree of organ support.

References:

1. Durell J, Hall NJ, Drewett M, Paramanantham K, Burge D. Emergency laparotomy in infants born at <26 weeks gestation: a neonatal network-based cohort study of frequency, surgical pathology and outcomes. Arch Dis Child Fetal Neonatal Ed. 2017 Nov;102(6):F504-F507. doi: 10.1136/archdischild-2016-312195. Epub 2017 May 3. PMID: 28468896.
2. Wright NJ, Thyoka M, Kiely EM, Pierro A, De Coppi P, Cross KM, Drake DD, Peters MJ, Curry JI. The outcome of critically ill neonates undergoing laparotomy for necrotising enterocolitis in the neonatal intensive care unit: a 10-year review. J Pediatr Surg. 2014 Aug;49(8):1210-4. doi: 10.1016/j.jpedsurg.2014.01.052. Epub 2014 Feb 10. PMID: 25092078.