On day 51, K.A. was noted to have a worsening clinical picture with abdominal discoloration, blistering and sloughing of the skin on his abdomen. He was emergently returned to the operating room at our institution. This time, exploration revealed necrosis of 45 cm. of small bowel, requiring resection, and necrosis of the abdominal wall. Multiple biopsies of the abdominal wall including skin and the underlying tissue were performed and revealed necrotizing fasciitis. Additionally, peritoneal fluid cultures that had been obtained during his initial surgical procedure had grown Enterococcus, two species of Escherichia coli, Klebsiellaoxytoca and Proteus mirabilis.
During this second operation, K.A.’s entire abdominal wall was resected to include subcutaneous tissue, full thickness skin, and fat down to the inguinal crease and form flank to flank leterally. The surgical wound was covered with xeroform gauze because edema of the surrounding tissue did not permit closure.
Because K.A. was premature and also had an open abdominal wound, conserving insensible losses was particularly essential. Premature infants have a body composition of approximately 85% water, and for K.A., his open abdominal wound placed him at even greater risk for excessive evaporative fluid losses. Thus K.A. was placed in a Lahey bag (from the abdomen down), a sterile plastic bag that is used to help conserve insensible losses, prior to returning to the NICU for postoperative care.