36: Ostomy Care

I. INDICATIONS

A variety of surgical procedures may require an ostomy, a temporary or permanent intestinal diversion. The majority of these ostomies in the neonatal intensive care unit are for the management of necrotizing enterocolitis (NEC). Other indications are anorectal malformations, meconium ileus (related to cystic fibrosis or due to very low birthweight), Hirschsprung disease, volvulus, and intestinal atresias and these are discussed elsewhere in this book. A gastrostomy (surgical opening in the stomach) may be necessary for feeding or decompression in a variety of conditions, such as the inability to swallow (neurologic or congenital anomalies such as Pierre Robin sequence), or esophageal abnormalities.

II. OSTOMY CLASSIFICATION

1. Ileostomy. Stoma opening from the ileum, used for NEC, intestinal malrotation or volvulus, and small bowel atresia or stenosis.

2. Colostomy. Stoma opening from the colon, used for NEC, Hirschsprung disease, malrotation or volvulus, imperforate anus, and colonic atresia.

3. Mucous fistula. Distal nonfunctioning limb of intestine secured flush to skin with a mucocutaneous anastomosis.

4. Hartman pouch. Distal intestine is left in the abdominal cavity rather than removed or secured as mucous fistula, allowing reconnection to stoma at later date.

5. Double-barrel stoma. Loop of bowel is completely divided and 2 ends brought out as stomas to abdominal surface. Skin and fascia are closed between ends to provide separation of stomas.

6. End ostomy. Intestine is completely divided. The functioning proximal end is everted, elevated above skin, and secured circumferentially.

7. Loop ostomy. The intestine is incompletely divided with an opening at the antimesenteric side, while leaving the mesenteric side intact. This is used when temporary diversion or minimal surgical procedure is needed. It is not performed as often as end ostomy.

8. Gastrostomy. Surgical opening into the stomach, where a gastrostomy tube (GT “or g-tube”) is inserted into the opening for nutritional support, medications, or gastrointestinal decompression.

III. EQUIPMENT

1. Ostomy. Ostomy bag or pouch (1-piece or 2-piece system), skin barrier wafer, skin preparation agents, sterile water, gauze pads, petroleum gauze, and gloves. Products that improve security of pouch include plasticizing skin sealants, skin barrier paste (protect exposed skin), adhesive agents (improve adherence), and skin barrier powder (dusted onto denuded skin to form protective crust).

2. Gastrostomy tube. 12–14F balloon or mushroom gastrostomy tube; similar-sized Foley catheters are sometimes used. Silicone is preferred over latex, skin barrier as for ostomies.

IV. PROCEDURES

1. Ileostomy and colostomy

   1. Postoperative ileostomy and colostomy care

      1. No bag is applied first 24–48 hours postop due to minimal stool production.

      2. Apply petrolatum gauze to stoma until first stool output appears.

      3. Measure effluent output. Volume >2 mL/kg/h should be replaced with 1/2 normal saline (NS). Some institutions add 10–20 mEq KCl/L.

   2. Changing ostomy bags. Not a sterile procedure, but regular hand washing and gloves are important. Goals are containment of stool/odor and protection of the peristomal skin. Minimize skin sealants, adhesives, and adhesive removers in ...