14 days old born at 27 week with birth weight 840 gms was on enteral feeds. Suddenly noted to have abdominal diatension platelets 32000 but no ither iasues. 

Any suggestions about xray. 

Although the photo is a bit low-pixelated, it looks like rather extensive intramural gas, i.e. NEC.

Suggest stopping feeds, TPN and antibiotics. Follow the clinical course and consult your ped surgeon.

Some input from Twitter:

 

 

On 8/31/2019 at 3:45 AM, Stefan Johansson said:

and consult your ped surgeon.

I've come late to the conversation after being on vacation and of course the dx of pneumatosis is not in question.

I am, however, interested in the recommendation for surgical consultation: What is everyone's threshold for consulting surgery in NEC?  Frankly, if I did not need to worry about my relationship with the surgeons more generally, I would only call them if I thought ex-lap or a drain made sense.  This was the practice at the last in-born ICU I worked in whereas as the outborn unit I last worked in every child with NEC got a surgical consult.  The difficulty with this was that the surgeons would then insist on driving the decisions on abx and NPO

@bimalc good point about as to whether a surgeon would be consulted. We always discuss those cases with the surgeons, they want to keep updated and don't like to be surprised if there is a deterioration (and we really need them...) In my experience, those we work with are not liberal with interventions, so consultations do not "complicate" the management. But I suppose this may well be a possibility that more surgical consultations also "drive" the rate of surgical interventions.

Would be great from other members about this!

I can appreciate Dilated bowel loops no portal vein gas no pneumatosis 

any Gastric Residual, vomiting, bloody stools 

check for electrolytes esp Na 

Do CRP, blood Cs start antibiotics according to your antibiogram

serial x ray follow up

blood gas to check for metabolic acidosis

CBC monitoring to check for further drop of platlets 

regarding pedia surgical consultation 

in NEC I & NEC II they have no rule but if you can involve them if you have suspecion 

NEC III THEY SHOULD INTERVENE EITHER PUTTING A DRAIN OR TAKE THE PATIENT TO OR 

Treat the patient as a whole and do not treat the x ray