DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
TYPES OF STOMA
Split stoma and mucus fistula
- Bowel is divided and both ends brought out through abdominal wall separately
- Proximal end is the functioning stoma and distal end is the mucus fistula
- Operation note should make it clear where the stoma and mucus fistula are situated on the abdomen
- Stoma and mucus fistula may sometimes be fashioned side-by-side without a skin bridge. The wound is closed with dissolvable sutures
Fig.1: Split stoma and mucus fistula
End stoma without mucus fistula
- Proximal bowel end is brought out through abdominal wall as stoma and distal end is closed and left within the abdominal cavity
Fig. 2: End stoma without mucus fistula
Loop stoma
- Formed by suturing a loop of bowel to the abdominal wall and making an opening into bowel, which remains in continuity
Fig 3: Loop stoma (slightly prolapsed)
MANAGEMENT
Application of stoma bag
- Before stoma starts working, fit an appropriately sized stoma bag and empty 4–6 hrly
- In a split stoma and mucus fistula, fit the stoma bag on the proximal stoma only, where possible, and leave mucus fistula exposed and dressed with a paraffin gauze dressing (e.g. Jelonet) or Vaseline® and non-sterile gauze dressing
- Change bag every 1–3 days (maximum) or if it leaks
- Remove using a stoma adhesive remover wipe
- Clean skin around stoma with warm tap water and dry with non-sterile gauze
Monitoring
- Examine baby’s abdomen and stoma daily
- Look for:
- dehydration
- abdominal distension
- wound infection or breakdown
- peri-stomal skin excoriation
- granulation tissue formation
- stomal bleeding
- discolouration of stoma or mucus fistula
- stomal prolapse or retraction
- stoma bag leakage
- rectal discharge
- If stoma becomes dusky or black, call the surgical team
- If skin surrounding the stoma is excoriated, identify cause and treat
Weight
- Babies with small bowel stoma: measure and record weight daily. Inadequate weight gain or weight loss may be secondary to:
- insufficient calorie intake
- malabsorption
- dehydration (high stoma output)
- electrolyte abnormalities (high stoma output)
Stoma effluent
- Maintain a regularly updated fluid balance chart and record:
- fluid intake and stoma losses
- colour and consistency of stoma effluent
Serum electrolytes
- Measure at least every 2 days in the first 7 post-operative days
Urinary electrolytes (sodium and potassium)
- Monitoring is extremely important for nutrition and growth
- Measure weekly
- Babies with stomata (especially small bowel stomata) are at risk of losing a significant amount of sodium into the effluent. They will often fail to gain weight if total body sodium is depleted. Serum sodium is an unreliable indicator of total body sodium
- Urinary sodium and Na+:K+ ratio are better indicators
- Sodium supplements usually required in babies with a small bowel stoma until the stoma closed
- If urinary sodium is <20 mmol/L or ratio of concentration of urinary sodium to potassium is <3:1, increase sodium intake
NUTRITION
Total parenteral nutrition and no enteral feeds
- Check surgical discharge letter and operation notes for instructions on starting enteral feeds
- Introduce enteral feeds slowly and increase gradually (see Nutrition and enteral feeding guideline)
- Useful indicators of potential feed intolerance are:
- vomiting and abdominal distension
- bile in nasogastric aspirates
- large nasogastric losses
- low stoma losses – indicating dysmotility/obstruction
- high stoma losses – indicating malabsorption
- reducing substances or fat globules in the stool/stoma effluent
Combination of parenteral nutrition and enteral feeds
- Increase enteral feeds gradually (see Nutrition and enteral feeding guideline)
- It is not possible to predict how much enteral feed baby will be able to tolerate. As a general rule, the more distal the stoma, the better the absorption of feeds
- The amount of stoma effluent and presence/absence of reducing substances or fat in the stoma effluent should guide the advancement of enteral feeds
- Do not automatically increase enteral feed in response to weight gain, but rather in response to stoma output volume
Full enteral feeds
- Tolerance of enteral feeds can fluctuate with time and babies with stomata are at high risk of life-threatening dehydration and electrolyte abnormalities as a result of gastroenteritis. There should be a low threshold for readmission to hospital and appropriate resuscitation
COMPLICATIONS
High stoma output
- Daily output >20 mL/kg/day in premature or low-birth-weight babies and 30 mL/kg/day in term babies
Measure serum and urinary electrolytes - Replace stoma losses (when >20 mL/kg/day) mL-for-mL using sodium chloride 0.9% with potassium chloride 10 mmol in 500 mL IV
- Consider either reducing or stopping enteral feeds until losses decrease, liaison with surgical team is encouraged
- Test stoma effluent for reducing substances and fat globules
- If reducing substances are positive or fat globules present, consider reduction of enteral feed or changing type of enteral feed after consultation with a surgeon, specialist surgical outreach nurse or dietitian
- Perform blood gas; (stoma effluent may be rich in bicarbonate and metabolic acidosis may be present; consider sodium bicarbonate supplementation)
Mucus fistula
- If present, consider recycling of stoma effluent (see Recycling stoma losses via a mucus fistula guideline). Before recycling, consult surgical team to decide whether a contrast study through the mucus fistula is required
- If contrast study advised, make arrangements with surgical unit and inform surgical team when the study will take place
- Surgical team will review and advise if recycling may start
- If baby not thriving, consider parenteral nutrition (see Parenteral nutrition guideline)
Increasing enteral feeds in a baby with poor weight gain and a high output stoma will worsen the situation
- If none of the above measures are effective, stop enteral feeds, start parenteral nutrition and consult surgical team to discuss surgical options
Stomal stenosis
- May be present if:
- stomal output reduces or stoma stops functioning
- stoma effluent becomes watery
- Call surgical team for advice
Prolapse
- Call surgical team for advice. If stoma is discoloured, emergency action required
STOMA CLOSURE
- Often aimed to be performed when baby is well and thriving, which may be after discharge from hospital
- Indications for early closure are:
- failure to achieve full enteral feeds
- recurrent stomal prolapse with/without stomal discolouration
- stomal stenosis
- high stoma output not responding to measures outlined above
DISCHARGE PLANNING AND PARENTAL TEACHING
- Discharge when baby well, tolerating feeds and thriving
- It is the responsibility of the ward/unit nurse to teach parents stoma care
- When discharge planned, inform:
- secretary of surgical consultant who fashioned the stoma to arrange outpatient follow-up
- local stoma care specialist to order stoma supplies for home and support family
- neonatal surgical outreach service (if involved in care)
Who to call when you need help?
Surgical team
- Call team of consultant surgeon who performed the surgery
- In an emergency out-of-hours, contact on-call surgical registrar
- Stoma care specialist [e.g. Gail Fitzpatrick at BCH (mobile 07557 001653)] for management of stoma-related complications, and parent and staff training
- Neonatal surgical outreach service [e.g. Louise Lawrence (mobile 07769 367483)] for advice, support and training on surgical management