Indications for surgery include clinical deterioration, perforation, peritonitis, obstruction, and abdominal mass. When NEC has been detected early and appropriate therapy instituted promptly, only a small percentage of infants will require surgical intervention (50,51). Since perforation is an ominous complication, however, a close watch by a surgeon is essential. Infants with spontaneous perforation of the bowel are often more mature. Signs such as rapid clinical deterioration, manifested by persistent acidosis, consumption coagulopathy, a fall in the platelets, bradycardia, hyponatheremia, and urinary output deterioration in the face of adequate therapy, or if there is free air within the abdomen and if the child shows sudden onset of abdominal tenderness, the child must be promptly explored surgically. The goal of surgery is to stabilize gross peritoneal infection without sacrificing bowel length. The organisms recovered after perforation of the bowel represent the bowel flora and include Enterobacteriaceae as well as anaerobes (17). Antimicrobial coverage should therefore provide coverage against these organisms in a manner similar to the one used after any spontaneous rupture of the viscus (see chap. 22).
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