When Transfer Is Impossible: Emergency Management of Perforated Necrotizing Enterocolitis in a Neonate With Uncorrected Dextro-Transposition of the Great Arteries.

Dextro-transposition of the great arteries (d-TGA) is a congenital heart disease (CHD) characterized by parallel circulations, in which survival depends on intercirculatory mixing. CHD as a whole is a recognized risk factor for necrotizing enterocolitis (NEC), which carries high morbidity and mortality. Managing perforated NEC in a neonate with uncorrected complex d-TGA presents a complex challenge, particularly in centers lacking specialized pediatric cardiac surgery facilities. We report the successful emergency management of a 28-day-old preterm neonate with uncorrected complex d-TGA, a large ventricular septal defect, and severe subpulmonary obstruction requiring urgent surgery. Due to vital urgency and the impossibility of transfer to a specialized center with pediatric cardiac surgery, local care was optimized through remote expert consultation and an intensive multidisciplinary briefing. Anesthesia was tailored to maintain systemic vascular resistance and preserve pressure-driven intercirculatory mixing. The team relied on multimodal noninvasive monitoring, integrating cerebral near-infrared spectroscopy (NIRS) and continuous noninvasive hemoglobin (SpHb). Cerebral NIRS complemented conventional monitoring, detecting a drop in regional oxygen saturation (rSO2) and prompting a proactive transfusion strategy that stabilized the infant intraoperatively. Following a successful left hemicolectomy, the infant was later transferred to a specialized cardiac center for further management of d-TGA. Although surgery in such critical neonates is ideally performed in specialized centers, this case demonstrates how leveraging multidisciplinary teamwork, advanced monitoring, and physiological understanding can bridge the gap between gold standards and the practical realities of life-threatening neonatal emergencies in nonspecialized facilities.