MECONIUM

1

• MECONIUM
• PERITONITIS/
• CASE PRESENTATION
• Presented by dr Farah A- Khawaja
• DISCUSSED BY
• DR. K. GHANDOUR.
• DR. A. HAMAM.

2
HISTORY

• B/O A was a N/B male baby, diagnosed in utero, at
  G.A. of 30 weeks to have hydrops fetalis
  maternal polyhydramnios.
• He was delivered at 1000 am on 16/2/2004 by
  elective C/S, GA31 weeks.

3
EXAMINATION AFTER DELIVERY

• H.R 175, R.R 50, Temp 37.5, BP 57/30,
  O2 sat 99 (O2 via N/P).
• Measurements Weight 2.330 Kg,
• HC 31 cm,
• Length 45 cm.

4
EXAMINATION/ Cont.

• Pink, not jaundiced having moderate respiratory
  distress with irregular breathing.
• Gross abdominal distension, AG35 cm, generalized
  abdominal tenderness.

5
EXAMINATION/ Cont.

• Rest of physical examination was unremarkable.

6
MANAGEMENT

• N/G tube drained greenish material.
• Peritoneal tap was performed immediately a
  sample was sent for analysis, the fluid came out
  as yellowish green, 170 ml in the 1st hour with a
  total of 290 ml at the end of his 1st day.

7
PERITONEAL FLUIDANALYSIS

• Protein3.1 g/dL, PH7.5, SG1010, sugar44
  mg/dL, LDH430 U/L,
• Serum Protein3 g/dL, serum LDH839 U/L,
  fluid/serum LDH0.5, sugar66 mg/dL.

8
LAB RESULTS

• CBC Hb 14 g/dL, PCV41, WBC7.7103 mm3,
  N33, L55, M12, Plt 492 103 mm3
• LFT, KFT Normal.
• TORCH Negative.
• PCR/ Cystic Fibrosis Negative.

9
ABDOMINAL US

• Diffuse adrenal glands enlargement consistent
  with diffuse hyperplasia. The gall bladder was
  slightly distended. Small amount of fluid was
  seen in the Morisons pouch.

10
MANAGEMENT/ Cont.

• NPO.
• He received Oxygen through N/P.
• UAC, UVC were inserted, I.V.Fluids, Ampicillin,
• Cefotaxime started empirically.

11
1ST LAPAROTOMY

• Done on the next day.
• Indications
• Meconium peritonitis ,
• Intestinal obstruction.

12
1ST LAPAROTOMY/Intraop Findings

• Diffuse meconium peritonitis,
• jejunal atresia, loss of small
• bowel, inspissated meconium
• in terminal ileum.
• Segmental SB volvulos, the cause
• is meconium ileus in utero.

13
1ST LAPAROTOMY/ Procedure

• Resection with end end
• anastomosis.
• Length of healthy remaining SB is 70 cm in
  addition to the ileocecal valve.

14
1ST LAPAROTOMY/Cont.

• Closure of abdominal wall was performed without
  stomas or drains.
•  
• Metronidazole was added.

15
COURSE IN HOSPITAL

• The baby was kept NPO for 7 days was receiving
  intravenous fluids antibiotics.

16
COURSE IN HOSPITAL

• His N/G tube drainage was not significant during
  the 7 postop days.
• On 22/2/2004 (5th post op) UAC was removed
  feeding was started on 23/2/2004 by continuous
  N/G drip as 1cc/hour G/W 5 then shifted the next
  day to ½ strength Comformil or Breast Milk with
  gradual increase.

17
COURSE IN HOSPITAL

• Sucking was started on 25/2/2004 with gradual
  build up in the amount. Initially there was milk
  residue in the stomach that decreased over time.
  The baby was in a stable general condition was
  gaining weight off Oxygen since 23/2/2004.
• He was taking 35-40 ml / feed.

18
28/2/2004

• UVC was removed, tip was sent for C/S revealed
  E.Coli, which was sensitive to Imipenem-Cilastatin
  , Amikacin, and Piperacillin-Tazobactam but
  resistant to Ampicillin Cefotaxime.

19

• Yet, the babys general condition was stable,
  sucking well was gaining weight so
• Ampicillin, Cefotaxime,
• Metronidazole IVF were discontinued on
  2/3/2004.

20
5/3/2004

• The baby was noticed to take the Breast Milk
  adequately but slow in taking the Comformil so
  the milk was changed to Similac NeoSure in a
  trial to take more calories in a smaller volume
  (NeoSure 0.74 Kcal/ml vs. 0.70 Kcal/ml for
  Comformil).

21
7/3/2004

• The baby developed hypoactivity, intolerance to
  feed, and abdominal distension as the abdominal
  girth increased from 27cm to 31cm in the same
  day. So he was kept NPO, Metronidazole
  Piperacillin-Tazobactam started again.

22
8/3/2004

• The babys general condition deteriorated.
• Abdominal XR revealed bowel loops distension with
  intramural air shadows suggestive of NEC.
• A plan for a second laparotomy on the same day
  was decided.

23
2ND LAPAROTOMY

• Indications
• Suspension of gangrenous SB.
• Presumptive diagnosis
• Extensive NEC or adhesion
• obstruction with gangrene.

24
2ND LAPAROTOMY/Intraop Findings

• Extensive NEC involving the
• remaining small bowel, the
• small bowel was dusky
• didnt respond to 100
• oxygen.

25
2ND LAPAROTOMY/Procedure

• A small opening was done in the
• small intestinal wall irrigation
• by warm saline done. Peritoneal
• cavity was irrigated also by warm
• saline.
• Abdominal wall closed with no
• stomas or drains.

26
2ND LAPAROTOMY/Cont.

• The baby came from the operative theatre on
  mechanical ventilator with a plan to maintain him
  on the ventilator to achieve good oxygen
  saturation adequate PaO2.

27

• Lab results post op showed decreasing WBC
  4.3103 mm3 (preop 11.2).
• Platelets 337 103 mm3 (532).
• Na 129 meq/L (134).
• ABGs PH 7.3, PaCO2 31.2mmHg, PaO2 61.7mmHg,
  HCO3 18.4meq/L, BE - 6.6, Oxygen Sat 91.8.
• On 9/3/2004 Amikacin was added.

28

• The babys condition worsened with increasing
  abdominal distention worsening lab results with
  decreasing Hb, Platelets, WBC, Na, persistent
  loop distention by abdominal XR.

29

• Peritoneal tap was done 3 times before the 3rd
  laparotomy, the fluid came out as dark red to
  black.
• Peritoneal tap cultures.

30

• Elective extubation was done on 12/3/2004 the
  baby remained on Oxygen given through N/P.
• Tip of ETT C/S revealed
• E. Coli Pseudomonas.

31
16/3/20043RD LAPAROTOMY

• Indications
• Suspected gangrene of the SB.
• Findings intraop.
• Gangrenous SB preserving the
• proximal 5 cm of jejunum
• 5 cm of terminal ileum.

32
3RD LAPAROTOMY/Procedure

• Resection of gangrenous SB
• with formation of proximal
• distal stomas.

33
3RD LAPAROTOMY/Cont.

• The baby came out from the operative theature on
  mechanical ventilator but was extubated
  electively after 9 hours put on Oxygen given
  through N/P.

34
17/3/2004

• The baby started to have attacks of bradycardia
  low
• oxygen saturation.

35
18/3/2004

• He continued to have low oxygen saturation 40s
  so he was put on mechanical ventilator .
• But he didnt improve despite being on high
  setup. He started to develop low BP was started
  on Dopamine.

36
19/3/2004

• Last CBC
• Hb7.9 g/dL, PCV24, WBC0.69103mm3,
  Plt18103mm3.
• The baby died at 1000 am.

37
MEDICATIONS/ SUM.

• 1- Ampicillin, Cefotaxime 16/2-2/3/2004.
• 2- Metronidazole 17/2-2/3/2004.
• 3- Tazobactam/ Piperacillin 7/3-14/3/2004.
• 4- Pentaglobin for 5 days 8/3/2004.
• 5- Amikacin 9/3/2004.
• 6- Imipenem/ Cilastatin 14/3-16/3/2004.
• 7- Tazobactam/ Piperacillin 16/3/2004.
• 8- Filgrastim 16/3/2004.
• 9- PRBCs, Platelets, FFP.