Taylor Harrington, NICU Nurse.
This case study follows Sai, a premature infant whose Neonatal Intensive Care stay was complicated by Necrotising Enterocolitis (NEC) requiring a laparotomy and bowel resection with subsequent intestinal failure.
Sai was born at 24 weeks + 1 day gestation weighing 650g. His weight was around the 50th centile for his gestation. He was born in good condition and was transferred to NICU on CPAP. He had one dose of surfactant and was being treated with caffeine for apnoea of prematurity. He received antibiotics for 36 hours after his birth, but these were stopped as the blood cultures remained negative.
Sai had been slowly grading up on gastric feeds and by day of life (DOL) 7 he was tolerating 120ml/kg/day of fortified breast milk. He was having normal stools and his abdomen was soft with good bowel sounds.
On DOL 8, Sai became unwell and required intubation after having an increased number of apnoeic episodes. He had developed abdominal distention, feed intolerance and presumed sepsis. His full blood count revealed at 70% left shift and he was commenced on antibiotics. Blood cultures remained negative. There were concerns of NEC, so he was placed nil by mouth (NBM) and his antibiotics were adjusted to cover for gut concerns.
X-ray films at that time showed symmetric gaseous distention down to the rectosigmoid consistent with ‘CPAP belly’ and were not overly concerning. However, Sai continued to deteriorate and on DOL 10, x-ray films showed an asymmetrical mottled gas pattern with a significantly more dilated small bowel. There was no free air or pneumatosis noted at that time. Sai continued antibiotics and was being treated for medical NEC.
Two days, later DOL 12, x-ray revealed a progressively abnormal gas pattern with significant bowel wall thickening, interloop fluid and a large amount of free air in the abdomen indicating perforation.
At 25 +6 weeks corrected gestion, weighing 800 grams, Sai was prepped for surgical intervention.
Sai arrived in theatre and underwent an urgent laparotomy. When the surgeons opened Sai’s abdominal cavity, they immediately encountered milk. Upon closer examination they discovered an obliterated right ascending colon with unidentified caecum and appendix. The macerated bowel was stuck to his liver and needed to be carefully dissected away. The edges of the bowel were ragged and there was free contamination of inspissated milk. There was a moderate amount of necrosis but it was relatively well demarcated. The rest of the bowel appeared healthy with no evidence of NEC. The ends of the obliterated and necrosed bowel were resected and his abdomen was irrigated. The impacted milk was milked out of the bowel and then the bowel was placed in a warm pack for 5 minutes before being reinspected. It appeared much healthier at that time with no other areas of impending necrosis. In total, Sai lost approximately 10 cm of colon and an ileostomy was formed just proximal to where caecum would have been. The surgeons also formed a mucous fistula from the right ascending colon and closed Sai’s abdomen.
Sai had a difficult post-operative course. He suffered an acute kidney injury secondary to post-op hypotension and required inotropic support. He developed a significant post-op wound dehiscence that required special dressing changes and close monitoring for signs of infection.
Sai required prolonged ventilation support with multiple unsuccessful extubation attempts. On DOL 36, 24 days post-op, Sai was successfully extubated to CPAP after a course of dexamethasone. His corrected gestation age was 29 +2.
Sais biggest post operative hurdle was his high stoma outputs and static growth. His stoma outputs were 40-50 mls/kg/day and he was IVN dependant with additional electrolyte infusions. He also required ml for ml intravenous replacement of his stoma losses with a special electrolyte solution to prevent dehydration and further electrolyte imbalances. In his first two days post-op he became slightly oedematous and gained 200 grams of presumed fluid, but from post-op day (POD)2 to POD 41, Sai had only gained 50 grams. That is less than 1.5 grams per day. His growth chart plateaued, and he was dropping towards the 3rd centile for his corrected gestation. The medical team in collaboration with a dietician, were attempting to increase his gastric feeds in the hopes of weaning him off TPN. Sai had short periods of time on full enteral feeds of expressed breast milk(EBM), but his growth remained static and his stoma losses remained high enough to need intravenous ml for ml replacement. Each time the team tried to introduce fortifier to his enteral feeds, his stoma outputs would drastically increase, and he would eventually end up back on trophic feeds and full intravenous TPN. After Sai’s post-op dehiscence had mostly healed, the team decided to trial chyme reinfusion therapy in an attempt to help him grow and wean of TPN once and for all.
At 31+5 weeks corrected gestation (DOL 53), Sai was started on chyme reinfusion therapy using The Insides® Neo. He was POD 41 and weighed 1150g at that time.
Sai had already been fitted with the ‘Hollister Pouchkins Bag’. With his next stoma bag change, the device was fitted and ready for use. The nursing team used a size 6 Fr gastric tube for refeeding which they assembled with the device and inserted into the distal fistula. It was secured at the 5 cm marking on the outside of the bag with the provided clip. The chyme was withdrawn from the bag every 4-6 hours and reinfused using a syringe pump over the next 4-6 hours.
Sai’s stoma outputs remained high at 45 ml/kg on trophic gastric feeds of EBM at a rate of 3 ml/hour continuous. The team trialled stopping the IV replacement of his ml for ml stoma losses and reinfused the entire volume of chyme into the mucous fistula instead. At this point he remained on TPN for nutrition, but it quickly became evident that Sai was tolerating the chyme reinfusion and feeds were slowly graded up. He had his first bowel motion less than 48 hours after initiating re-feeding Sai’s medical team and parents celebrated!
Within 14 days, he was gradually graded back up to full gastric feeds of fortified EBM at a volume of 180 ml/kg/day. His central line remained in situ with fluids running TKVO due to his history of high stoma outputs and feed intolerance. Although his stoma outputs remained high, he was tolerating the entire volume of chyme being reinfused with no signs of reflux from the distal fistula. His growth chart started to normalise and he began tracking along the 10th centile nicely. At DOL 67, corrected gestation age (CGA) 33 +5, he weighed in at a 1700g. He gained 550 grams in 14 days! That is 40 grams per day, a drastic improvement from his previous 1.5 grams per day prior to chyme reinfusion therapy.
A few days later, the medical team was confident enough to remove Sai’s central line, and for the first time in his life, he was TPN free!
Once Sai started refeeding, he quickly progressed and followed the typical path that preterm babies follow. He was gaining weight consistently; his respiratory status was improving and he progressed to high flow. He even started breast feeding.
The real stars of Sai’s Chyme reinfusion journey were his Parents. They quickly became proficient with all aspects of chyme reinfusion using The Insides® Neo. They learned everything from assembling the device, changing the bag, inserting the refeeding tube, withdrawing the chyme to starting the reinfusion. They were even teaching new nurses and students how the chyme reinfusion system worked. They had some great feedback for the device which led to the development of a ‘Patient Card’ that can be filled out attached to each patient’s cot. This patient card helps to clearly identify patients using The Insides® Neo, a diagram of the abdomen identifying the proximal and distal fistulas, which sized gastric tube to use for refeeding and a maximum rate of reinfusion documented by the surgeons. It has helped the medical team keep details clear and consistent without having to search through the patient’s notes each time they are looking for information.
On Day of life 111, 40 weeks corrected (his due date!), weighing 2900 grams, Sai went back to surgery for his reanastomosis. He spent a total of 58 days using The Insides® Neo and had gained a total of 1750 grams! That was an average of 30 grams per day.
This was an exciting day for Sai and his parents, getting him one step closer to home. His post-op recovery was so much easier this time around and he spent minimal time ventilated and on TPN. He remained NBM for 6 days, to give his anastomosis time to heal, and then was slowly graded back up to full enteral feeds.
When referring to figure one, you can clearly see that after Sai’s primary laparotomy at 25+6 corrected gestational age (CGA), he had a 6 week period of static growth dropping toward the 3rd centile. When chyme reinfusion therapy was commenced at 31 +5 CGA he had an immediate rapid weight gain and then continued to track along the 10th centile. During this period, he was started back on full enteral feeds and completely weaned off TPN by approximately 34 weeks CGA. His central line was removed a few days later after the medical team was confident that he was tolerating his enteral feeds and chyme reinfusion therapy with steady weight gain. He went from an and average weight gain of 1.5 grams per day up to 30 grams per day with the initiation of chyme reinfusion therapy via The Insides® Neo. At 40 weeks CGA, Sai underwent his reanastomosis, where he had a small dip in his weight to the 3rd centile, but then started tracking up the growth curve once on full enteral feeds.
After Sai’s reanastomosis and recovery, he had a typical ex-preterm journey working toward getting home. He worked on feeds and weaned off respiratory support and onto low flow oxygen which he would be discharged with. He was discharged home 6 weeks after his reanastomosis after spending a total 154 days in Neonatal Intensive Care. He was 46 weeks corrected and weighed 3910 grams.
Sai has the most amazing and supportive parents who we by his bedside nearly 24/7. On his sickest days they would take shifts and sit at his bedside to comfort him. They were, and still are amazing advocates for Sai. He is a very lucky boy and his parents are happy to finally have him home after such a long and difficult NICU journey.
In conclusion, Sai spent a total of 58 days using The Insides® Neo after undergoing a laparotomy NEC. He had a period of static growth prior to starting chyme reinfusion therapy, but thrived using The Insides® Neo and was able to gain weight and wean off of TPN. He recovered well post reanastomosis surgery and was able to transition back to gastric/oral feeds quickly. He spent a total of 154 days in intensive care before being discharged home with his very excited parents.
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This case study follows Adrienne, a premature infant whose Neonatal Intensive Care stay was complicated by bowel perforations, significant faecal peritonitis and large volume turbid ascites, secondary to a milk curd obstruction. She required a beside laparotomy in the Neonatal Intensive Care Unit (NICU) and her postoperative journey was very difficult, complicated by hypovolemic shock, an aortic clot, a wound dehiscence with a fistula formation, and a further deterioration with septic shock leading to reduced blood flow to her small bowel.