Guideline for the Management of Bolus and Intermittent, Abdominal Stoma Refeeding for Infants

Adverse reactions

Reason

Symptoms

Action

Prevention

Excessive prolonged bleeding from the distal stoma

• Trauma
• Infection
• Internal stenosis/adhesions
• Bleeding
• Tachycardia
• Hypotension
• Mottled skin
• Lethargy
• Unsettled

• Stop the procedure
• Seek surgical review
• Clean technique
• Ensure use of correct size tube

Perforation of the bowel

• Trauma
• Infection
• Grey pallor
• Tachycardia
• Hypotension
• Abdominal distension
• Pyrexia
• Bilious aspirate

• Seek urgent surgical review
• Ensure gentle insertion of tube to the advised length between 2-5cm

Excoriation of the peristomal area

• Leakage of stoma effluent onto the skin
• Erythema
• Leaking serous fluid
• Ulceration
• Assess the wound
• Take photograph
• Take swab MC+S
• Apply orahesive powder lightly
• Seek advice surgical nurse specialist

• Wash with warm water, pat dry and apply skin barrier after each procedure

PROCEDURE

No.

ACTION

RATIONALE

1

Wash and dry the skin around the distal stoma and follow stoma care plan

To ensure skin is clean and choose correct appliance and accessory products

2

Apply barrier film to surrounding skin- cover a large area of skin that may come in contact with any leakage from re-feeding.

To protect skin from effluent

3

Apply light covering or orahesive powder (only on broken skin), dust off the excess

To ensure the duoderm will adhere to the skin

4

Apply duoderm extra thin as a keyhole dressing around the mucus fistula

To protect the skin from leaking effluent during the procedure

5

Lubricate and insert correct sized Naso-gastric tube or foley catheter (doctor to inflate balloon and document volume. .

To minimise risk of perforating lumen of intestine. Dr to undertake 1st procedure

6

Wrap round near to the base of tube with tape and anchor onto duoderm

To anchor into position

7

Cut a square of jelonet. Cut half way as keyhole and place around the tube and mucus fistula 

To protect the skin

8

Dispose of equipment appropriately and wash your hands 

Infection prevention

PROCEDURE

No.

ACTION

RATIONALE

1

Use a 2 piece stoma appliance so that the base plate can stay in position for as long as possible without compromising skin integrity- AS per stoma care plan

To protect the skin integrity

2

Wash and dry the skin around the distal stoma

To ensure the skin is clean

3

Apply barrier film to surrounding skin- cover a large area of skin that may come in contact with any leakage from re-feeding.

To protect skin from effluent

4

Apply light covering or orahesive powder, dust off the excess- only to broken skin.

To ensure the duoderm will stick to the skin

5

Apply stoma base plate into position

To protect the skin

6

Lubricate and insert the NGT or Foley catheter to 2.5cm as per Consultant/registrars  instructions. Inflate balloon with 0.5ml water. Gently pull back until it is held in position. Document on PPM+

To minimise risk of perforating lumen of intestine. Doctor to undertake 1st procedure

PROCEDURE

No.

ACTION

RATIONALE

1

Pass the ‘inside ‘ part of the cone up inside the stoma bag to approximately the area where the tube will be placed into the stoma

To place in the right position

2

Place the cap on the outside of the stoma bag over the cap on the inside of the stoma bag

To fix the cap into position

3

Fix firmly together

To fix the cap into position

4

Take out the ‘inside’ cap

Inside cap not required - more comfortable for the patient

5

Trim the top of the cap to fit snugly the catheter being inserted

To ensure the hole is the correct size for the tube

6

Pull the catheter through the device 

Anchors into position

7

Insert the catheter into the stoma to prescribed length. 

Anchors into position

8

Tape into position on a piece of duoderm on the abdomen so it cannot be pulled accidently

To hold in position without causing harm to the skin

PROCEDURE

No.

ACTION

RATIONALE

1

Explain procedure to the family. Give written information.

Family is well informed.

2

Ensure privacy and dignity of the patient throughout the procedure.

To uphold confidentiality and privacy.

3

Prepare equipment and ensure warm environment.

To ensure all equipment is available and the infant is not exposed longer than necessary.

4

Wash hands and apply gloves and apron.

Prevention of infection.

5

Ensure patient supine and supported comfortably.

For ease of access to stoma’s and infant is comfortable to minimise distress.

6

Empty stoma bag every 4 hours,  with an enteral feeding syringe and keep to one side.

To collect effluent for re-feeding and ensure no waste

7

Take off the stoma appliance if necessary. Assess the stoma and peristomal area. 

Assessment of the skin integrity and identify the most suitable appliance to use.

8

Carry out stoma care as normal

Ensure skin cleaned and assessed

9

Apply ‘witches hat’ to stoma bag and apply over the stoma as normal.

To aid positioning of re-feeding tube

10

Place a new stoma bag into position if single piece appliance is used 

To preserve skin integrity

11

Secure tube to exit of ’witches hat’ with tape and anchor to the abdomen

To prevent accidental displacement of re-feeding tube

12

Prime the long extension with stool

To minimise air introduced into intestine

13

Lubricate 1 - 2cm of the tube and gently pass the tube to the length advised by Consultant Surgeon, or 2 - 5cm maximum if not stated 

Safe passage of tube

14

Fixate the tube as for intermittent stoma re-feeding using the ‘cap anchor’ device to hold the tube solidly, through the stoma bag. Connect the syringe of stool to the long extension and flush through to the end

To anchor into position and minimise air introduced into intestine

15

Ensure it is documented by the Consultant surgeon that the maximum amount of stool that is to be refed

To monitor fluid balance safely

16

Record the procedure on the fluid balance chart. Indicating the volumes collected and to be re-fed over the next four hours 

To accurately measure fluid balance

Discard excess stool and use fresh stool every 4 hours

Limit risk of infection from stool

17

Discard all of the equipment in the waste bag

Infection prevention

18

Ensure patient is comfortable, warm and settled

To ensure patient comfort and dignity

Setting up re-feeding pump

1

With gloved hands, Attach enteral syringe, with stool to,  an extension set and prime the line

2

Load the syringe onto alaris syringe driver- it is clearly marked ‘Faecal feeding pump’ (this may change over time)

Avoid using syringe drivers that would be used for IV therapy. Risk of infection/contamination

3

Hang re-feeding pump on separate stand to IV pumps

IPC measure

4

Keep stoma re-feeding lines away and clear of any Intravenous or central  lines at ALL TIMES

Risk of cross contamination of bacteria and infection control risk

5

Attach extension set to NGT or foley catheter

The procedure is a clean technique not sterile.

Ensure attached to correct tube

6

✓ Infuse the volume prescribed by the surgeon over 4 hours maximum.

✓ If there is not enough stool for total 4 hours just stop re-feeding until next syringe filled at 4 hours

✓ If there is too much stool then discard excess stool

Need to ensure stool not left hanging too long. Risk of infection, bugs growing in stagnant stool

7

If prescribed to give ALL stoma losses then divide the total to infuse over 4 hours maximum.

8

Document stool re-feeding volumes on fluid balance chart

Also document discarded stool.

To evaluate tolerance of re-feeding and volumes

PROCEDURE

No.

ACTION

RATIONALE

1

Explain procedure to the family. Give written information.

Family is well informed.

2

Ensure privacy and dignity of the patient throughout the procedure.

To uphold confidentiality and privacy.

3

Prepare equipment and ensure warm environment.

To ensure all equipment is available and the infant is not exposed longer than necessary.

4

Wash hands and apply gloves and apron.

Prevention of infection.

5

Ensure patient supine and supported comfortably.

For ease of access to stoma’s and infant is comfortable to minimise distress.

6

Take off the stoma appliance if necessary. Assess the stoma and peristomal area. If there is a loop ileostomy / colostomy (stoma and mucus fistula side by side), use a two piece appliance, so that the base plate can be left in position. 

Assessment of the skin integrity and identify the most suitable appliance to use.

7

Collect stoma fluid from acting stoma with the enteral feeding syringe. 

Not to waste effluent as it contains electrolytes.

8

Prime the long extension with the stool. 

There is no waste and minimal air is introduced into the intestine.

9

Lubricate 1 - 2cm of the tube. Gently pass the tube to the length advised by Consultant Surgeon, or 2 - 5cm maximum if not stated. 

To enable easy passage of the tube to maximum of 5cm as per literature.

10

Gently push / puisate the effluent into distal stoma over 5 - 10 minutes.

To pass the stool slowly as no reservoir - it goes straight into intestinal lumen. Not to cause perforation.

11

Ensure it is documented by the Consultant surgeon that the maximum amount of stool that is to be refed. 

To ensure patient safety and that Dr is aware of volumes of fluid replaced. To ensure consistent measure of fluid replacement.

12

Remove tube slowly, wash the area and pat dry. Apply a skin barrier product.

Gentle manipulation of the tube when inside the mucosa so as not to cause trauma. To ensure good skin integrity.

13

Record the procedure on the fluid balance chart. Indicating the volumes collected and refed.

To monitor fluid balance accurately.

14

Discard all of the equipment in the waste bag. 

Infection prevention.

15

Ensure patient is comfortable, warm and settled. 

To maintain patient comfort and dignity

1. Explain procedure to the family. Give written information.

2. Ensure privacy and dignity of the patient throughout the procedure.

3. Prepare equipment and ensure warm environment.

4. Wash hands and apply gloves and apron.

5. Ensure patient supine and supported comfortably.

6. Take off the stoma appliance if necessary. Assess the stoma and peristomal area. If there is a loop ileostomy / colostomy use a two piece appliance so that the base plate can be left in position between refeeding every 4-6 hours.

A stoma appliance can be placed over the proximal stoma as usual.

7. Collect stoma fluid from acting stoma into the enteral feeding syringe.

8. Prime the tube with stool.

9. Lubricate 1-2cm of the ng tube. Gently pass the tube to the length advised by Consultant Surgeon, or 2-5cm maximum if not stated.

10. Gently push/puisate the effluent into distal stoma over 5-10 minutes (Liverpool Alder Hey Children’s Hospital).

11. Ensure it is documented the maximum amount of stool to be refed by Consultant Surgeon.

12. Remove tube slowly, wash the area and pat dry. Apply skin barrier.

13. Record the procedure on the fluid balance chart. Indicating the volumes collected and refed.

14. Discard all of the equipment in the waste bag.

15. Ensure patient is comfortable, warm and settled.