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Ostomy Care
Objectives:
1. Focus on managing the pre-term neonates stoma 2. Review briefly common diseases affecting the preterm neonates that result in fecal diversion 3. Discuss ostomy management particularly skin barrier properties 4. Identify guidelines and practical strategies for managing premature ostomates.
Disclosure: NO grant or support has been received from any product company for this presentation!
INTRODUCTION
NICU personnel and pediatric surgeons have successfully improve the survival rates of premature neonates.
Surgical creation of fecal stomas allowing recovery of disease organs and surgical anastomosis distal to enterostomy Usually temporary, creating a stage in the surgical management of congenital or acquired disease.
Caring for these low, very low or extremely low birth weight infants with their tiny stomas can be challenging and frustrating.
Challenges
Wide variety of stomas and stomal complications More ostomy products that can be used However: NOT available LACK knowledge
Stoma care is inappropriate for low gestational age infants Inconsistent care among caregivers Ineffective care in containing effluent from stoma and preventing stomal complications
Common Conditions Requiring Stomas in Premature Infants Necrotizing Entero-Colitis (NEC) Anorectal Malformation Hirschsprung Disease (HD) Meconium Ileus Intestinal Atresia
Necrotizing Entero-Colitis
Occurs in 1-7.5% of newborn population
Garvin G, (1994)
Characterized by one or more areas of intestinal necrosis interspersed with segment of normal bowel Terminal ileum and right colon, left colon and sigmoid colon most commonly affected areas
Pokorny WJ, (1995)
Necrotizing Entero-Colitis
Pathogenesis: Availability of a substrate such as formula Ischemic mucosal injury of the intestine during perinatal asphyxia Hypothermia or vasospasm during umbilical artery catheterization Bacterial colonization
Roberts P. (1990)
Necrotizing Entero-Colitis
Medical Management: Bowel rest NG decompression IV alimentation Transfusion Antibiotics
Necrotizing Entero-Colitis
Surgical Interventions: Indicated only if infants fail to respond to medical management or When gangrene develops or perforation of the bowel occurs Surgery is required in 25 50% of newborn with NEC
Caty, M et al (2000)
Anorectal Malformations
Occurs in 1 in 4000 births
Pea, A. (1994)
Encompass wide range of congenital abnormalities GI, urinary, and reproductive systems Results in abnormal communications between rectum, GUT, or perineum
Guardino KO, (2000)
Anorectal Malformations
Requires immediate surgery: If passage of urine or stool is obstructed Feces is diverted via descending colostomy (double barrel or loop) until infant is old enough to tolerate definitive surgical correction of the defect Complex anorectal malformation requires extensive surgical management
Pea, A.(1994) Kiely EM; Pea, A. (1995)
Characterized by the absence of ganglion cells in the distal bowel Causing lack of peristaltic waves and spastic contraction of the affected segment Resulting to difficulty in passing stool 90% are diagnosed during the first 24 hours of life. (fails to pass meconium, abdominal distention, vomiting)
Puri, P. (1997)
Meconium Ileus
Results from abnormalities of the exocrine mucous secretion Contribute to the production of thick, sticky meconium that obstruct the small intestinal lumen 95% of patients with meconium ileus will have cystic fibrosis Obstruction occurs in the distal 15 -30 cm terminal ileus
Haga, LI. (1999)
Meconium Ileus
Management: Resection of the dilated ileus and formation of an ileostomy Simple meconium ileus: instillation of Nacetylcysteine into the bowel lumen through one or more enterostomies soften inspissated stool, manipulation of the bowel to move the meconium into the colon where it can be easily expelled
Groff, DB. (2000)
Meconium Ileus
Management:
Complicated meconium ileus Occurs when meconium contaminates peritoneum in utero / in the immediate perinatal period Bowel perforation + spillage of meconium results to
meconium ileus Volvulus Intestinal atresia or Stenosis
Rescarla FJ, (1998)
Intestinal Atresia
Common cause of bowel obstruction in neonates Rare, occurring in about 1 in 5000 live births Atresia most often occur in the small intestine Up to 12% of infants with one small bowel atresia are found to have additional atresia
Newman K.. (1997)
Intestinal Atresia
Surgery is emergent Involves resection of involved bowel with end-toend anastomosis Stomas are created only on unstable patients with peritonitis, vascular compromise, or meconium ileus
Millar , Rode and Cywes (2000)
Epidermal Barrier
Resides in the stratum corneum Normally forms in utero during the 3rd trimester Increases in maturity with increasing gestational age Full-term Infants: Born with competent barriers similar in adult with 10 20 layers Premature Infants: under developed barriers making them illequiped to cope with outside environment < 30 wks: 2- 3 layers 24 weeks: No stratum corneum
Lund C., (1999)
Dermal-Epidermal Junctions
Normally characterized by undulations or rete ridges Bonds the two layers of the skin In Premature Infants: Fewer anchoring elements that bonds the epidermis to dermis Epidermis stripping during adhesive removal Susceptibility to friction injury and blistering
Vulnerable to microorganism invasion Increased Transepidermal water loss Increase Percutaneous absorption
Nutritional Status
Preterm infants are at risks for the deficiencies in nutrients stored during the latter part of pregnancy Neonates with stomas are furthermore, at risk for mal-absorption
Garvin G (1990)
Stoma Management
Principle: PROTECT the skin!
From: Damaging Effluent Enzyme content pH level Liquid content Improper pouching technique (Mechanical Trauma) Aggressive adhesives Improper adhesive removal Inappropriate cleaning Incorrect or inappropriate use of ostomy products
Many ostomy products and management techniques used effectively for an older child or adult ostomates may NOT be safely used in preterm infant.
Contain alcohol causing topical and systemic effect like skin blisters, burn, necrosis, death due to elevated blood alcohol level.
Harpin V., 1982 Schick JB, 1981
Moisturizing Soap Should be avoided ; interferes with pouch adherence Commercial Wipes Lanolin-based with alcohol; not suitable for cleansing peristomal skin
Currently, the only alcohol-free skin sealant on the market is CAVALON No Sting Film (3M)
Choosing an Appliance
Consider the following:
Size of the infants abdomen Diameter and profile of the stoma Number and proximity of stoma Consistency and content of digestive enzymes (effluent) Volume of stool and gas effluent from stoma Presence of abdominal contours and scars Peristomal skin integrity Cost and product availability
When choosing an appropriate appliance, however, it is important to consider that NICU nurses may be unfamiliar with ostomy care, and it is important to design the simplest pouching system with the lowest likelihood of complications.
Wilson RE, 1994
Pouches filled with air can quickly compromise the pouch seal. Some infant pouches come with a built-in charcoal filter, which allows the release of gas without a detectable odor.
Air-filled pouches, as with pouches containing stool, should be emptied frequently to prevent pressure from compromising the seal.
Pouches can be angled to the side rather than toward the feet, allowing the liquid to drain away from the stoma while the infant is in a supine position. A pouch with a drainage spout can be connected to continuous drainage if the effluent is high volume and liquid. Gel crystals that absorb liquid several times their weight, can be used in preemie pouches.
Key Points
Although guided by principles that are the same for all patients with an enterostomy, managing the ostomy of a premature infant is not comparable with managing the ostomy of an adult, child or even a full-term infant and must take into consideration the unique characteristics of the preemie. Research-based evidence must guide the use of every substance used in caring for the premature infant with a stoma. Products and practices used safely in the adult population may pose a risk to the preemie. The simpler the pouching system that will maintain a good seal for 24 to 48 hours, the more reproducible it will be for the multiple caregivers involved in the care of the premature infant with an ostomy.
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