Anesthesiology APPLIED Exam › Pediatric and neonatal

Necrotizing enterocolitis: the premature neonate for laparotomy

Pediatric and neonatal·~4 min read· Physician-reviewed✓ Sourced · 7

Stem

A 10-day-old girl born at 27 weeks, now 1.1 kg, has necrotizing enterocolitis with free air on the abdominal film. She is intubated on conventional ventilation, FiO2 0.45, with a dopamine infusion, an umbilical venous line and a peripheral IV. Hemoglobin is 9.6 g/dL, platelets 46,000, INR 1.8, lactate 4.4 mmol/L, glucose 56 mg/dL, temperature 36.3 °C. The surgeons want a laparotomy tonight.

Question

Where will you do this case, and how will you manage the anesthetic?

Ideal answer

HeadlineA septic, coagulopathic 1-kg neonate with perforated bowel. I choose the location with the NICU and surgeons, then run an opioid-relaxant anesthetic around volume, heat and oxygen.

Decide bedside versus OR together, because transport risks the tube, lines and heat; the sickest stay in the NICU.¹
Fentanyl and a non-depolarizing relaxant, no nitrous oxide, volatile only if she tolerates it.¹^,2
Replace 6–10 mL/kg/h losses, blood 1:1, guided by hematocrit, lactate and urine over 0.5 mL/kg/h.²
Normothermia, 36.5–37.5 °C: room warmed before she arrives, plastic drapes, warmed fluids, blood and irrigation.³^,1^,2
SpO2 90–95%, agreed with the NICU, because both hypoxemia and oxygen excess harm her.⁴^,1

Watch for: hypotension at incision and closure, hypoglycemia, hypocalcemia, and bleeding that may need vitamin K.¹

Breaking down the answer

Bedside or OR — bedside patients are sicker, often on oscillation or several vasopressors; there is no volatile at the bedside.¹ Changes if: she is stable on conventional ventilation; the OR gives better light, warming and volatile.
Keep her ventilator — a NICU ventilator or oscillator usually stays; sidestream capnography draws about 150 mL/min, too much for some neonates.¹ Changes if: the tube leaks; I change it cautiously, same size or 0.5 smaller.¹
Oxygen target — in SUPPORT, 85–89% versus 91–95% cut retinopathy (8.6% versus 17.9%) but raised death (19.9% versus 16.2%); NeOProM found more death and NEC with restricted oxygen.⁴ Changes if: cyanotic heart disease or pulmonary hypertension.⁴
Products — platelets 10–20 mL/kg, >50,000 for surgery; plasma 15–20 mL/kg for bleeding with long clotting times; cryoprecipitate 5–10 mL/kg if fibrinogen <100 mg/dL.⁵ Changes if: no bleeding; an abnormal INR alone is not treated.⁵
Glucose, calcium, red cells — dextrose continues against hypoglycemia;¹ calcium gluconate 10% 100–200 mg/kg (1–2 mL/kg) for low ionized calcium;⁶ red cells 15 mL/kg below 10 g/dL if ventilated in week 2.⁵ Changes if: bleeding; I replace losses.
Pressors — epinephrine 0.02–1 mcg/kg/min, norepinephrine 0.05–0.1 mcg/kg/min, vasopressin for refractory shock.² Changes if: the heart is the problem; epinephrine over vasoconstrictors.
Stakes — mortality reaches 63% or more with perforation and peritonitis.⁷ Changes if: she is too unstable even for the bedside; drain placement under local is a bridge.⁷

Follow-up question

As the surgeons close the abdomen, peak airway pressure climbs from 20 to 34 cmH2O, SpO2 falls to 80%, and the arterial pressure drops from 42/24 to 28/16 mmHg. What do you do?

Follow-up answer

HeadlineAbdominal compartment physiology from a tight closure until proven otherwise; I tell the surgeons to stop and reopen.

I hand-ventilate in 100% oxygen and feel the compliance. I check the tube for kinking, displacement and secretions, and for pneumothorax. As the closure is released, I give 10 mL/kg of blood or albumin and escalate epinephrine.² If pressures stay high, the surgeons leave the abdomen open with a temporary silo. I reassess airway pressure, saturation, pressure and urine output, and check a gas.

Pitfalls that cost points

Moving a baby on high-frequency oscillation to the OR by default.
Chasing saturations of 100% throughout the case.
Uncounted flushes and drug volumes overloading a 1-kg baby.¹

Rapid-fire

Q: What tube sizes do these babies use? A: 2.5–3.5 mm, often uncuffed in the NICU.¹

Q: What are the absolute surgical indications? A: Pneumoperitoneum, peritonitis and clinical deterioration, Bell stage III.⁷

Q: Which laboratory values do you follow? A: Hemoglobin, platelets, INR, glucose, calcium and blood gases.¹

Numbers to know

Item	Value
Third-space and evaporative loss	6–10 mL/kg/h²
Urine output goal	>0.5 mL/kg/h²
Preterm SpO2 target	90–95%⁴
Epinephrine infusion	0.02–1 mcg/kg/min²
Platelets for surgery	Keep >50,000; 10–20 mL/kg⁵
Temperature target	36.5–37.5 °C³
Mortality with perforation	≥63%⁷

Sources

1.Bedside Exploratory Laparotomy in the NICU: SPA Case Guide · Society for Pediatric Anesthesia, 2024 · www2.pedsanesthesia.org
2.Exploratory Laparotomy (OR): SPA Case Guide · Society for Pediatric Anesthesia, 2025 · pedsanesthesia.org
3.Procedural thermal bundle: neonates · NHS Lothian, 2020 · rightdecisions.scot.nhs.uk
4.Oxygen Saturation Targets for Preterm Infants (clinical pathway) · Johns Hopkins All Children's Hospital, 2023 · hopkinsmedicine.orgSummarizes SUPPORT and NeOProM.
5.Neonatal Transfusion bookmark (BSH guidelines on transfusion for fetuses, neonates and older children, 2016, with 2020 addendum) · NHS Blood and Transplant / British Society for Haematology, 2020 · shotuk.org
6.Electrolyte disorders related emergencies in children · BMC Nephrology (Zieg, Ghose, Raina), 2024 · europepmc.orgCalcium gluconate 100 mg/kg per dose (hyperkalemia); symptomatic hypocalcemia 20 mg/kg elemental calcium, about 2 mL/kg of 10% gluconate, over 10-20 min.
7.Modern aspects of anesthesia during surgical interventions for necrotizing enterocolitis in newborns · Pediatric Anesthesia and Critical Care Journal (Nasibova, Quseynova), 2024 · anestesiarianimazione.com

Facts on this page were checked against these sources on Oct 22, 2026. Guidelines change; confirm doses against current institutional protocols.