Conundrum of hematochezia in infants with single ventricle physiology in the interstage period: Is it all really cardiac NEC?
Presented By:
Nickey Barr, RN, CPN; Amy Ricketts, MSN, CPNP-AC; Lori Erickson, PhD, CPNP-PC; Melissa Elliott, PhD(c), FNP-BC
Children's Mercy Kansas City
nabarr@cmh.eduOverview:
Purpose: Hematochezia (blood in stool) had seemed to rise in documentation during the interstage surgical neonatal hospitalization during the last two years resulting in frustrations from parents as this is an interstage red flag and once noted may cause an increased length of stay. The last two years has provided team and family stress from the pandemic, Ranitidine coming off the market (Stress-Ulcer Prophylaxis), focus on Venous thromboembolism (VTE) prophylaxis (GI bleeding risk), and in immunology literature, there has been an increased report of cows milk allergy (CMA). However in the interstage population, this has to be interpreted cautious as hematochezia may be ischemia/reperfusion as an early indicator for cardiac NEC (cNEC) and not necessarily CMA. Our purpose of this project was to evaluate the incidence of documented hematochezia and cNEC in our interstage population over the past three years with overall hospitalization occurrence and any associations of clinical, demographic, or medication findings.
Project Design: This QI project consisted of a single site, retrospective review, cross-section of neonates who underwent CHD procedures from 1/2019 to 11/2021. Cardiac High Acuity Monitoring Program (CHAMP®) registry was used for evaluation of demographics and clinical findings. Infants were excluded from this analysis that did not discharge home during the interstage or who were not include included in the CHAMP registry for our institution.
Results: Of 57 infants, there were no differences across the 2019 cohort (n=26) and 2020-21 cohort (n=31) on patient or SES demographics, surgery types, echo dysfunction or AVVR, rate of PPI use at dc, pre-operative risks and non-NEC post-op complications. Between the two time periods, there was an increase in hematochezia (46 to 72%, p=.016), treatment for cNEC from 15 to 39% (p=.047) and increased length of neonatal stay (44 to 70 mean days, p.006). Inversely, there was a noted lower rate to full feeds (4.4 to 9.29 mean days, p.014) post-op. At discharge, there were also difference between time periods of 35% in 2019 to 0% of infants discharged home on Ranitidine (p<.001), more infants discharged home on Reglan (0 to 16%, p.023), Lovenox use (12 to 48% p=.002), less kcal (23.46 to 22.19 mean kcal/oz, p.005) and more infants were on more sole formula without breastmilk (50 to 83.9%, p.023).
Conclusion: With this evaluation, we confirmed that there was an increase in both the incidence of hematochezia and treatment for cNEC from 2019 to current with an increased length of stay. Although there was an increased rate of Lovenox use at discharge, the importance of VTE prophylaxis is critical for hematologic and neurologic outcomes so we would be cautious to push as a reason for increased hematochezia. There seems to be a protective effect of feeding cautiously with slower rate to full feeds and less kcals at discharge. Our next step is to examine hematochezia at a patient level (labs, milk type, radiology) on the med-surgery unit to see if there are factors for increased odds of bloody stools for potential practice changes.
Project Design: This QI project consisted of a single site, retrospective review, cross-section of neonates who underwent CHD procedures from 1/2019 to 11/2021. Cardiac High Acuity Monitoring Program (CHAMP®) registry was used for evaluation of demographics and clinical findings. Infants were excluded from this analysis that did not discharge home during the interstage or who were not include included in the CHAMP registry for our institution.
Results: Of 57 infants, there were no differences across the 2019 cohort (n=26) and 2020-21 cohort (n=31) on patient or SES demographics, surgery types, echo dysfunction or AVVR, rate of PPI use at dc, pre-operative risks and non-NEC post-op complications. Between the two time periods, there was an increase in hematochezia (46 to 72%, p=.016), treatment for cNEC from 15 to 39% (p=.047) and increased length of neonatal stay (44 to 70 mean days, p.006). Inversely, there was a noted lower rate to full feeds (4.4 to 9.29 mean days, p.014) post-op. At discharge, there were also difference between time periods of 35% in 2019 to 0% of infants discharged home on Ranitidine (p<.001), more infants discharged home on Reglan (0 to 16%, p.023), Lovenox use (12 to 48% p=.002), less kcal (23.46 to 22.19 mean kcal/oz, p.005) and more infants were on more sole formula without breastmilk (50 to 83.9%, p.023).
Conclusion: With this evaluation, we confirmed that there was an increase in both the incidence of hematochezia and treatment for cNEC from 2019 to current with an increased length of stay. Although there was an increased rate of Lovenox use at discharge, the importance of VTE prophylaxis is critical for hematologic and neurologic outcomes so we would be cautious to push as a reason for increased hematochezia. There seems to be a protective effect of feeding cautiously with slower rate to full feeds and less kcals at discharge. Our next step is to examine hematochezia at a patient level (labs, milk type, radiology) on the med-surgery unit to see if there are factors for increased odds of bloody stools for potential practice changes.
