Case discussion: bloody stools and abdominal distension

[smq123]

You're like the kids at the temple, but nobody's gonna cut you in half with a light saber .

So for you smq, what if your patient was a geezer hanging out on the step down. IV access is minimal and what was there was a pain to get. And he gets a distended abdomen and has a bloody stool. What are the principles of your treatment (the DDx is different, although NEC is known rarely to occur in adults) and plan. And remember you don't work alone.

Well, when you put it that way....

Yeah, he'd get a central line. No question - if he's going to need IV abx, possibly for a long time, and possibly need a lot of volume resuscitation fast, the strong possibility of a central line comes in right away. So...yeah, I would start thinking about a central line for this baby, too. If not, then a lot more peripheral IVs, however possible.

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[J-Rad]

As the attending pediatron you are The General. You are now in an unconventional battle. You need your special ops people. Who are they?!?
Make the call General Kenobi...


(sorry, nice feeling of banana rum going down the gullet and settling in the belly...I just felt like blurting that out. That's the cool thing about SDN cases...emergency pediatrics with a buzz on). BTW where the hell is BNPG? He's the one on the island.

 

[oldbearprofessor]

BTW where the hell is BNPG? He's the one on the island.

BNPG, like Chuck Norris would have the baby on ECMO in 15 minutes.

Single handedly.

 

[Stitch]

Dimoak, smq123 don't be afraid to throw stuff out. Believe it or not your med student training is relevant here. You might not know the exact answer, but neither does the pediatric resident. Have a little fun with this. OBP's like Yoda and I guess Stitch and I are fresh Jedi Knights. You're like the kids at the temple, but nobody's gonna cut you in half with a light saber . Go for principles, not details (who cares which three antibiotics, the principle is broad spectrum w/ anaerobic coverage. That's what was going through your head-appropriately).
So for you smq, what if your patient was a geezer hanging out on the step down. IV access is minimal and what was there was a pain to get. And he gets a distended abdomen and has a bloody stool. What are the principles of your treatment (the DDx is different, although NEC is known rarely to occur in adults) and plan. And remember you don't work alone.

Best description ever.

Seriously, never be afraid to be wrong. It's how you learn, and often you'll find that you're on the right path.

 

[J-Rad]

Well, when you put it that way....

Yeah, he'd get a central line. No question - if he's going to need IV abx, possibly for a long time, and possibly need a lot of volume resuscitation fast, the strong possibility of a central line comes in right away. So...yeah, I would start thinking about a central line for this baby, too.

And? As OBP pointed out, putting in umbilical lines may be tough. Truth be told, as a general pediatrician your skills and comfort with putting in a CVL in a child this size may be suspect. Besides, the groin will be as difficult as the belly. So now what? If you were facing the same clinical scenario in the MICU?

 

[J-Rad]

BNPG, like Chuck Norris would have the baby on ECMO in 15 minutes.

Single handedly.

I hear he carries around an ECMO circuit in his backpack. Along with his Glock.

 

[oldbearprofessor]

Here's some help on the prognosis issue. Note the sentence I underlined. No real improvement in outcome in the last 30 years! This is amazing when you consider what's happened in regards to most other neonatal diseases.

Annu Rev Med. 2008 Sep 25. [Epub ahead of print]

Necrotizing Enterocolitis.

Henry MC, Moss LR.

Necrotizing enterocolitis (NEC) remains a major cause of neonatal morbidity and death. The pathophysiology is poorly understood. Prevailing evidence suggests that NEC is due to an inappropriate inflammatory response of the immature gut to some undefined insult. The mortality rate (15%-25%) for affected infants has not changed appreciably in 30 years. Many infants with NEC recover uneventfully with medical therapy and have long-term outcomes similar to unaffected infants of matched gestational age. Infants with progressive disease requiring surgical intervention suffer almost all of the mortality and morbidity. Of these, 30%-40% will die of their disease and most of the remainder will develop long-term neurodevelopmental and gastrointestinal morbidity.

 

[Dimoak]

Well, since you guys promised not to ream me, I'll just dig right in.

1.) I'd call in the parents to the conference room, and explain to them that their child is very ill. The next 7-10 days will be very crucial, but we're going to do the best we can and utilize all experts and any of the most advanced technology available to us. I'd assure them that nothing they did during gestation or the pregnancy caused this; it was just a very unfortunate circumstance, but we'll do our best to help their child pull through. I'd also maybe mention as many positives in the case as I could, such as the solid platelet count (at least so far) and the almost 2kg weight.

2.) The prognosis is poor but could be worse (the neonate could've been super scrawny, 1.5kg+ weight improves the prognosis). AXR demonstrates NEC totalis, with fairly expansive pneumoperitoneum, suggesting existence of perforation. Stat surgical consult for drainage and enterostomy.

3.) Take off any 0.9NS and replace it with LR. No reason to make the patient more acidotic, right? Start whatever Gorillacillin is in the formulary, TPN, and pressors. Have vent ready. CVC access should be there as well.

 

[oldbearprofessor]

Well, since you guys promised not to ream me, I'll just dig right in.

AXR demonstrates NEC totalis, with fairly expansive pneumoperitoneum, suggesting existence of perforation.

? why do you say this

 

[oldbearprofessor]

TPN

Great thought! Nutrition matters. Finding a bag of TPN at 2 AM in a community hospital NICU isn't a real likelihood though. Besides, do you want to give potassium in the TPN to a baby in shock/potential renal failure?

Even more problematic is giving bicarb in an IV line that is running TPN. Why is that a problem?

 

[Dimoak]

? why do you say this

Oops I meant pneumatosis....but it doesn't matter since that won't affect my management.

Finding a bag of TPN at 2 AM in a community hospital NICU isn't a real likelihood though.

Wouldn't there be an overnight pharmacist available to mix it up?

Besides, do you want to give potassium in the TPN to a baby in shock/potential renal failure?

Well can't we adjust the formula to minimize the potassium? How else do we feed this patient? Really, I'm more worried about protecting as much bowel as we can than potentially reversible renal failure. We can juggle the electrolytes.

Even more problematic is giving bicarb in an IV line that is running TPN. Why is that a problem?

Why not just give the TPN through a picc line? If not that, couldn't we at least get an umbilical line? The patient is getting a laparotomy pretty soon anyway.

 

[oldbearprofessor]

Wouldn't there be an overnight pharmacist available to mix it up?

That wouldn't even happen at the largest children's hospitals in the country. Those places may have premixed TPN for certain situations, but 24/7 individualized TPN isn't a-happening, especially in community hospitals. Mixing TPN is a big deal anywhere, it's not the same as drawing up a med.

Meanwhile, I know that some of the more senior forum members are lurking on this thread....give us your thoughts. Soon we'll move on to the end of the case and the discussion about NEC in 33 weekers. What would you like to cover?

 

[generic]

Does this baby need to be transported to a level III NICU/place with pedi surg coverage yet?

When do surgeons decide to laparotomize and resect necrotic bowel? We already know there's free air/bowel wall air, right?

Has anyone done studies of probiotics as prophylactic or primary/adjuvant Tx for NEC?

Can you not give NaHCO3 in TPN line because it will react with other electrolytes? I think Calcium?

 

[Dimoak]

That wouldn't even happen at the largest children's hospitals in the country. Those places may have premixed TPN for certain situations, but 24/7 individualized TPN isn't a-happening, especially in community hospitals. Mixing TPN is a big deal anywhere, it's not the same as drawing up a med.

Ah, the reason I asked that was because as an undergrad, I worked as a pharmacy tech at a Level 2 trauma non-teaching hospital, and I could remember us receiving daily TPN orders, as well as the capability of doing a stat TPN using an admixture device, where you just hung the ingredients and entered the recipe, but now I just realized I merged my recollection of TPNs with bananabags.

When do surgeons decide to laparotomize and resect necrotic bowel? We already know there's free air/bowel wall air, right?

Perforation will essentially warrant surgical intervention, as that indicates stage III (unless the situation is peek n' shriek, at which point resection may be deemed futile).

 

[smq123]

Wouldn't there be an overnight pharmacist available to mix it up?

As OBP stated, TPN orders aren't available 24 hours a day.

As an MS3/MS4, one of my jobs was to MAKE SURE that my patient's TPN orders make it down to the pharmacy by noon sharp. If the order wasn't in by noon, the patient wasn't going to get any TPN the next day.

Why not just give the TPN through a picc line? If not that, couldn't we at least get an umbilical line? The patient is getting a laparotomy pretty soon anyway.

PICC lines don't happen overnight, either. Usually it's done by a PICC team (mostly made up of nurses), and they usually stop placing PICCs by 5 PM, M-F (at least at the hospital where I went to med school). It's kind of a production - a lot of patients on trauma end up staying an additional day or two (or more, if it's a weekend) just because the PICC team won't be able to get to them for a few days.

As for the question of access - if getting umbilical access is hard, I might have to resort to an intra-ossesous approach or maybe a saphenous cut-down. I don't know how comfortable an average general peds person is going to be doing cut-downs, though (my guess would be "not very.")

Well can't we adjust the formula to minimize the potassium? How else do we feed this patient? Really, I'm more worried about protecting as much bowel as we can than potentially reversible renal failure. We can juggle the electrolytes.

I wouldn't be so worried about exacerbating the renal failure with the potassium in TPN; I'd be more worried about hyperkalemia.

 

[Dimoak]

PICC lines don't happen overnight, either. Usually it's done by a PICC team (mostly made up of nurses), and they usually stop placing PICCs by 5 PM, M-F (at least at the hospital where I went to med school). It's kind of a production - a lot of patients on trauma end up staying an additional day or two (or more, if it's a weekend) just because the PICC team won't be able to get to them for a few days.

As for the question of access - if getting umbilical access is hard, I might have to resort to an intra-ossesous approach or maybe a saphenous cut-down. I don't know how comfortable an average general peds person is going to be doing cut-downs, though (my guess would be "not very.")

I think we should clear up the order of events. I think, and I could be wrong of course, is that the definite next step is the neonate is going to the OR. Really, things like PICC access and TPN are going to be part of post-surgical recovery. Based on the available information, this patient is not a candidate for medical management at the moment until the dead bowel is resolved.

I wouldn't be so worried about exacerbating the renal failure with the potassium in TPN; I'd be more worried about hyperkalemia.

But he's probably already hyperkalemic due to the necrosis and acidosis. I do agree about keeping his potassium down in anticipation of the surgery, but I don't think it's as much of a concern post-op.

 

[oldbearprofessor]

You tell the parents that you need to look at their baby and will talk to them as soon as possible. You go to the bedside and find the baby has a very distended abdomen and is gasping. Perfusion is poor. You ask for a 3.0 uncuffed endotracheal tube and intubate the baby using the rule of 7-8-9 (tube to the lip with a 3.0 tube at the 8 mark on the ETT), listen for breath sounds to be equal. You have the RT bag the baby. You ask the nurses to push () another 20 mL of NS through one IV. The heart rate is 230 (the baby's, yours is close).

No one is an island (as noted by one of our esteemed members) so you pick up the phone and dial 1-800-INEEDAFRIGGINGNEOCONSULTSTAT and quickly describe what is going on and ask for urgent transport to their center with a pediatric surgeon and Level 3 care.

The neonatologist advises you as follows:

Place the baby on sIMV with a rate of 30, and inspiratory time of 0.4 seconds and a PIP as needed to move the chest and get good breath sounds - a guess would be 25-30 cm. Use a PEEP of 5 and oxygen to obtain saturations 88-94%.

You are advised to use the second peripheral IV you have to give the following meds:

Vancomycin
Gent (or cefotaxime)
Clindamycin (of Flagyl)
Fentanyl (or Morphine - this is a major debate)
Bicarb (once ventilating)

Transport team is being mobilized and will be there in 2 hours.

You talk to parents and explain that their baby has severe NEC, what that means and that there is no surgery needed right now, as the baby does not have a perforation of his intestine, but that this might be needed soon. You explain the need for blood products and obtain consent for these and for transport.

 

[oldbearprofessor]

Can you not give NaHCO3 in TPN line because it will react with other electrolytes? I think Calcium?

calcium plus carbonate = calcium carbonate = rocks. Rocks in your TPN are bad. You can give acetate, but not pushes of bicarb in a line that is running TPN that has calcium in it.

 

[oldbearprofessor]

Questions to consider:

1. How much volume do you give? How do you decide when to stop pushing volume acutely?

2. What are your criteria for starting dopamine? How much?

3. Would you give blood products prior to transport?

4. Should you give bicarb after the first dose? Why or why not? (this is very controversial).

 

[J-Rad]

OK so I'm going to use my imagination and make up some aspects of the scene since we don't exactly know everything about this community hospital with a level II nursery:

Got the call...
1. ...Ask for NGT, suction, bolus (as discussed)...To calling RN: "after you get off the phone stat page the surgeon on call. Tell him the bullet and tell him to have his arse in here ASAFP. Yes, I know (at a community hospital) (s)he's a general surgeon and not a pediatric surgeon. But A. I'm not there yet and I don't know if this is an emergently surgical abdomen. So what's say transport is 5 hours away or your in Guam. WWBNPD? BNPG's gonna call whoever may help. General surgeons did a little peds surg in residency and most, in an emergency, will open up even a neonate if need be. Does the belly need to be decompressed? Hopefully need doesn't be, but... Also, if the decision is made that a CVL is needed, a GS should be able to do it.

2. Get in and look at the baby. Where I trained the order of events in regards to talking to the parents would be similar. However, where I am now is different. The parents are allowed in on just about everything. I just watched a prolonged attempted resuscitation (for likely sepsis and blood in the abdomen. I was there for an echo for some other reasons). The parents were looking in on the whole thing including the surgeon decompressing the abdomen. I think this was/is the right thing, and data supports family members being allowed to witness codes/resuscitations. So, I'm checking the kid out and calling the parents over to talk. Basically explain what was already said. The words "critically ill" will escape my lips at some point as will "transfer to a higher level of care" and surgeon coming to take a look. Labs I want after arrival: lactate (the surgeon may want it, and I'll be curious), H&H (I don't remember you giving that on the CBC), and set of coags (PT, PTT, Fibrinogen, D-Dimer), type and cross. Start triple cocktail of abx.

Back to baby...

3. (Under breath "A, B, C...A, B, C"). Airway-not emergently obstructed. Like most intubations, have time to set it up (while attending to other urgent issues). Break out baby code card or Harriet:
EGA (wk), Wt (g)[*], ETT Size (mm,) ETT Depth of Insertion (cm from upper lip)
24, 700, 2.5, 7
26, 900, 2.5, 7
28, 1100, 2.5–3.0, 7
30, 1350, 3.0, 7
32, 1650, 3.0, 7
34, 2100, 3.5, 8
36, 2600, 3.5, 8
38, 3000, 3.5–4.0, 9

While RT getting equipment set up and someone bagging is probably when I'm calling nearest level III and neo and apprising of situation/requesting transport and admission. Advising of my plan. May or may not ask about vent settings because I remember that just about all three-thousand and one ventilator modes/management strategies are voodoo and ultimately come down to what the Neo likes to use, though they will all protest/attest to why their particular favorite is "the best" (sorry OBP ). I'm typically comfortable with PC/PS using my bagging PIPs as the PIP for the vent or VC (using 5-8ml/kg for volume). BTW, I'm concerned that this kid with a pH of 7.08 has a pCO2 of 35 on his CBG. Why isn't it lower in compensation? From the story, he doesn't sound like he has underlying lung disease...I don't like this. Versed to calm kid down for intubation if needed and will give strong consideration to sedation with paralysis to reduce metabolic demand.

4. Fluids (Circulation). Bolus until perfusion improved, blood pressure stable. If that gets stabilized and want to start IVF: D10 1/4NS. As for K+, the level is high-normal for age and may have been a cap sample. Has the kid been peeing? Whatever...leave it out until transport. ARF? The cause of ARF in this kid will be-as in most cases-due to underperfusion. Fix underperfusion. If I have THAM acetate, I'm using that for now unless my BMP shows current RF. Does not need to be ventilating to use THAM. O/W bicarb when ventilating. May start vent at higher rate than 30 given previous concern over disconnect of acidosis and pCO2. Back to fluids: if perfusion not improving, keep bolusing. Stop if liver going down (have fun with that with distended abdomen), new gallop, wet lungs. CVL might be nice to have in place for monitoring CVP, but won't hold process up for this. What are BPs doing? Rule of thumb I learned is Mean Arterial Pressure should be about the minimum of = to EGA. Then the intensivists made fun of the Neos for always talking about MAPs. don't ignore SBP, DBP, and pulse pressure. We already know this is bad, but widening pulse pressure and bounding pulses are clinical data to put in the brain bag. If there is fluid refractory shock based on VS and clinical exam, then start the DA at 5 and titrate to MAP 33-40ish and better exam. If still refractory shock consider adding dobutamine. If transport is truly 2 hours away, you may never have to go beyond. On Guam, and pressor resistant shock, consider hydrocortisone for adrenal insufficiency.

5. Blood? What was the H&H again? At all low and having BP/perfusion issues-transfuse 10-15ml/kg. Though of quick question-is the abdomen distended or rock-hard like there could be blood in it? What was the bicarb question? Bicarb after first dose of blood? Never did that, though some liked a dose of lasix either during or after the blood.

 

[J-Rad]

Comment on umbilical lines: the abdominal distension notwithstandig, four day old umbilical stumps are pretty dessicated. Occasionally this can actually make placing lines easier, but my experiences with dry cords and lines was never good.

 

[TexasRose]

Comment on umbilical lines: the abdominal distension notwithstandig, four day old umbilical stumps are pretty dessicated. Occasionally this can actually make placing lines easier, but my experiences with dry cords and lines was never good.

J-Rad, great commentary above! Just one question, what is THAM acetate?

 

[J-Rad]

THAM (tromethamine) is a "proton sink". Binds H+. Earlier in my residency I found the Neos to be reluctant to use it based on old experiences with THAM and liver damage. But when it was pointed out that Neofax (the neonatal dosing bible for those who don't know) addressed this issue I saw it used more.

 

[oldbearprofessor]

THAM (tromethamine) is a "proton sink". Binds H+. Earlier in my residency I found the Neos to be reluctant to use it based on old experiences with THAM and liver damage. But when it was pointed out that Neofax (the neonatal dosing bible for those who don't know) addressed this issue I saw it used more.

THAM has most often been used in neonatology when the serum sodium has gotten so high, usually > 155 or so that there is a need to buffer without giving sodium. Given the current bias against using much buffer in general, there may not be as much interest in THAM. Many if not most neo code carts, etc don't contain it. I am pretty neutral on it as I've not much experience with it and have never seen it used except in situations that were already hopeless.

Here's a slightly dated, but worthwhile abstract reviewing it

: Drugs. 1998 Feb;55(2):191-224.

Erratum in:
Drugs 1998 Apr;55(4):517.

Guidelines for the treatment of acidaemia with THAM.


THAM (trometamol; tris-hydroxymethyl aminomethane) is a biologically inert amino alcohol of low toxicity, which buffers carbon dioxide and acids in vitro and in vivo. At 37 degrees C, the pK (the pH at which the weak conjugate acid or base in the solution is 50% ionised) of THAM is 7.8, making it a more effective buffer than bicarbonate in the physiological range of blood pH. THAM is a proton acceptor with a stoichiometric equivalence of titrating 1 proton per molecule. In vivo, THAM supplements the buffering capacity of the blood bicarbonate system, accepting a proton, generating bicarbonate and decreasing the partial pressure of carbon dioxide in arterial blood (paCO2). It rapidly distributes through the extracellular space and slowly penetrates the intracellular space, except for erythrocytes and hepatocytes, and it is excreted by the kidney in its protonated form at a rate that slightly exceeds creatinine clearance. Unlike bicarbonate, which requires an open system for carbon dioxide elimination in order to exert its buffering effect, THAM is effective in a closed or semiclosed system, and maintains its buffering power in the presence of hypothermia. THAM rapidly restores pH and acid-base regulation in acidaemia caused by carbon dioxide retention or metabolic acid accumulation, which have the potential to impair organ function. Tissue irritation and venous thrombosis at the site of administration occurs with THAM base (pH 10.4) administered through a peripheral or umbilical vein: THAM acetate 0.3 mol/L (pH 8.6) is well tolerated, does not cause tissue or venous irritation and is the only formulation available in the US. In large doses, THAM may induce respiratory depression and hypoglycaemia, which will require ventilatory assistance and glucose administration. The initial loading dose of THAM acetate 0.3 mol/L in the treatment of acidaemia may be estimated as follows: THAM (ml of 0.3 mol/L solution) = lean body-weight (kg) x base deficit (mmol/L). The maximum daily dose is 15 mmol/kg for an adult (3.5L of a 0.3 mol/L solution in a 70kg patient). When disturbances result in severe hypercapnic or metabolic acidaemia, which overwhelms the capacity of normal pH homeostatic mechanisms (pH < or = 7.20), the use of THAM within a 'therapeutic window' is an effective therapy. It may restore the pH of the internal milieu, thus permitting the homeostatic mechanisms of acid-base regulation to assume their normal function. In the treatment of respiratory failure, THAM has been used in conjunction with hypothermia and controlled hypercapnia. Other indications are diabetic or renal acidosis, salicylate or barbiturate intoxication, and increased intracranial pressure associated with cerebral trauma. THAM is also used in cardioplegic solutions, during liver transplantation and for chemolysis of renal calculi. THAM administration must follow established guidelines, along with concurrent monitoring of acid-base status (blood gas analysis), ventilation, and plasma electrolytes and glucose.

 

[oldbearprofessor]

Yes, I know (at a community hospital) (s)he's a general surgeon and not a pediatric surgeon. But A. I'm not there yet and I don't know if this is an emergently surgical abdomen. So what's say transport is 5 hours away or your in Guam. WWBNPD? BNPG's gonna call whoever may help. General surgeons did a little peds surg in residency and most, in an emergency, will open up even a neonate if need be. Does the belly need to be decompressed? Hopefully need doesn't be, but... Also, if the decision is made that a CVL is needed, a GS should be able to do it.

Without an actual perf, the current trend in babies over about 1 kg is to avoid operating on the acute abdomen if at all possible (we'll discuss that more shortly). Under 1 kg or so, some would use drains without a lap. This is a very very controversial topic right now and not well settled.

Given my choice, with two peripheral IVs in place, I'd prefer IR to GS for the CVL (IR placed PICC), but that's a matter of style, availability, skills, etc.

 

[oldbearprofessor]

4. Fluids (Circulation). Bolus until perfusion improved, blood pressure stable. If that gets stabilized and want to start IVF: D10 1/4NS. As for K+, the level is high-normal for age and may have been a cap sample. Has the kid been peeing? Whatever...leave it out until transport. ARF? The cause of ARF in this kid will be-as in most cases-due to underperfusion. Fix underperfusion. If I have THAM acetate, I'm using that for now unless my BMP shows current RF. Does not need to be ventilating to use THAM. O/W bicarb when ventilating. May start vent at higher rate than 30 given previous concern over disconnect of acidosis and pCO2. Back to fluids: if perfusion not improving, keep bolusing. Stop if liver going down (have fun with that with distended abdomen), new gallop, wet lungs. CVL might be nice to have in place for monitoring CVP, but won't hold process up for this. What are BPs doing? Rule of thumb I learned is Mean Arterial Pressure should be about the minimum of = to EGA. Then the intensivists made fun of the Neos for always talking about MAPs. don't ignore SBP, DBP, and pulse pressure. We already know this is bad, but widening pulse pressure and bounding pulses are clinical data to put in the brain bag. If there is fluid refractory shock based on VS and clinical exam, then start the DA at 5 and titrate to MAP 33-40ish and better exam. If still refractory shock consider adding dobutamine. If transport is truly 2 hours away, you may never have to go beyond. On Guam, and pressor resistant shock, consider hydrocortisone for adrenal insufficiency.

This is a great paragraph. Should be an SDN classic! I like it because it reflects the way we often think in these situations. Note also that 2 heads are better than one. Neos, cardiologists and PICU docs do think differently about these situations and that's okay. Sometimes a bit of discussion (esp. with cards) is very insightful on issues like epi vs dopamine vs vasopressin, etc.

However, I'd like to summarize or restate in my way a few of the key ideas, as what's written might be a bit hard to follow for those earlier in their training.

In initial shock, the BP may go up before dropping. The Starling curve (remember that??) tells us that the heart rate is going to be high, in this case for a wide range of reasons and it is serving to improve cardiac output. In a small baby, a HR of 220-240 with poor peripheral perfusion means that we are likely intravascularly depleted (why?) and need to give more volume. However, there is a maximum benefit and real risks with too much volume (what?). We're not in an MICU, we can't do central pressure monitoring and we have to use some clinical judgment in figuring out when to stop. Also, pushing saline, glucose and bicarb have their own metabolic issues (hypernatremia, hyperglycemia).

Ulitamately, all such babies will need a pressor. Most would start with dopamine at 3-5 microg/kg/min and titrate up as needed to maintain an adequate BP, where adequate needs to be considered both as the MAP AND the diastolic (why does the diastolic matter?). In the first few hours, this will be all that is needed, epi, etc are unlikely needed before transport. Steroids should wait for a while, but are another very difficult clinical decision (what are the negatives both metabolically and developmentally?).

 

[Stitch]

Man, J-Rad beat me to all the good discussion! Stupid work....

We generally did a total of 30-40 mL/kg divided up in 10/kg boluses before moving to pressors unless the overall perfusion was just terrible or the MAPs were really low. Even then, how do you feel about running dopamine through a PIV? Less than ideal, but it sounds like we don't have much choice.

In terms of bicarb, I'd want another gas now that the kid is on the ventilator. Giving bicarb with higher pCO2s (greater than 55 I think?) can result in a worsening acidosis, which I'm guessing is why some people use THAM. My only real experience with THAM has been with intubated asthmatics with CO2s close to 100, however.

Steroids won't help the surgeons out in terms of repairing that bowel. If the kid has perforated, how likely is he to end up with a penrose drain, at least to start with until this 'hot' belly cools off? Developmentally, are you referring to the prolonged steroid tapers used to wean kids with bad lungs off the vent?

 

[edmadison]

Great discussion, I'm sorry to join it so late. As others have also similarly commented, I am amused by some people's suggestion to "get a CVL". It reminds me of the old joke about the chemist, physicist and economist trapped on a desert island with a can of beans. The punch line is by the economist, "assume a can opener!" Unless you've been there, you have no idea how difficult access can be on a sick preemie

The case we are discussing is bringing back a bit of a nightmare for me. I was a 3rd year resident in the NICU when a previous 29 weeker doing great, feeding and growing, no issues dropped of a cliff in about 8 hours. For 24 hours two nurses, me and the neo we doing all we could to keep this kid alive. Our biggest problem was poor IV access. Many medications are incompatible. I remember my favorite question that day from the nurse. "what do you want, the dopamine drip or the stat calcium bolus?". I wasn't allowed to have both. Kid ended up surviving for about a year. Lost a ton of bowel, but saved the IC valve. Had multiple bowel lengthening procedures, but ended up dying from liver failure due to TPN cholestatis.

Second case is one for every pediatrician to tuck away in the back of his/her head. I got called down to the ED for a consult on a lethargic 4 day old who was not feeding. ED had gotten a babygram (but hadn't looked at it yet). It was just full of pneumatosis. Just remember that you can see NEC in a term baby.

Ed

 

[J-Rad]

...
In initial shock, the BP may go up before dropping. The Starling curve (remember that??) tells us that the heart rate is going to be high, in this case for a wide range of reasons and it is serving to improve cardiac output. In a small baby, a HR of 220-240 with poor peripheral perfusion means that we are likely intravascularly depleted (why?) and need to give more volume. However, there is a maximum benefit and real risks with too much volume (what?). We're not in an MICU, we can't do central pressure monitoring and we have to use some clinical judgment in figuring out when to stop. Also, pushing saline, glucose and bicarb have their own metabolic issues (hypernatremia, hyperglycemia).

Ulitamately, all such babies will need a pressor. Most would start with dopamine at 3-5 microg/kg/min and titrate up as needed to maintain an adequate BP, where adequate needs to be considered both as the MAP AND the diastolic (why does the diastolic matter?). In the first few hours, this will be all that is needed, epi, etc are unlikely needed before transport. Steroids should wait for a while, but are another very difficult clinical decision (what are the negatives both metabolically and developmentally?).

Diastolic=coronary artery perfusion (http://www.medscape.com/viewarticle/566970_3). Low DBP and a HR in the 200s even for a denizen of the frog pond is bad JuJu.

My thoughts on steroids in this scenario: I agree it's unlikely that we would have gotten to that point prior to transport. But it was thinking down the line to "what if things don't go right?" (transport is delayed and pressors aren't helping). I would probably be on DA, Dobuta, and maybe Epi before steroids. But if I was on that much and was still having difficulty maintaining pressure, I'd give it strong consideration. I might check a spot cortisol not caring about the absolute number, but if it was low, normal, or only mildly elevated I'd consider it further justification for steroids. I think the clinical treatment of fluid and pressor refractory shock would outweigh the increased risk of intestinal perforation with steroids (this is one of those better of two evils or do the least harm things). Other risks of steroids: in the short term, hyperglycemia and hypertension [in our case along with my imaginations more a later problem]. Developmental outcomes and steroids are a little confusing to apply here as they've mostly been looked at from the perspective of steroids for treatment/prevention of BPD. At baseline this is a child with lower risk of bad neurodevelopmental sequelae of prematurity or CLD of prematurity. In this case steroids would be for replacement of absolutely or relatively deficient endogenous circulating steroid.

 

[oldbearprofessor]

The transport team arrives on schedule, walking into your NICU at 5 AM. They are impressed with the job you've done at stabilizing the baby until about 5 minutes after they get there when the baby starts to become bradycardic with a widened QRS and peaked t-waves. You send stat chemistries and a blood gas, but the QRS is widening and need to take action long before these results come back or the baby will be coding.

The NNP on the transport team, knowing your mind, hands you a medication to push in slowly. Then she draws up the next set of meds.

For the med students and entering interns only, what med did she hand you first, and what comes next?

 

[swim2006]

The transport team arrives on schedule, walking into your NICU at 5 AM. They are impressed with the job you've done at stabilizing the baby until about 5 minutes after they get there when the baby starts to become bradycardic with a widened QRS and peaked t-waves. You send stat chemistries and a blood gas, but the QRS is widening and need to take action long before these results come back or the baby will be coding.

The NNP on the transport team, knowing your mind, hands you a medication to push in slowly. Then she draws up the next set of meds.

For the med students and entering interns only, what med did she hand you first, and what comes next?

Well the I think the first med is CaCl2. I am not sure but I think the second might be bicarb. If there is only one PIV then you would have to flush the IV before giving the bicarb (I don't remember if at this point there is 1 or 2 PIVs)

 

[bjackrian]

Agree with Calcium Cl as the first drug. Bicarb would work as a second drug, but I would use insulin/glucose first since it should work faster to drive potassium intracellularly.

 

[DarthNeurology]

In older children (not the patient in this case) the dogma has been to use 1/4NS, 1/2NS and NS (base) fluids based on age based on estimates of electrolyte "needs".

This is based on an article published by Holliday and Segar (also the article from whence everyone doses the MIVF rates 10-4, 10-2, 1-1). The dogma is fairly well entrenched, however, there are those that argue that it isn't good dogma (Moritz being the main proponent). If you read the original article the "evidence" for this approach is fairly underwhelming. So to save myself from thinking a whole lot, when I write the fluid orders, almost every (older) kid goes on D5NS with 20 of KCL (if kidneys working and peeing). LR is used a lot in the OR and not infrequently in the ED. Don't remember seeing it in the NICU and did use it sometimes in the PICU.

Excellent point, the Holliday and Segar stuff goes back to 1957 and it is for *healthy* children, the Na and K requirements, 3 and 2 mEq/100kcal/24hour are based on intake of those healthy infants receiving cow and breast milk. In illness the energy needs and electrolyte needs exceed that in healthy infants and toddlers, also ADH is not secreted appropriately in some hospitalized patients and obligate losses occur in gastroenteritis, contributing to hyponatremia, hypotonic fluids can imperil a hospitalized infant or toddler who has low-normal Na to develop hyponatremia, you have to take the clinical picture in account as where isotonic fluids may help some pediatric patients, they can imperil infants to develop hypernatremia if excreting hypotonic urine.

 

[oldbearprofessor]

Well the I think the first med is CaCl2. I am not sure but I think the second might be bicarb. If there is only one PIV then you would have to flush the IV before giving the bicarb (I don't remember if at this point there is 1 or 2 PIVs)

Agree with Calcium Cl as the first drug. Bicarb would work as a second drug, but I would use insulin/glucose first since it should work faster to drive potassium intracellularly.

Calcium is first as it will NOT change the serum calcium but will make the myocardium more resistant to the effects of hyperkalemia. Clinically what one sees is a rapid normalization of the EKG (if you're not in V-fib....) and an effect that lasts about 10-15 minutes. During this time, you go with the glucose and insulin. Bicarb can also be given via a different IV or after flushing the line well. In general we do not use kayexalate for preemies.

As an aside, although CaCl2 is often recommended, use whatever you have. Calcium gluconate needs a first pass through the liver, but this happens in seconds, a lot faster than one can get a dose of CaCl2 from the pharmacy if Calcium gluconate is what you have in front of you.

 

[oldbearprofessor]

After stabilizing the infant from the hyperkalemia (serum K+ was 8.5), the baby is transported to the referring hospital.

Over the last 10 years or so, I've probably been the receiving doctor on call or on service for about 10-15 such babies and my colleagues have cared for at least that many more. I'd like to tell you that it goes well, but a big baby with NEC totalis does not do well in my experience.

So, to be honest with what happens...

Over the next 12 hours, the infant develops overwhelming DIC but does NOT have an obvious perforation of the intestine on Xray. Platelet count drops to 15,000 and requires transfusions along with FFP, dopamine and epi drips. IR had placed a PICC on arrival to the NICU and the IR attending is now enjoying the 6 pack of beer the neos bought them for doing this on a Saturday AM.

Finally, hoping to find a fixable waledl-off perforation or overwhelmingly dead bowel to remove, the surgeons perform a laparotomy. They do not find anything except the NEC and find nothing obvious to remove so they don't. Note that doing a lap here was not what they wanted to do, just a last resort.

After the surgery, the situation is as follows:

Infant is on an oscillator, settings are: delta P = 48, MAP = 15, Hz = 12 and 100% oxygen:

ABG shows: pH 7.15, PO2 - 50, PaO2 = 60, serum lactate is 14, BUN is 30, Creatinine is 1.4 and there has been 0.5 mL/kg/hr urine output over the last 6 hours.

Clinical diagnosis include:

NEC totalis
DIC
Pulmonary hemorrhage

Neurological status is uncertain as the baby is heavily sedated and is too unstable for a CT or MRI.

A stat head U/S is ordered and appears to show some intracranial hemorrhage.

You go to talk to the family.

Do you recommend:

-Withdrawal of care (extubate): Is this permissible?
-Continue current care (but no CPR): Remember that saying no code drugs doesn't mean much in a baby on an epi drip, but you could indicate that you won't escalate care or do compressions.
-Continued full aggressive management: What would make you reconsider?

There is no right answer on this one, but there is NO WAY the family can figure out this situation on their own. You need to help them. They get to make the final decision, but you need to guide them. What do you believe is in the infant's best interest to do right now?

 

[J-Rad]

I don't have time for an extensive post at this moment, but a few questions/comments:
-(this isn't an important question, just curiosity) In the discussion you didn't talk about pulmonary hemorrhage. Was blood seen in the tube?
-What is the trend of the respiratory status? Your OI is sucky (~25)-is this stable, worsening, or getting better? (thoughts for NO?) Hemorrhage controlled on the oscillator?
-I really would like a little more about this IVH. Original grading and, depending on time elapsed, follow up Head US.

I already have a feeling for what the discussion with the parents is going to be (in my eyes), but I'd like a fuller data set. There is, however, much I don't like in the story. Overall survival for NEC is decent, but there are confounding factors and survival statistics often become hard to apply to meaningless in the setting of an individual case.

 

[oldbearprofessor]

I don't have time for an extensive post at this moment, but a few questions/comments:
-(this isn't an important question, just curiosity) In the discussion you didn't talk about pulmonary hemorrhage. Was blood seen in the tube?
-What is the trend of the respiratory status? Your OI is sucky (~25)-is this stable, worsening, or getting better? (thoughts for NO?) Hemorrhage controlled on the oscillator?
-I really would like a little more about this IVH. Original grading and, depending on time elapsed, follow up Head US.

I already have a feeling for what the discussion with the parents is going to be (in my eyes), but I'd like a fuller data set. There is, however, much I don't like in the story. Overall survival for NEC is decent, but there are confounding factors and survival statistics often become hard to apply to meaningless in the setting of an individual case.

Sorry, at this point I figured I'd beaten the medicine in the case nearly to the ground and wanted to get to ethical issues and then discuss prevention of NEC, etc.

In the setting of DIC in a baby like this, we'd usually get substantial pulmonary hemorrhage, likely to lead to high vent settings and ultimately to oscillation. The oscillator settings in this case leading to a stable but only fair gas are moderately high, but not extreme.

ECHO shows a small TR jet with some bidirectional, mostly L to R flow through the foramen ovale, no PDA, decent function bilaterally with some RV decreased function.

Neuro status is extremely hard to get a handle on here. There's no way to get this kid down for advanced imaging, so ultrasound is all you've got and that won't get you much here. EEG might be of help, but given the baby is heavily sedated and is this sick, won't tell you all that much. We'd all like more data and more data that is prognostic, but it just isn't there. A small cerebral bleed is technically a Grade IV, but as some folks who know the scoring system well will say, that doesn't tell you much in this circumstance.

In deciding how to advise families, you have to decide if, even though there is no single condition that is incompatible with life, if the overall picture is incompatible with life or with meaningful life. If not, what about doing CPR? When and how would you reevaluate these decisions? Assume that you have a family that is asking "what will happen?" "Will he survive?". Some families do not want this discussion at this point. Others sense pain and futility earlier.

Also, it is now Saturday night, you need to think about things like - does the family want to call in a clergy member? Does the family want to try to hold on until distant family members arrive? So, you need to have that talk even if you're not sure.

 

[Stitch]

I agree, knowing whether he has a grade I (seems unlikely) versus a grade IV bleed may help when discussing his neurological prognosis. With the kid's kidneys shutting down, you're also likely going to have to discuss dialysis.

OI = (FiO2 x 100) x MAP / PaO2. You're already using HFOV and are on considerable settings. I think you're running out of room, and you're seeing multiple end organ failure. Even if we add NO, are we going to get anywhere?

Babies are amazingly resilient, but the overall picture here just doesn't look good. I've found it's very hard to just pull the tube, but given he's already on an epi drip, I don't know that adding chest compressions (he'll likely code at some point), let alone dialysis is going to be ultimately beneficial.

 

[oldbearprofessor]

I don't know that adding chest compressions (he'll likely code at some point), let alone dialysis is going to be ultimately beneficial.

How would you explain that to parents (chest compressions)?

Would you get a renal consult? What do you expect them to say with a 1900 g baby with DIC about dialysis?

 

[J-Rad]

(Parents) "We need to have to have a very serious and difficult conversation. (Name of Baby) is extremely critically ill. The pediatricans at Outside Hospital did an outstanding job in stabilizing him and he likely would not be alive right now if not for their efforts.* At this point we are basically at the point of maximally supporting him to the best of anyone's capabilites. As you (likely already know) he has necrotizing enterocolitis which can severely damage his intestinal tract. What makes him particularly ill are the other systems of his body which have been affected. He is in a state known as multi-system organ dysfunction (MSOD) in which multiple organ systems are dysfunctional, failing, or have failed. In his case his lung, liver, heart, and kidney systems are not functioning normally. Individually an organ system may recover but the more systems involved and the severity of the dysfunction reduce the likelihood of individual organ system recovery. Further complicating the treatment is the fact that the liver dysfucntion is contributing to him developing a condition known as diseminated intravascular coagulation. Simply put DIC is the body being severely dysfunctional in regards to internal clotting and bleeding. Instead of the normal balance between the two, Baby's body is clotting and bleeding in ways that are hurting him which contributed to the bleeding from his lungs. The blood vessels in his body are leaky from diffuse inflammation and that is why his blood pressure has been difficult to control. This is sometimes referred to as "capillary leak syndrome". Lastly there is evidence that he has bled into parts of his brain. He is not stable enough to get detailed imaging of the extent of the damage in his brain (which would require CT or MRI) but that information may or may not give useful information right now. Stepping briefly back to the individual organ dysfunctions, under certain circumstances we can do the work for failing organs, but Baby's clinical situation make that not a viable option. Due to his DIC dialysis for his kideys would be extremely difficult and due to the DIC and bleeding in his brain ECMO-which is a machine that help with the work of the lungs and the heartl almost a "bypass" machine-is also not a possibility. I don't mean to overwhelm you with details, but I want you to understand the gravity of this situation. In the past when the prognosis of NEC and MSOD together was studied in infants under 1500 grams MSOD of involving more than two systems was associated with a >80% death rate. Likewise capillary leak and NEC was also associated with >80% death rate. Unfortunately that means that we need to make some difficult decisions together. Until and unless our interventions are truly futile, we will do everything for your child within our capability and in accordance with your wishes. However we all need to ask ourselves when we are causing more suffering than benefit. We can continue as we are and continue to support his organ functions as best we can understanding that our efforts are not likely to have a favorable outcome. There is a chance that his heart may succumb to the dysfunction at that point we really have no more medicines to treat this, however, we may need to do chest compressions. This is one of those interventions that we need to decide whether to utilize should this scenario arise. We also need to think about the most difficult decision of all. Given the severity of Baby's illness our other option is to removed the tubes and lines, let you hold him and do everything we can to make him comfortable. (Expect long pause).
May I ask that if you have a spiritual tradition is there a clergy member that we may call for you? (if this hasn't already been done long before) Or is there a family member, advisor, or friend you would particularly like here? What questions do you have?
I'll come back and talk to you after some time..."
(obviously this monologue does not account for any individual variation for parental understanding or questions and the parents' intellectual grasp of the goings on and individual conversational styles will need to be adapted to)

 

[oldbearprofessor]

J-Rad - thanks for the post. Rarely are these things written out. I have a few comments and suggestions, but it's a good talk. Let's see if anyone else has anything to add first.

 

[J-Rad]

I forgot the asterisk: the comments about the Outside Hospital are important in this conversation. This family will at some point, likely, reach for something or someone to blame (stages of grief stuff) whether this child survives a little or a lot longer or whether the baby dies. They may blame god(s), themselves, each other, etc. It's easy when your kid's now at an ivory tower with all the bells and whistles available to think that it was OSH and the docs there that were to blame. I think it's worth giving credit where credit is due. And if they didn't do everything perfectly or like you do at Mecca Regional Quarternary Hospital to commend them on that which they did do to the parents. I'd imagine the OSH docs who are practicing with less of a net would be grateful.

 

[J-Rad]

One other thing, the 80% data was from a 1998 article that I dug out and was not a huge cohort of patients. I don't know if this data is cited much by Neos (OBP, comment?). It was the only data I could find about this particular scenario though I didn't search extensively.

PS

From someone's bliggidy-blog

 

[J-Rad]

Does this make a record for longest thread on the Peds forums? And it isn't even about interviews or "which residency?" (Yeah, I know I just padded the post )

 

[Stitch]

How would you explain that to parents (chest compressions)?

Would you get a renal consult? What do you expect them to say with a 1900 g baby with DIC about dialysis?

No, renal won't want anywhere near him at this point. I only brought it up as an option for continuing agressive, 'everything' care in the unlikely event we can get past where he is.

I like JRad's speech, and definitely appreciate the compliment to the OSH. As someone who sends sick babies from OSH to the NICU, I'm sure it helps cover my rear.

From this point, it's important to emphasize that you're doing everything for the baby that is possible. Parents need to hear that you're not giving up the infant. At the same time you have to be realistic. Something to the effect of we've maxed out on BP meds as well as oxygenation options and that even with his kidneys shutting down, he's too sick to go on dialysis. If his heart stops, we can give him chest compressions, but that won't fix his current situation. We can keep attempting to bring him back, but at some point even chest compressions may not be effective.

Neurologically, even should the child survive his current state, the damage is likely to be severe. Though we can't know the extent right now, we do know that the prolonged acidosis and MSOD, will likely leave him seriously and profoundly disabled.

My goal would be to make the child as comfortable as possible with fentanyl, and allow the family to be with him, but ultimately it's up to them. They have to feel like we and they did everything possible. And that may include chest compressions or just waiting things out.

 

[oldbearprofessor]

In deciding if the situation has reached a point that we would recommend withdrawal of care, we would like to be able to have clear evidence that any one organ failure will be lethal or lead to a hopeless outcome. However, in reality, that is almost never the case at this point. Consider a baby with hypoplastic left heart - that is "fixable", but is it fixable if the baby also has a moderate short gut and needs home TPN? Is it fixable if the baby has severe BPD? These are tough calls.

In terms of neurological outcome, this muddies things even more. It is extraordinarily hard to provide meaningful prognosis at this point even with an MRI in hand. Asking neurology to consult is common, but may or may not be helpful at this point. EEG's can be helpful, but not always. Furthermore, some families simply don't want to consider this aspect right now. They only focus on survival. Most would care about prognosis, but simply can't integrate concerns about long-term outcome with the multi-organ system failure discussion and thinking.

 

[oldbearprofessor]

In speaking with families, the first step is to ask them what they know and understand about the situation. This can seem awkward, but is very helpful and oftentimes one realizes they understand very little. Then proceed, as J-Rad did, to describe the current situation. I generally try to avoid too much lingo in this and simply describe what each major organ system is "doing" and what we are "doing" about it. I'll briefly mention what has happened to this point (including the OSH's fine job).

Then, comes the tough part. At this point you need to say, as was described nicely by the others, that you've reached a maximum in what you can do. I often will say something to the effect that "we are giving every therapy that is possible and have no more therapies left to add." I don't usually talk about dialysis, ECMO (unless we are really considering it), etc at this point.

Finally comes the toughest part of all. I will tell them in this situation that we don't really think that chest compressions would be useful and that they would not change the outcome since we are already using every possible medication. I will ask them for permission to "not do" compressions if it comes to that and explain that these are painful and won't be helpful.

Then comes the tears and we wait through that. Usually I have the bedside nurse and if daytime a social worker with me, as well as the resident, NNP, fellow, etc. When you tell parents that CPR is not going to be helpful, they really get what is going on.

We will then talk about other family members who are coming, clergy, etc. Questions are asked for throughout.

After this talk, it's back to the bedside for the family while I write and document the conversation and the code status.

 

[oldbearprofessor]

To finish the case, as I don't want to drag this part out, it is likely that the infant will, in fact, start having bradycardias or drop out his BP and/or sats. Whether a trial of steroids is given is dependent on the team. It often is and may buy another 12-24 hours.

Ultimately, after the HR drops very low repeatedly, or severe oliguria develops leading to anasarca, it will be clear that it is time to withdraw care. The exact timing of this and how the decision is made is highly variable and not a topic worth belaboring here.

When the parents are ready, the heart monitor is turned off, a note written in the chart and the ETT withdrawn. Photos are taken and the parents are given, with the extended family, as much time as they want with their baby.

The neonatology team has to make a few phone calls and discuss some things with the family and others. What are some of their responsibilities at this point?

We'll discuss later today current thinking on prevention of NEC.

 

[J-Rad]

In speaking with families, the first step is to ask them what they know and understand about the situation.

Agree this is critical for all physicians taking care of patients (really, of all ages) in the hospital to ask family members. Some parents don't understand why their kids asthma exacerbation requires hospitalization and others are remarkably in tune with the goings on with their loved one. Much misunderstanding can be avoided with this question.

 

[Stitch]

How do you guys feel about allowing parents who want chest compressions to stay in the room during a code? I'm seeing more of that 'open unit' mentality, especially in some PICUs. It seems to me that when parents see first hand the brutality of chest compressions and the torture that can be a code situation, they're more likely to get what's going on.