Atlas of Procedures in Neonatology, 4th Edition
Neonatal Ostomy and Gastrostomy Care
Linda C. D'Angelo
An ostomy is the construction of a permanent or temporary opening in the intestine (enterostomy) or urinary tract (urostomy) through the abdominal wall to provide fecal or urinary diversion, decompression, or evacuation (1). Gastrostomies (G tubes) are stomas that allow direct access into the stomach and are used for feeding, medication administration, and decompression. This chapter discusses care of simple and complex ileostomies, colostomies, urostomies, and gastrostomies. Tracheostomy care is discussed in Chapter 35.
Enterostomies and Urostomies in the Neonate
Ostomies may be indicated in the neonate for a variety of congenital or acquired conditions (Table 40.1). The stoma is usually temporary, and reanastomosis of the bowel or urinary tract and closure of the stoma is performed during infancy or early childhood (2,3).
- Types of Ostomies
- There are several types of intestinal stomas. The patient's condition, the segment of bowel affected, and the size of the patient's abdomen often determine the type of stoma and its external location. Figure 40.1 depicts the most common types of neonatal stomas (1).
- Urostomies are urinary diversions constructed to bypass a dysfunctional portion of the urinary tract. Ileal conduits and ureterostomies are rarely performed in the neonatal period.
- A vesicostomy is an opening directly from the bladder through the abdominal wall and is a more common urinary diversion in the neonate. Urine flows freely through the stoma from the bladder.
- Ostomy Assessment
The neonate with a stoma needs careful observation and assessment for a variety of potential complications (4). Monitoring the infant for function of the ostomy is paramount in the initial postoperative period. Possible surgical complications are paralytic ileus, intestinal obstruction, anastomic leak, and stomal necrosis. The factors to be considered during evaluation of the stoma are listed below.
- Type of stoma:The segment of bowel from which the stoma is made.
- Viability:A healthy stoma should be bright pink to beefy red and moist, indicating adequate perfusion and hydration (Fig. 40.2). The stoma is formed from the intestine, which is very vascular and therefore may bleed slightly when touched or manipulated, but the bleeding usually resolves quickly. The stoma is not sensitive to touch because it does not have somatic afferent nerve endings (4).
- A purple or dark brown to black stoma with loss of tissue turgor and dryness of the mucous membrane may indicate ischemia and possible stomal necrosis.
- A pale pink stoma is indicative of anemia.
- Size:The stoma shape (round, oval, mushroom, or irregular) and diameter (length and width) in inches or millimeters is noted. In the early postoperative period, the stoma will be edematous. After the first 48 to 72 hours, the edema should resolve and result in a reduction in size of the stoma, which should, however, still remain everted from the skin surface. Stomas generally continue to decrease in size over 6 to 8 weeks postoperatively. It is not uncommon for the stoma to become edematous when exposed to air while changing the pouch; this edema generally resolves quickly when the pouch is replaced.
- Stomal height:The degree of protrusion of stoma from the skin. Ideally, the surgeon will evert the stoma prior to suturing it to the skin to produce an elevation, which will promote a better seal with the ostomy wafer. With the stoma elevated above the surface of the skin, the effluent will be more likely to go into the pouch instead of staying in contact with the skin (2). Eversion of the stoma, referred to as maturing the stoma, is not always possible in neonates, in whom blood supply may be tenuous, and in situations in which the bowel is markedly edematous (1,5).
TABLE 40.1 Conditions Necessitating Ostomy in the Neonate
FIG. 40.1. A: End stoma. The end of the bowel is everted at the skin surface. B: Loop stoma. Entire loop of bowel is brought to the skin surface and opened to create a proximal, or functioning, end and a distal, or nonfunctioning, end. The distal side is called a mucus fistula because of the normal mucus secretions it produces. C: Double-barrel stoma. Similar to a loop stoma, except the bowel is divided into two stomas, a proximal and a distal stoma. The distal stoma functions as a mucus fistula. (Adapted from
Gauderer MWL. Stomas of the small and large intestine. In: O'Neil JA, Rowe MI, Grosfeld JL, et al., eds. Pediatric Surgery. 5th ed. St. Louis, MO: Mosby; 1998:1349–1359
, with permission.)
- Stomal construction:The ostomy may be an end, loop, or double-barrel (Figs. 40.1 and 40.3).
- Abdominal location
- Peristomal skin:Ideally the peristomal skin should be intact, nonerythematous, and free from rashes. However, frequently the stoma(s) is not separate from the surgical incision (Fig. 40.4). There is often not enough space on the baby's abdomen for the surgeon to create separate incisions. In addition, stomas are often in close proximity to the umbilicus, ribs, or groin, which may interfere with pouch selection and adherence (6).
- Stomal complications
- Hemorrhage during the immediate postoperative period is caused by inadequate hemostasis (4).
- Trauma to stoma caused by improper fitting pouch. A wafer cut too close to the stoma can injure the delicate tissue. Stomal lacerations can occur as a result of the edge of the wafer rubbing back and forth against the side of the stoma (4).
- Necrosis: Caused by ischemia and may be superficial or deep. Necrosis extending below the facial level may lead to perforation and peritonitis, requiring additional surgical intervention (4).
- Mucocutaneous separation: This condition is caused by a breakdown of the suture line securing the stoma to the surrounding skin, leaving an open wound next to the stoma.
- Prolapse: Telescoping of the bowel out through the stoma. In infants this condition is frequently related to poorly developed fascial support or excessive intra-abdominal pressure caused by crying.
- Retraction: The stoma is flush or recessed below the skin surface. This condition may result from insufficient mobilization of the mesentery or excessive
tension on the suture line at the fascial layer, excessive scar formation, or premature removal of a support device (4).
- Stenosis: The lumen of the ostomy narrows at either the cutaneous level or the fascial level. Sudden decrease in output may indicate stenosis.
- Peristomal complications
- Allergic dermatitis
- Contact dermatitis: Most common type of peristomal skin complication seen, generally from the leakage of fecal effluent on the skin.
- Mechanical trauma: Epidermal stripping, abrasive cleansing techniques, or friction due to ill-fitting equipment are the most common causes of mechanical injury to the peristomal skin.
- Hernia: A peristomal hernia appears as a bulge around the stoma that occurs when loops of the bowel protrude through a facial defect around the stoma into the subcutaneous tissue (4).
FIG. 40.2. Immediately postoperative loop ileostomy. Segment of bowel on left is the exteriorized perforation from necrotizing enterocolitis.
FIG. 40.3. Premature infant with double-barrel colostomy.
FIG. 40.4. End ileostomy and wound closure with retention sutures posing a challenge for placing a pouch.
- Ostomy Care
- Immediate postoperative care
- Assess stoma for adequate perfusion.
- Protect the stoma. Although stool output is usually minimal in the initial postoperative period, covering the stoma with an ostomy pouch prevents the mucosa from drying out, especially if the baby is under a radiant warmer. Petrolatum gauze may be used in the postoperative period if placement of the pouch has to be delayed because of problems with skin integrity.
- Cover the mucus fistula with a moisture-retentive dressing to keep it from drying out. When securing a dressing on a neonate, use low-tack adhesives. There is increased risk of skin tears in neonates, especially when they are premature with delayed epidermal barrier development. Avoid placing petrolatum gauze over the pouching surface for the stoma, as it can impede adherence.
- Subsequent care
- Regular assessment of the stoma
- Protect peristomal skin from the effects of the effluent by pouching (Fig. 40.5). The effluent from a small bowel stoma contains proteolytic enzymes that can rapidly cause skin erosion. Ideally the bag should remain in place for at least 24 to 72 hours. The bag must be changed if there is any evidence of leaking effluent under the skin barrier wafer. Frequent bag changes, however, can result in denuded skin, especially in the premature infant (2,4,7). In situations with frequent leaking and pouch changes, expert help may be required to preserve the skin and obtain acceptable wear time. When a pouch cannot be maintained, it may be necessary to leave the pouch off and protect the peristomal skin with a protective barrier paste that will adhere to denuded skin to allow the skin to heal. The barrier ointment can be covered with petrolatum-impregnated gauze; fluff gauze can then be placed on top to absorb the effluent and changed as needed. In some cases of severe skin damage, some neonatal centers stop enteral feedings briefly to limit stool production and allow the skin to heal (2).
- Protect stoma from trauma. Measures include accurate sizing of the opening to clear the stoma as the size changes. If the infant's movements cause the inner edge of the barrier to rub against the stoma, a moldable barrier between the stoma and the wafer can be used to protect the stoma.
FIG 40.5. One-piece ostomy appliance on small newborn dwarfs this infant, but provides longer wear time and holds larger volume of output than the preemie pouches previously used.
Several different types of pouches and ostomy care supplies are available (Tables 40.2 and 40.3). One-piece pouches come with a barrier and pouch attached as a single unit. Two-piece appliances have a barrier and pouch separate, with a mechanism for attaching the pouch to the wafer, generally in the form of a plastic flange that snaps together. The type of pouch used with a neonate is generally either an open-end pouch that allows the passage of thick or formed effluent or a urostomy pouch with a spout designed for drainage of urine or liquid effluent. The type of pouch and the need for accessory products varies depending on the size of the child, the condition of the peristomal skin, abdominal size and contours, and institutional preference. In general, it is best to keep the procedure simple and to use as few products as possible (2). Special consideration needs to be given to the premature infant whose skin is immature and fragile. Several companies manufacture pouches for neonates and premature infants (Fig. 40.7). Neonatal units should have several varieties to choose from in order to meet each patient's individual needs.
- Clean gloves
- Warm water
- Small basin or tub
- Clean, soft cloth
- 2 x 2-in gauze
- Appropriate-size pouch with clip/closure device
- Protective skin barrier wafer (if not using one-piece pouch)
- Other ostomy accessories as appropriate (Table 40.3 and Fig. 40.8).
- Scissors or seam ripper
- Stoma-measuring device
- Applying the Pouch: Routine/Simple Ostomies (2,6,8)
- Remove old pouch by gently pulling up the edges and using water to loosen while pressing down gently on the skin close to the edge to reduce traction on the epidermis. Adhesive remover should not be used on a neonate <2 weeks of age. Limited use of adhesive remover, followed by thorough cleansing of the area to remove any chemical residue, is recommended only when the adhesive bond of the barrier to the skin is so strong that the skin might be injured during removal (2).
- Use damp soft gauze or paper washcloth to gently cleanse the stoma to remove adherent stool or mucus. It is common to have a little bleeding of the stoma when it is cleansed.
- Wash peristomal skin with water; pat dry. Soap is not recommended because it may leave a chemical residue that could cause dermatitis; furthermore, many soaps contain moisturizers that can adversely affect the adherence of the barrier to the skin. It is also not advisable to use commercial infant wipes, because most are lanolin-based and contain alcohol (2).
- Measure stoma(s) using stoma measuring device (Fig. 40.9). The opening generally is cut 1/16to 1/8 in larger than the stoma, to limit the skin exposed to effluent. In tiny infants, in which the mucus fistula may be immediately adjacent to the functional stoma, one pouch may be sized to fit over both the stoma and the mucus fistula.
TABLE 40.2 Ostomy Pouches
- Trace hole size onto wafer. Cut hole(s) using small scissors or a seam ripper (Fig. 40.10). After cutting, and before removing the paper backing, check the fit around the stoma and trim more if needed. Run a finger along the inside of the opening to make sure there are no sharp edges; these can be cut or smoothed by rubbing with the finger. It may be necessary to trim the wafer to avoid umbilicus, groin, etc. Cutting small slits along the edges of the wafer may help the barrier conform to the contour of the stomach.
- Warm wafer in hands to promote flexibility and enhance bonding to the skin. Avoid using a radiant heater to heat the wafer, because the amount of heat absorbed cannot be controlled and may burn immature skin (2).
- Press wafer to skin and hold for 1 to 2 minutes. Secure the edges of the wafer down to the skin to improve wear time. Avoid the use of high-tack adhesives. Pink
tape is a waterproof tape that contains zinc oxide; it is very gentle and generally can be used safely. Other low-tack alternatives are paper tape, silicon tape, or clear film dressing.
- Change dressing to mucus fistula using a folded 2 x 2-in gauze piece and low-tack adhesive, or secure with diaper or tubular elastic dressing.
TABLE 40.3 Ostomy Accessory Products
FIG 40.6. Barrier paste applied to wafer.
FIG 40.7. Examples of appliances for pouching a neonate.
- Emptying the Pouch
- Clean gloves
- Diaper or syringe for withdrawing stool/effluent
- 30- to 60-mL syringe for irrigating/washing the bag
- Tap water
- The pouch should be emptied when it is one third to one half full. Gas must also be released or vented to prevent pulling the adhesive wafer away from skin. Neonates generally produce large amounts of gas, related to increased intake with sucking and crying (2). Effluent can be drained directly into a diaper or withdrawn from the bag with a syringe. Use of two or three
cotton balls placed in an open-end pouch can improve wear time by wicking the effluent away from the barrier and also may facilitate easy drainage of the pouch. It is generally not necessary to wash the pouch, but it may be necessary to add fluid to help loosen up thick or pasty stool. For the hospitalized neonate, measurement of ostomy output is usually indicated.
- Close the pouch with a closure device or rubber band.
FIG 40.8. Examples of ostomy accessories.
- Complicated Stomas and Peristomal Skin Problems (5,9)
Table 40.4 lists complications and interventions for treating complex stomas and common stoma problems. Note that many of items used are not generally recommended for use on premature neonates or neonates <2 weeks of age, but in situations of deterioration of the peristomal skin they are sometimes used cautiously to prevent further deterioration and maintain an effective seal.
FIG 40.9. Measuring the stoma.
FIG 40.10. Cutting a hole in the wafer.
- Vesicostomy Care
A vesicostomy does not require pouching; urine drains directly into the diaper. Care is similar to general perineal care of normal newborns (4). Occasionally, skin breakdown does occur; it can be treated with moisture barrier products and frequent diaper changes.
For indications and insertion technique, see Chapter 39.
- Types of Tubes
See Table 40.5.
- Gastrostomy Care
- The health care provider must know if the patient has undergone a Nissen fundoplication or other antireflux procedure together with the gastrostomy.
- Tolerance to feedings
- Type and size of tube
- Insertion site
- Condition of the peristomal skin
- Special considerations for patients with Nissen or other antireflux procedure
- Patient cannot vomit or burp.
- Vent tube after crying and at first sign of gagging, discomfort, or distress.
- Gastrostomy tube site and routine skin care (6,10)
- Clean gastrostomy tube site two to three times per day in the postoperative period and once per day after the site has healed. Use normal saline and sterile cotton swabs in the early postoperative period. Use mild soap and water after the site has healed. Diluted hydrogen peroxide (50% hydrogen peroxide and 50% water) is not recommended unless the site has dry, crusted blood (9).
- Ensure that the antimigration device is flush against skin and the gastrostomy tube has not migrated.
- Position tube at 90-degree angle.
- A bottle nipple placed over the tube with the flanges resting on the abdominal wall may also be used to keep the tube at a 90-degree angle; secure with tape (Fig. 39.5).
- Stabilize gastrostomy tube to prevent excess movement of tube, to decrease risk of stoma erosion, infection, bleeding, and development of granulation tissue.
- Use an anchoring device (e.g., Hollister Tube Drainage Attachment Device, Hollister Inc., Libertyville, IL, USA) if the patient is allergic to tape or as a routine to secure the tube to skin.
- Rotate bolster, flange of nipple, or wings of button every 4 to 8 hours to prevent pressure necrosis of skin. Do not place gauze between skin and bolster. A tension tab can be created by placing tape on the tube and pinning it to the diaper. A one-piece shirt with snap enclosure or tubular elastic dressing can also be used to cover the tube.
- Assess site and peristomal skin for leaking, irritation, redness, rashes, or breakdown. Erythema and a minimal amount of clear drainage are to be expected in the first postoperative week.
- Gastrostomy Tube Complications
Table 40.6 lists interventions for treating complications related to gastrostomy tubes.
TABLE 40.4 Complications and Complex Ostomies
TABLE 40.5 Types of Gastrostomy Tubes
TABLE 40.6 Interventions for Gastrostomy Tube Complications
The author acknowledges the work of Elizabeth E. Jarosz, Linda J. Haga and Jayashree Ramasethu, who wrote the chapter for the third edition of the Atlas, which formed the basis for this chapter.
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