Timing of surgery in NEC: Do respiratory requirements influence time to operating room?

• Respiratory compromise is prevalent in preterm neonates prior to NEC diagnosis. • Escalation in respiratory support needs is associated with shorter times to surgery, likely due to the increased risk of NEC in premature infants with severe respiratory difficulties. • Further studies are needed to consid respiratory parameters as potential objective markers of clinical deterioration and surgical decision-making in this population. Necrotizing enterocolitis (NEC) is a severe gastrointestinal emergency in preterm infants, often associated with respiratory compromise. We evaluated the association between respiratory support requirements at NEC diagnosis and time to surgery in very low birth weight (VLBW) infants with surgical NEC. A retrospective review of VLBW, preterm neonates (< 1500 grams and <34 weeks gestational age) with surgical NEC from January 2010 till December 2019 was conducted at an academic tertiary care center. Respiratory parameters were recorded after NEC onset. Time to the operating room (OR) was defined as median duration (hours) from diagnosis to surgery. High respiratory support group was defined as patients on invasive respiratory support. Sixteen neonates were included. Mean gestational age and age at diagnosis were 26.9 ± 2.9 weeks and 18.9 ± 12.3 days, respectively. Average birth weight was 951 ± 338 grams. Infants in the high respiratory support group (n = 10) had a shorter median time to OR (28 vs 229 hours, p=0.2), with respiratory acidosis significantly more prevalent in this group (90% vs. 33%, p = 0.03). These infants had longer hospital stays (159 vs. 73 days, p = 0.2) and a higher likelihood of multiple surgeries (80% vs. 50%, p = 0.3). Mortality was higher in neonates with low respiratory requirements, though this difference did not reach statistical significance (50% vs. 20%, p = 0.3). Higher respiratory support requirements at NEC diagnosis were linked to earlier surgical intervention, greater disease severity, and prolonged hospitalization. While limited by small sample size, our findings suggest that worsening respiratory status may serve as an early, objective marker of clinical deterioration, warranting closer monitoring and potentially expediting surgical decision-making in very low birth weight infants.