Journal of pediatric surgery · 2025
'Impact of a Regional Damage Control Surgery Pathway on Time to Surgery for Neonates With Severe Necrotising Enterocolitis. A Prospective Cohort Study'.
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Suren Arul G, Jones Alison, Martin Jeffrey, Philpott Alex, Nash Matt, Hughes Andrea, Hulbert Sarah, Tajik Myrthe, Pachl Max, Soccorso Giampiero, Singh Michael, Jester Ingo, Patel Hetal, Lander Anthony, Krishnan Kanthimathinathan Hari
Аннотация
BACKGROUND: In the UK, published time from diagnosis of perforation to surgery for babies with Necrotising Enterocolitis (NEC) was 23·5 h. We aimed to determine if a standardised regional referral pathway, combined with a damage control surgical approach (DCS) could reduce timings associated with referral to first surgical intervention.
METHOD: Our pathway standardised referrals, transfer, blood-crossmatching and DCS. Criteria to trigger pathway was a neonate with NEC and either perforation or requiring inotropes. Pathway implementation used quality improvement and appreciative inquiry principles. Timings and physiological data were collected prospectively as were other secondary outcomes including mortality, stoma rate and time on parenteral nutrition.
RESULTS: From 01/08/2021 to 31/12/2023, 60 neonates (median gestation 26 weeks, birth weight 815g) with NEC, triggered our DCS pathway. All timing metrics (referral to PICU admission, admission to blood availability, PICU to surgery, and referral to surgery) showed statistically significant reduction over the course of the study. The time from referral to surgery was median [interquartile range] 347 [289-514] minutes, with reduction from 449 min in the earlier part of study to 323 min in the latter half[p = 0.01]. Median operative time for DCS 26 min. Twenty patients (33 %) had stoma. Seventeen patients died within 28 days (28 %) after surgery. There were 42 babies with birthweight <1000g (mortality 33 %). Median time on PN after primary anastomosis was 30 days versus 93 days after stoma.
CONCLUSION: This is the first prospective report of interventions to expedite time to surgery in severe NEC. In this study we demonstrated reduction in all timings measured. Clinical outcomes were better than expected compared with historical datasets. Further work is needed to establish whether improved outcomes are associated with earlier transfer to surgery, the damage control approach, the standardised coordinated regional approach, or the cumulative effect from all aspects of this pathway.
LEVEL OF EVIDENCE: 2B GS Arul et al.
METHOD: Our pathway standardised referrals, transfer, blood-crossmatching and DCS. Criteria to trigger pathway was a neonate with NEC and either perforation or requiring inotropes. Pathway implementation used quality improvement and appreciative inquiry principles. Timings and physiological data were collected prospectively as were other secondary outcomes including mortality, stoma rate and time on parenteral nutrition.
RESULTS: From 01/08/2021 to 31/12/2023, 60 neonates (median gestation 26 weeks, birth weight 815g) with NEC, triggered our DCS pathway. All timing metrics (referral to PICU admission, admission to blood availability, PICU to surgery, and referral to surgery) showed statistically significant reduction over the course of the study. The time from referral to surgery was median [interquartile range] 347 [289-514] minutes, with reduction from 449 min in the earlier part of study to 323 min in the latter half[p = 0.01]. Median operative time for DCS 26 min. Twenty patients (33 %) had stoma. Seventeen patients died within 28 days (28 %) after surgery. There were 42 babies with birthweight <1000g (mortality 33 %). Median time on PN after primary anastomosis was 30 days versus 93 days after stoma.
CONCLUSION: This is the first prospective report of interventions to expedite time to surgery in severe NEC. In this study we demonstrated reduction in all timings measured. Clinical outcomes were better than expected compared with historical datasets. Further work is needed to establish whether improved outcomes are associated with earlier transfer to surgery, the damage control approach, the standardised coordinated regional approach, or the cumulative effect from all aspects of this pathway.
LEVEL OF EVIDENCE: 2B GS Arul et al.