Boris Sudel, MD, B U.K. Li, MD
+
+
• Coagulopathy (prothrombin time > 18 seconds).
• Thrombocytopenia (platelet count < 100,000/mcL).
• Recent intestinal tract surgery (< 1 month ago).
+
• Lubricant gel.
• Nasogastric (NG) tube.
• Larger diameter, polyethylene NG tube for suction and decompression.
• Smaller diameter, silicone NG tube for enteral feeding.
• Water or normal saline at room temperature.
• Drainage bag or feeding pump.
• 60-mL catheter tip syringe.
• Stethoscope.
+
• Bleeding.
• Perforation.
+
• Measure length of tube insertion by positioning
the tube from the nares or mouth to the ear, then to the umbilicus.
• There is also a standard table, which uses height of child.
• If the tube is obstructed, flush first with water; longstanding
obstruction may be removed by flushing the tube with caffeinated
soda.
+
+
+
• Ask the patient to cooperate by swallowing while
the tube is being inserted.
• Advance the tube to the length mark.
• To check position, aspirate tube with 50-mL syringe (Figure 25–3); gastric aspirate (pH = 1–3)
confirms positioning in stomach.
+
• Insert small amount of air (20–30 mL)
via NG tube while listening to epigastric area of stomach with stethoscope.
• If unsure about tube placement, verify tube position by obtaining
a chest film before starting enteral feeding or drug treatment.
• Secure tube to the face with tape.
++
++
++
Arbogast D. Enteral feedings with comfort and
safety.
Clin J Oncol Nurs. 2002;6:275–280.
[PubMed: 12240488]
Gopalan S, Khanna S. Enteral nutrition delivery technique.
Curr Opin Clin Nutr Metab Care. 2003;6:313–317.
[PubMed: 12690265]
Levy H. Nasogastric and nasoenteric feeding tubes.
Gastrointest Endosc Clin N Am. 1998;8:529–549.
[PubMed: 9654567]
Boris Sudel, MD, B U.K. Li, MD
+
+
• Coagulopathy (prothrombin time > 18 seconds).
• Thrombocytopenia (platelet count < 100,000/mcL).
• Recent intestinal tract surgery (< 1 month ago).
+
• Lubricant gel.
• Large bore orogastric tube.
• Terumo 60-mL catheter tip syringe.
• Normal saline at 38 °C.
• Drainage basin.
• Stethoscope.
+
• Perforation.
• Bleeding.
+
• Measure length of tube insertion by positioning
the tube from the nares or mouth to the ear, and to the umbilicus.
• There is also a standard table, which uses height of child.
• If the tube is obstructed, flush first with water; longstanding
obstruction may be removed by flushing the tube with caffeinated
soda.
+
+
• Lubricate tube with gel.
• Insert the tube through the mouth midline after lubrication.
• Ask the patient to cooperate by swallowing while the tube is
being inserted.
• Advance the tube to the length mark.
• To check position, aspirate tube with 50-mL catheter tip syringe
(Figure 26–2); gastric aspirate
confirms positioning in stomach.
+
• Insert small amount of air (20–30 mL)
via orogastric tube while listening to the epigastric area with
stethoscope.
• If unsure about tube position, obtain a chest film to confirm
tube position.
• Secure tube to the face with tape.
• After insertion of the orogastric tube, begin to irrigate stomach
with saline.
• Use 10–15-mL/kg aliquots of warm (38 °C) isotonic saline.
• Lavage should continue until the effluent is clear.
• For diagnostic lavage, notice presence of fresh red blood, blood
clots, or coffee ground material to confirm upper gastrointestinal
bleeding.
• At this time, diagnostic lavage should be stopped.
• Confirm presence of blood with Gastroccult cards.
++
++
+
• Aspiration.
• Bleeding.
• Perforation.
• Mucosal tears.
+
• There is no certain evidence that gastric lavage
improves clinical outcome, and it can cause significant morbidity.
• In experimental studies, the amount of marker removed by gastric
lavage was highly variable and diminished with time.
• Gastric lavage should not be considered unless a patient has
ingested a potentially life-threatening amount of a poison and the
procedure can be undertaken within 60 minutes of ingestion. Even
then, clinical benefit has not been confirmed in controlled studies.
Bartlett D. The ABCs of gastric decontamination.
J Emerg Nurs. 2003;29:576–577.
[PubMed: 14631350]
Tucker JR. Indications for, techniques of, complications of,
and efficacy of gastric lavage in the treatment of the poisoned child.
Curr Opin Pediatr. 2000;12:163–165.
[PubMed: 10763767]
Vale JA, Kulig K; American Academy of Clinical Toxicology; European
Association of Poisons Centres and Clinical Toxicologists. Position
paper: gastric lavage.
J Toxicol Clin Toxicol. 2004;42:933–943.
[PubMed: 15641639]
Boris Sudel, MD, B U.K. Li, MD
+
• First change should be performed 6–8
weeks after initial gastrostomy tube placement.
• Dislodged gastrostomy tube or gastrostomy button.
• Replacing a gastrostomy button.
• Blocked gastrostomy tube or gastrostomy button.
+
+
• Coagulopathy (prothrombin time > 18 seconds).
• Thrombocytopenia (platelet count < 100,000/mcL).
• Recent intestinal tract surgery (< 1 month ago).
+
• Lubricant gel.
• Gastrostomy catheter.
• Button.
• Normal saline.
• 10-mL syringe.
+
• Bleeding.
• Perforation.
+
• Prepare new tube for insertion.
• Remove old tube.
• Insert new tube into stoma.
• Without moving the tube, inflate balloon fully.
• Tug on tube to check whether the balloon is inflated and then
secure (Figure 27–1).
+
• While firmly pulling tube upward, push fixation
bolster down to the skin so that any in-out movement of the tube is
prevented.
• Small amount of slack (~2–5 mm) is advised for comfort and
to prevent pressure necrosis.
• Gastric contents will probably now be apparent in the tube.
• If not, and stoma is new, aspirate tube to check.
• If stoma is well established (> 3 months) and this is not the
first tube change, aspiration test is unnecessary.
++
+
• Balloons deflate over time (by osmosis), so contents should
be checked monthly (more often leads to increased risk of bursting).
• Withdraw the contents of balloon using a 10-mL syringe; hold
the tube in place carefully to avoid displacement.
• Observe amount withdrawn and top up to correct amount.
• Refill balloon with normal saline.
• Note: It is wise to push the tube
down into the stomach to avoid accidentally pulling it out. (If
this happens, simply push the tube back in.)
• Caution:
• You may feel resistance if you are inflating the balloon in
the tract. Stop and push in further. Deflate the balloon and reposition
the tube.
• Pushing the tube in too far can place it through the pyloric sphincter
into the duodenum. If you inflate the balloon there, the stomach
cannot empty, causing excessive billous, formula free vomiting,
and tube leakage.
+
• Assess balloon inflation.
• Evaluate position of the gastrostomy tube for blockage, dislodgment.
• Check the skin for infection or granulation tissue as well as
around the tube for leakage.
Arrowsmith H. Nursing management of patients receiving
gastrostomy feeding.
Br J Nurs. 1996;5:268–273.
[PubMed: 8715740]
Kirby DF, Craig RM, Tsang TK, Plotnick BH. Percutaneous endoscopic
gastrostomies: a prospective evaluation and review of the literature.
JPEN J Parenter Enteral Nutr. 1986;10:155–159.
[PubMed: 3083129]
Willwerth BM. Percutaneous endoscopic gastrostomy or skin-level
gastrostomy tube replacement.
Pediatr Emerg
Care. 2001;17:55–58.
[PubMed: 11265912]
Boris Sudel, MD, B U.K. Li, MD
+
• Diagnostic sampling of ascitic fluid (eg, internal
bleeding following blunt abdominal trauma, chylous ascites after surgery,
rule out malignancy, identification of infectious organism in spontaneous
bacterial peritonitis).
• Therapeutic removal of the ascitic fluid (eg, chylous ascites,
tense ascites, intestinal lymphangiectasia).
+
+
• Infection of the abdominal wall.
• Coagulopathy (prothrombin time > 18 seconds).
• Thrombocytopenia (platelet count < 100,000/mcL).
• Recent intestinal tract surgery (< 1 month ago).
+
• Alcohol swabs, povidone-iodine.
• 23-gauge and 21-gauge needles or angiocatheters with syringes.
• Local anesthetic (eg, 1% lidocaine).
• Large bore needle with plastic catheter.
• Sterile containers for fluid collection.
• Appropriate culture tubes for microorganisms.
+
• The puncture site should be shaved, if necessary,
and cleansed with povidone-iodine.
• Inject local anesthetic, infiltrating the skin first and then penetrating
into deeper layers.
• A small 3-mm incision can be made with a scalpel to help insert
the needle. Using Z-track technique, insert the tap needle 1–2
inches into the abdomen (Figure 28–2).
+
+
• Remove the needle and apply a pressure dressing
to the puncture site.
• If an incision was made, it may be closed using 1 or 2 stitches.
• The ascitic fluid removed may be replaced 1:1 with 5% albumin
IV.
++
++
+++
Diagnostic Peritoneal
Lavage
++
+
• The puncture site should be shaved, if necessary,
and cleaned with povidone-iodine.
• Inject local anesthetic, infiltrating the skin first and then penetrating
into deeper layers.
• A small 3-mm incision can be made with a scalpel to help insert
the needle.
• Insert the tap needle 1–2 inches into the abdomen.
+
• Insert a trochar and peritoneal catheter until the peritoneal cavity
is reached (the resistance suddenly gives away).
• Remove the trochar and fix the catheter to the skin with a stitch.
• Aspirate.
• If no bloody fluid is withdrawn, infuse 20 mL/kg of Ringer’s
lactate over 5–10 minutes:
• Turn the patient from side to side.
• Siphon the fluid off.
• Inspect for level of turbidity.
• Send fluid to laboratory for red and white blood cell counts,
bacterial culture, amylase.
• Ascitic fluid should be sent for cytology, amylase, albumin,
triglycerides, and culture.
+
+++
Diagnostic Peritoneal
Lavage
++
+
• Aspiration of free flowing blood, or
• Aspiration of feces, or
• Bloody lavage fluid, from peritoneal lavage catheter containing:
• RBC > 100,000/mcL.
• WBC > 500/mcL.
• Amylase > 175 IU/dL.
+
+
• Clear lavage fluid:
• RBC < 50,000/mcL.
• WBC < 100/mcL.
• Amylase < 75 IU/dL.
+
Gerber DR, Bekes CE. Peritoneal catheterization.
Crit Care Clin. 1992;8:727–742.
[PubMed: 1393748]
Grabau CM, Crago SF, Hoff LK et al. Performance standards for
therapeutic abdominal paracentesis.
Hepatology. 2004;40:484–488.
[PubMed: 15368454]
Kramer RE, Sokol RJ, Yerushalmi B et al. Large-volume paracentesis
in the management of ascites in children.
J
Pediatr Gastroenterol Nutr. 2001;33:245–249.
[PubMed: 11593116]
Sartori M, Andorno S, Gambaro M et al. Diagnostic paracentesis.
A two-step approach.
Ital J Gastroenterol. 1996;28:81–85.
[PubMed: 8781999]
Marybeth Browne, MD, Anthony Chin, MD, Marleta Reynolds, MD
+
• A hernia is a benign process unless the contents
within the hernia sac become incarcerated.
• Incarceration is the inability of the hernia’s contents
to be reduced.
• The risk of incarceration is highest during infancy with a 28–31% incarceration
rate before 3 months of age and 15–24% by 6 months
of age.
• Although the risk of incarceration gradually decreases with age,
the severity of its consequences mandates immediate manual reduction
when possible, followed by prompt operative repair.
+
+
• There are few risks with manual reduction.
• However, parents should be informed that once a hernia
has been incarcerated, it has a high probability of recurring.
• A hernia will not resolve on its own and operative management
will be required in the near future.
• If sedation is used during the reduction, a parent is required
to sign a consent form and be made aware of the risks and benefits
that accompany sedation.
• In addition, a parent should be instructed not to feed the child should
the hernia become strangulated or is not reducible and the patient
requires emergent operative intervention.
+
• The most common differential diagnosis for a
bulge in the groin consists of the following:
• Hernia.
• Hydrocele.
• Lymphadenopathy.
• Abscess.
• Undescended testis.
• A testicle in the groin may resemble a hernia; thus, it is imperative
to confirm the presence of the testis in the scrotum during initial
evaluation.
• A hydrocele is usually present at birth and can also be bilateral
in nature. It is generally described by the parents as a rapid swelling
of the scrotum that may cause the child discomfort if tense.
• With a communicating hydrocele, the swelling is most prominent
at the end of the day and reduces over night.
• On examination, a hydrocele is a soft, bluish, cystic swelling
within the scrotal sac that cannot be reduced.
• With a hydrocele, the spermatic cord should be able to be felt
at its upper limits unlike a hernia, whose upper margin is not clearly
defined and continues into the internal ring.
• Transillumination may help differentiate a hernia from a hydrocele.
• Hernias do not transilluminate as brightly as hydroceles.
• However, hernias can transilluminate if they are filled with
an air-filled loop.
• Simple hydroceles generally resolve by the age of 1 year and
do not require an operation until after this time.
+
• The child should be examined supine and undressed
to observe any asymmetry or obvious masses in the scrotum or groin
area.
• Both testicles should be palpated and identified separately from
the mass.
• Next, the index finger should be placed over the inguinal canal
in the attempt to palpate the cord structures.
• While perpendicular to the inguinal structures, the finger should
be rubbed from side to side.
• If the cord structures appear thickened compared with
the normal side, this is considered a positive silk glove sign.
• Ideally, this should feel similar to rubbing 2 pieces of silk
together or running your fingers over a plastic baggy that contains
a drop of water.
• If there is a good history of a hernia but the physical examination
does not demonstrate a bulge, attempts to reproduce the hernia may
be accomplished by increasing the intra-abdominal pressure.
• This can be achieved in infants by holding the patient with
legs and arms extended, which will cause some struggle and an increase
in intra-abdominal pressure.
• For older children, a Valsalva maneuver, such as blowing up a
balloon or pretending to blow out candles, may be performed.
• It is important to note the extent of the hernia sac and the ease
by which it reduces when the child is relaxed.
+
+
• However, the inguinal canal is not completely
developed, making it extremely short, and the external ring is placed almost
directly over the internal ring.
++
+
• The patient should be placed supine and allowed
to relax.
• If the hernia does not reduce with gentle pressure, consider
using mild or conscious sedation. After allowing enough time for
the sedation to take effect, attempts are made to align the hernia
sac in the inguinal canal.
• When attempting manual reduction, it is important to remember
that the inguinal canal is not completely developed, making it extremely
short, and the external ring is placed almost directly over the
internal ring.
• After alignment, firm, constant, posterior, and upward pressure
is applied to the hernia sac with the contralateral hand while guiding
the hernia’s contents through the internal ring with the
ipsilateral hand (Figure 29–2).
+
• This may take several minutes of constant pressure
and several attempts at reduction.
• Placing the patient in the Trendelenburg position, as well as
applying an ice pack to the groin area for several minutes prior
to manipulation, may help ease the reduction.
++
+
• Manual reduction has few complications.
• However, the physician who performs the reduction should be aware
that, with too much force, it is possible to cause a bowel perforation.
• There is also the possibility that a piece of strangulated bowel
may be reduced together with the hernia sac.
• If this should occur, the patient’s symptoms
will not resolve.
• Peritonitis may develop, requiring an emergent operation.
+
• Over 80% of incarcerated hernias can
be initially reduced with manual reduction.
• However, because most inguinal hernias do not spontaneously resolve
and have a risk of recurrent incarceration or possible strangulation,
definitive operative repair is necessary.
• Most surgeons will attempt operative repair 48 hours after the
manual reduction, allowing tissue swelling to resolve prior to the
procedure.
+
• A pediatric surgeon should be contacted to arrange
for prompt follow-up in all patients with an incarcerated hernia.
• However, if a patient has signs of intestinal obstruction, toxicity,
bowel strangulation, or an incarcerated hernia that cannot be reduced,
a pediatric surgeon should be notified immediately and the patient
prepared for operative repair.
Coles J. Operative cure of inguinal hernia in
infancy and childhood. Am J Surg. 1945;69:366.
D’Agostino J. Common abdominal emergencies in children.
Emerg Med Clin North Am. 2002;20:139–153.
[PubMed: 11826631]
Grosfeld JL. Current concepts in inguinal hernia in infants
and children.
World J Surg. 1989;13:506–515.
[PubMed: 2573200]
Gross RE. Inguinal Hernia. In Gross RE, ed. The
Surgery of Infancy and Childhood. Philadelphia: WB Saunders
Company; 1953:449–462.
Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles.
Pediatr Clin North Am. 1998;45:773–789.
[PubMed: 9728185]
Ladd WE, Gross RE. Abdominal Surgery
in Infancy and Childhood. Philadelphia: WB Saunders Company;
1941.
Ziegler MM, Azizkhan RG, Weber TR, eds. Inguinal and Femoral
Hernia. In: Operative Pediatric Surgery. New
York: McGraw-Hill Co; 2003:543–554.
Anthony Chin, MD, Marybeth Browne, MD, Marleta Reynolds, MD
+
• Most cases of rectal prolapse reduce spontaneously.
• Rarely, a surgical procedure may be necessary to correct a full-thickness
prolapse.
• Rectal prolapse should be promptly reduced to prevent a sustained
prolapse that allows edema to form and potential subsequent venous
congestion and thrombosis to develop, which may lead to ulceration
of the rectal mucosa with bowel ischemia and infarction.
• A rectal examination needs to be performed to differentiate prolapse
from an intussusception or rectal polyp.
• Diagnostic studies are often not necessary, but a proctoscopy,
colonoscopy, or barium enema may be indicated when the patient has
a history of rectal bleeding.
• Children need to be tested for parasites and cystic fibrosis as
well as other causes of anal straining (including neuromuscular
problems, proctitis, and inflammatory bowel disease).
+
• Presence of nonviable bowel or rupture of rectal
mucosa.
• Child appears toxic (ie, with fever, tachycardia, or leukocytosis).
+
+
• Gloves.
• Lubrication.
• Table sugar or salt.
• 6F rectal tube.
+
• There are very few risks with manual reduction.
• Parents should be informed that prolapse may recur and instructed
on proper technique for reduction.
• Discuss the potential risk of sedative medication.
• Recurrent prolapse or a prolapse that is not amenable to manual
reduction may require operative intervention.
+
• Rectal prolapse commonly presents in children
between the ages of 1 and 3 years, with a primary symptom of anal discomfort
or prolapse after defecation; occasionally it may present as bleeding.
• When a prolapse is not immediately present and the child is old
enough to cooperate, diagnosis can potentially be made with the
child squatting or straining on the toilet.
• A glycerine suppository may also aid in the diagnosis.
• Palpate the prolapsed segment between the fingers and thumb to
help differentiate mucosa from full-thickness prolapse.
• Mucosal prolapse tends to have radial folds and full-thickness
prolapse exhibits concentric folds (Table 30–1).
• Differentiate from polyp, which is plum-colored and does not
involve the entire anal circumference.
• Differentiate from intussusception, which on digital examination
allows the examiner to insert between the anal wall and the protruding
mass. With a prolapse, there is no space between the perianal skin
and the protruding mass.
++
+
• Rectal prolapse occurs with stretching of the
pelvic peritoneum, weakening and dilation of the rectal suspension mechanism,
and a low resting anal sphincter pressure that may be secondary
to protracted straining due to diarrhea and constipation.
• It may also be attributed to poor posterior rectal fixation, redundant
rectosigmoid colon, neurologic diseases, cystic fibrosis, infections,
malnutrition, previous surgery, undiagnosed Hirschsprung disease,
or imperforate anus.
• On examination, a mucosal prolapse is described as a swollen
rosette of mucosa with radial folds at the anal junction (Figure 30–1).
+
++
++
+
• The prolapsed rectum may be reduced with gentle
and steady digital pressure.
• The herniated bowel should be grasped with a lubricated glove
between fingertips with cephalad pressure applied to the tip of
the prolapsed rectum until reduction is complete.
• Firm and steady pressure for several minutes may be necessary
in edematous bowel to reduce swelling and allow reduction.
• A digital examination at the end of the procedure is necessary
to verify that the reduction is complete.
• Taping of the buttocks has been used in the past but is not always
effective.
• If manual reduction is unsuccessful, sedation and perianal field
block with local anesthesia may aid in the success of reduction.
• With significant bowel edema, the application of topical sucrose
or table salt applied to the prolapsed rectum may decrease edema
and allow reduction of herniated bowel.
• It has also been described that use of a soft, lubricated, 6F rectal
tube inserted through a segment of prolapsed bowel may help guide
reduction (Figure 30–3).
+
• Reduction is accomplished by pushing the prolapsed
segment over the tube.
• If all attempts fail, the prolapse needs to be surgically reduced.
• The parents should be instructed on how to reduce the prolapsed
rectum should it occur at home and instructed to call or return
to the emergency department if they are unable to reduce the prolapse.
• Surgical consultation should be obtained for the reduction under
the following circumstances:
• Presence of mucosal ulceration.
• Failure of reduction.
• Severe pain and discomfort.
• Patient with history of pull-through procedure for imperforate
anus and Hirschsprung disease.
++
+
• Treatment of rectal prolapse involves treating
the underlying cause of straining during defecation. Therapy includes
dietary modifications and identifying the cause (eg, intractable
diarrhea or constipation).
• If recurrent prolapse persists after several months of appropriate
and adequate medical therapy, surgical intervention in the form
of a cerclage, sclerotherapy, cauterization therapy, or transanal
or perineal rectopexy may be necessary.
Bhandarkar DS, Tamhane RG. Reduction of complete
rectal prolapse.
Trop Doct. 1992;22:180.
[PubMed: 1440901]
Coburn WM III, Russell MA, Hofstetter WL.
Sucrose as an aid to
manual reduction of incarcerated rectal prolapse.
Ann Emerg Med. 1997;30:347–349.
[PubMed: 9287900]
Corman ML. Rectal prolapse in children.
Dis
Colon Rectum. 1985;28:535–539.
[PubMed: 3893949]
Duhamel J, Pernin P. Anal prolapse in the child.
Ann Gastroenterol Hepatol (Paris). 1985;21:361–362.
[PubMed: 4096498]
Groff DB, Nagaraj HS. Rectal prolapse in infants and children.
Am J Surg. 1990;160:531–532.
[PubMed: 2240390]
Siafakas C, Vottler TP, Andersen JM. Rectal prolapse in pediatrics.
Clin Pediatr (Phila). 1999;38:63–72.
[PubMed: 10047938]
Stafford PW. Other Disorders of the Anus and Rectum, Anorectal
Function. In: O’Neil JA et al, eds. Pediatric
Surgery. 5th edition. St Louis: Mosby; 1998:1449–1460.