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Patient Information

Whether your child needs an urgent procedure or an elective operation, we understand how stressing this can be to all of you, and we want to make the experience as pleasant as possible. On this page, we provide you with information on anesthesia and pre- and postoperative aspects of your child’s surgical condition.You will also find enough background to help you understand the cause of the problem and, wherever possible, the different forms of treatment available.For general surgery questions, see below. For more information on conditions of the fetus, go directly to our Fetal Treatment Program page. Of course, you can always reach us at (401) 421-1939 if you need additional information.

The information below is also available in printer-friendly format. Click on the print icon next to each topic to obtain the information as a pdf file, or go to Forms.

Click on the terms below for more information

 

 

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This information is intended for parents of children who have or will need any type of central line (Broviac, Hickman, port-a-cath or temporary, single-, double- or triple lumen central venous catheter.

WHAT IS A CENTRAL LINE?

Central lines are soft plastic or silastic catheters (fine tubes) placed into the large veins of the body that drain directly into the heart. This allows these catheters to be large enough to be used for blood drawing and administration of medication and nutrition, all of which could be too irritating to the smaller veins of the arms or the legs.

Some central lines are actually threaded through the smaller veins of the arm, and advanced into the larger veins of the chest (so-called PIC lines, or Peripherally Inserted Catheters). Although they work well for the short-term, these catheters have a limited life span and do not reliably allow repeated sampling of blood.

All other central lines are introduced directly into the larger veins of the chest cavity, and ar usually placed while your child is under anesthesia in the operating room. To gain access into these veins, the surgeon either makes an incision over the vein in question, or accesses this vein through the skin using a needle. One end of the catheter is passed into this vein and threaded to position near the entry into the heart. The other end of the catheter is threaded underneath the skin and either comes out of the skin on the chest wall (Broviac or Hickman catheter) or is attached to a flushing chamber (port) that is also inserted underneath the skin surface, so that no part of the catheter is visible (Port-a-Cath type).

Reasons for using one approach to the vein over another are primarily technical (related to risks specific to the size of your child, his/her risk of bleeding, etc.), but are also affected by whether a vein needs to be used in the future, should another catheter be necessary.

WHAT HAPPENS AFTER THE OPERATION?

What you will see when your child returns from the operating room will be a small incision or needle mark either in the neck or underneath the collar bone (clavicle) where the catheter enters the vein. With a Broviac or Hickman catheter, you will see the hub of the catheter coming out of a small incision further down the chest wall, with one or two sutures holding it in place until it has a chance to heal. A sterile dressing will be in place to prevent infection from occurring at this exit site. With a Port-a-Cath, you will see a bump under the skin, which is the flushing chamber, and an incision through which this chamber was placed. This incision is generally closed with sutures underneath the skin surface, so that no sutures will need to be removed. Butterfly bandages or a biological glue will initially cover this incision for about one week. If your doctor needs to use the catheter immediately, a special type of needle (so-called "Huber" needle) will have been placed through the skin and into the chamber while your child was still under anesthesia. A bandage holds this needle in place.

WHAT ARE THE RISKS OF THIS PROCEDURE?

As with any operation, there are some risks associated with the placement and presence of central venous lines regardless of the type of catheter used.

The most common potential problem is a catheter infection. Although these catheters are placed in a sterile environment (the operating room), sometimes the skin harbors bacteria that can establish an infection. Other times, the bacteria are in your child's blood stream for other reasons and settle down on the inside of the catheter, starting a catheter infection. If a catheter infection occurs, it can usually be treated with antibiotics; however, sometimes the catheter will have to be removed.

At the time of placement of the catheter, the surgeon has two primary concerns, particularly when the catheter is placed with the needle method (the technical term is "percutaneous", or 'through the skin', i.e. without an actual incision). One is bleeding from the vein or the artery that is located next to the vein. This is not necessarily a major problem, unless your child's ability to stop bleeding is impaired: this may happen due to a low platelet count, for example. If the level is extremely low, a platelet transfusion will be necessary before surgery, to minimize the risk of continued bleeding. Soemtimes, however, an excessive risk of bleeding will force the surgeon th place the catheter by making an incision (in the neck or the upper chest) so that all potential bleeding can be controlled directly, and no blood vessels are accidentally punctured or injured.

The other concern is a pneumothorax, which is an accumulation of air around the lung that tends to collapse the lung. This happens as a consequence of a needle puncture into the lung, which releases a small amount of air into the chest cavity. It usually requires the placement of a small tube to evacuate the air and prevent the lung from collapsing. Although this complication is infrequent, a chest X-ray is routinely obtained after percutaneous placement of a central line, to rule out a pneumothorax.

 

 

 

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 Articles written by our faculty on this subject:

 

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WHAT IS APPENDICITIS?

The appendix is tubular structure the size of a worm (its Latin name is appendix vermicularis, or ‘worm-like attachment’), which is attached to the first portion of the large bowel (the cecum). It is hollow and communicates with the intestine. However, because of its narrow size, it may become plugged with hard stools. In part because of this, pressure and infection may build up inside the appendix. This inflammation and infection is called appendicitis. It most often presents as pain to the right lower portion of the abdomen, typically at a point between the belly button and the ridge of the pelvis on the right side. Not uncommonly, the onset of pain is followed by nausea, vomiting and fever. As the process worsens, pain becomes more intense, and the wall of the appendix may become severely infected and even necrotic. This may create a hole in the wall of the appendix, through which the infection can spread outside, into the abdominal cavity: the appendix is now perforated, or ruptured. If left unchecked, ruptured appendicitis would rapidly lead to severe inflammation and infection of the entire abdominal cavity (peritonitis), and eventually of the whole body. Once sepsis (i.e., spread of the infection to the blood and to other organs) sets in, the patient becomes severely sick and is at risk of dying, unless treatment is instituted.

Although it is very difficult to establish exactly when appendicitis starts, and how long it will take from early infection to rupture, this takes on average 24 to 72 hours. Some children may perforate early on, while occasionally it may take several days before frank rupture occurs.

Appendicitis can occur at any age. However, it is extremely rare in the first few years of life (but when it presents that early, i.e. before the age of 4, children are often very sick and the appendix is almost always already ruptured). It is also much less common in the elderly; it most commonly affects teenagers and young adults. There is no clear cause for appendicitis (except for the possible obstruction of the appendix by stool, which probably contributes to it), and it is not known why some children get it, and others don’t. There are no known risk factors for the development of appendicitis.

 

WHY DOES APPENDICITIS HAVE TO BE OPERATED?

There is no good non-operative treatment for appendicitis. If the condition is not treated at all, it will most certainly progress to perforation (rupture), making the child very sick. Therefore, operating early in the course of the disease offers the best chances for a simple operation and a speedy recovery. The risk of complications is much less if the appendix has not yet ruptured at the time of the operation.

Antibiotics, to fight the infection, have some effect on the disease. They may decrease the severity of the symptoms and, in some cases, delay the onset of perforation. Unfortunately, they only mask the severity of the condition, without preventing its complications.

 

WHAT NEEDS TO BE DONE BEFORE THE OPERATION?

In most cases, your child will be otherwise healthy, and the condition will not have been present for very long. Therefore, little needs to be done in terms of preoperative preparation or lab testing. It is always preferable that your child be without eating or drinking (NPO) for at least six hours before the operation. However, since this is an emergency, it may sometimes be safer to proceed rapidly with removal of the appendix. Since appendicitis is often characterized by abdominal pain, nausea and vomiting, chances are your child will not have eaten much recently anyway.

If your child has been sick for a while, and particularly if he has been vomiting a lot, has had high fevers and/or has had diarrhea, he may be dehydrated. In that case, we may want to give him fluids intravenously before the operation. We may also choose to give him antibiotics intravenously before the operation, if we suspect that the appendix is already ruptured.

 

WHAT HAPPENS DURING AND AFTER SURGERY?

The operation itself lasts about an hour, and is done under general anesthesia. The operation may be performed either through a small incision in the right lower part of the abdomen, or laparoscopically, through three tiny incisions in the umbilicus and the lower abdomen. Both techniques achieve the same goal, removal of the appendix, and both produce similar results in terms of recovery.

If the appendix has already ruptured, the operation may me more difficult and may last longer. Sometimes, a localized area of infection, an abscess, is found, and a drain is left inside, to be removed days later. If there has been a lot of infection and pus, the surgeon may find it safer to leave the skin open, to prevent more severe complications afterward. In that case, the wound will close by itself, over several days to weeks.

Complications are not infrequent with appendicitis, and their risk increases with more advanced disease stages: while unlikely if the appendix is only mildly inflamed, the risk of a postoperative wound infection or an abscess inside the abdomen or the pelvis after ruptured appendicitis is quite high, sometimes reaching 30%.

Your child will receive intravenous antibiotics during and shortly after the operation. Depending on the degree of inflammation and infection, antibiotics may have to be continued for several days after. If your child has recovered long before the antibiotics can be stopped, he may still be discharged home. In that case, a fine intravenous line will be left in his arm, to receive antibiotics at home. This will be done by a visiting nurse, as arranged before your child goes home.

You will be expected to return to your surgeon’s office within 2 to 3 weeks after discharge from the hospital.

 

 

 

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 Articles written by our faculty on this subject:

 

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WHAT IS PYLORIC STENOSIS?

Pyloric stenosis is a condition specific to young infants, usually between 2 and 5 weeks of age, who have been otherwise healthy, and feeding well for the first weeks of life. It presents as severe vomiting, usually after feeding. As the condition worsens, vomiting occurs after every feeding, and the baby is at risk of dehydration and malnutrition. Although babies may vomit for a lot of different reasons, what makes pyloric stenosis so typical is the fact that the baby is otherwise not sick, and is extremely hungry right after having vomited.

Normally, the contents of the stomach (food, fluids, formula, or the stomach’s own secretions) do not empty rapidly into the next portion of the intestinal tract (duodenum and small bowel). Instead, a sphincter-like muscle at the junction between stomach and duodenum (the pylorus) only allows stomach contents to empty intermittently, small portions at a time. It does this by alternatively opening and closing. In pyloric stenosis, the pyloric muscle remains contracted, and does not open at all. Therefore, the contents of the stomach never empty into the intestines. If the stomach’s efforts to ‘squeeze’ its contents past the closed pylorus are unsuccessful, these forceful contractions of the stomach will cause the child to vomit the undigested formula, often under considerable force (so-called projectile vomiting).

The exact cause of pyloric stenosis is unknown. It is more common in boys, often the first-born child, and it tends to run in families. However, nobody knows why it occurs, or why it is not present at birth (but rather a few weeks later). Children who have had pyloric stenosis are not at increased risk of developing stomach, intestinal or other diseases later in life.

 

WHY DOES PYLORIC STENOSIS HAVE TO BE OPERATED?

If left untreated, pyloric stenosis will eventually prevent the baby from taking in any fluids or formula. Therefore, he may rapidly become severely dehydrated and eventually malnourished. In addition, the frequent vomiting of stomach contents may cause severe imbalances in the composition of the baby’s blood and body fluids. There is no good medical (i.e., non-operative) treatment for pyloric stenosis.

We now know that, after the operation, the baby’s pylorus will eventually heal to become a normal, circumferential sphincter muscle. This occurs within 2 to 3 weeks of the operation. The baby is cured immediately, however, and can tolerate feedings within hours of the operation.

 

WHAT NEEDS TO BE DONE BEFORE THE OPERATION?

The most immediate dangers to your baby are dehydration and electrolyte (body fluids) imbalance. Malnutrition is not an immediate problem, and neither is the hypertrophy (exaggerated spasm) of the pyloric muscle. The pyloric stenosis itself is not causing any pain or discomfort to your baby, other than hunger and frustration.

Therefore, your baby needs to be hydrated first (with an intravenous fluid solution, since he can’t keep anything down). At the same time, we need to make sure that the electrolytes in his blood are not abnormally low; if they are, we need to correct the imbalance first, before your baby can undergo general anesthesia and surgery.

Once your baby is stable and well hydrated, we can proceed with the operation. The procedure, which has not changed much over the last several decades, is called pyloromyotomy.

 

WHAT HAPPENS DURING AND AFTER SURGERY?

The operation itself lasts about 30 minutes, and is done under general anesthesia. At the end of the operation, your baby will wake up and be transported to the recovery room. Once everything is settled, someone will bring you to your child, so that you can be there as he wakes up. Once your baby is fully awake and recovered, he will be transferred to his room. Feeding, first with water (Pedialyte), can be started six hours after the operation. Once your baby is tolerating a normal feeding schedule, you will be allowed to go home.

Not uncommonly, your baby will still vomit once in a while, although not as severely as before. In part, this is because the stomach still tries to forcefully squeeze its contents past a pylorus that, hours before, was still tightly closed. It is also possible that your child has reflux, a condition which, in its mild form, is almost always present in infants for the first few months of life.

 

 

 

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 Articles written by our faculty on this subject:

 

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WHAT IS AN INGUINAL HERNIA?

Unlike inguinal (groin) hernias in adults, it was not caused by straining, heavy lifting... or "old age." Instead, it is a defect that has been present since birth: a small hole in the abdominal wall, through which the spermatic cord (in boys) or the ovarian ligament (in girls) passes, failed to close. As a result, abdominal contents (sometimes a loop of bowel, or the ovary; and sometimes, just fluid) can slip through that hole, into the groin or the scrotum.

When the loop of bowel or the ovary gets stuck in the hole, the hernia is incarcerated. If the hernia is incarcerated, and the blood vessels to the loop of bowel are compressed, that piece of bowel may die off: the hernia is now strangulated.

WHY DOES A HERNIA HAVE TO BE FIXED?

To avoid incarceration and strangulation. This ‘hole’ in the abdominal wall (patent processus vaginalis is the medical term) has been present since birth, and will not close on its own. Therefore, it is recommended to have it fixed as soon as it is diagnosed; waiting months or years only increases the risk of a complication.

 

WHAT NEEDS TO BE DONE BEFORE THE OPERATION?

Not much, really. Unless your child has a medical condition that requires it, no preoperative testing is necessary: no blood test, no X-ray, no urine test. Simply, you will be asked to visit the operating suite a few days before, for about an hour. During this ‘POP’ (PreOperative Program), you will meet the operating room staff and the anesthesiologist (the doctor who will put your child to sleep), so that you can ask them questions (they may have some questions for you, too). Meanwhile, your child will familiarize him- or herself with the operating room environment, so that he/she will be less nervous the day of surgery.

One (business) day before surgery, you will be told at what time to come in for the operation. Your child will need to be without food or drink for several hours before the planned time of operation. Please follow the instructions closely; if your child does not have an empty stomach, anesthesia and surgery may be more risky.

 

WHAT HAPPENS DURING AND AFTER SURGERY?

The operation itself lasts about 30 minutes, and is done under general anesthesia. At the end of the operation, your child will wake up and be transported to the recovery room. Once everything is settled, someone will bring you to your child, so that you can be there as he/she wakes up. Once your child is fully awake, and can tolerate food (or at least something to drink), you will be allowed to go home. The stay in the recovery room should be about 1 to 2 hours.

 

WHAT HAPPENS WHEN WE GET HOME?

Your child may not be very active following the operation. In fact, he/she may be nauseous, and even vomit a few times. This is usually a result of the anesthesia, and is short-lived: it will be gone by the next morning. In the meantime, make sure your child is at least able to drink clear liquids, to avoid dehydration. An electrolyte solution such as Pedialyte if your child is young (under one year), or any clear liquids (apple juice, broth, ...) will do.

Your child should be much better by the next morning, and no further restriction of activities is necessary. He/she can go back to school or day care. Although there is no risk of tearing or rupturing anything, any type of straddling activity (rocking horse, tricycle, bike) should probably be avoided for a few days.

 

HOW DO I CARE FOR THE INCISION?

The incision in the groin is about one inch wide, in a skin crease. It is sutured with an absorbable suture: this suture will dissolve in a week or two, and will not have to be removed. The area is also covered with a plastic film (collodion), which keeps the area somewhat waterproof. The plastic layer will peel off in about a week.

Still, it is better not to give your child a bath for about 3 to 4 days (sponge-bathing is better).

 

WHAT'S NORMAL... AND WHAT'S NOT?

VOMITING

May be very disturbing, but will be short-lived: It will be over by the next morning. If your child vomits everything (including liquids), and is very young (under a year), however, dehydration may be a concern. If your child has one or two wet diapers that evening, and is otherwise cheerful and playful, you shouldn’t worry. If you’re not sure, call us.

FEVER

A low-grade fever may be seen the first evening or night; after that, any fever (particularly 101¡ or more) is abnormal, and you should call us.

WOUND PROBLEMS

There may be some mild redness at the wound, but this should improve within a day or two. There may also be a drop or two of clear fluid. If the redness gets worse, or the wound starts to drain more fluid (particularly if it is cloudy or bloody), you should call us.

PAIN

Your child will have surprisingly little pain beyond the first 1 to 2 days after the operation. If your child is older than 1 year, you received a prescription for acetaminophen (Tylenol) with codeine; give him/her the prescribed dose, as often as every 4 hours. After 48 hours, plain acetaminophen (Children’s Tylenol or similar product) will be sufficient.

If your child is under one year, do not give codeine; rather, give plain Tylenol (infant Tylenol, or similar product) as needed (as often as every 4 hours)

 

 

 

 

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WHAT IS INTUSSUSCEPTION?



Intussusception is a form of intestinal obstruction most commonly seen in infants and toddlers, whereby a segment of the small bowel ?telescopes? into another portion of the small, or the large intestine. As the intestines contract rhythmically, trying to push their content further down, they also push the intussuscepted loop of bowel further into the large intestine, making the blockage worse. These contractions of the intestines cause the child to experience very severe, cramp-like abdominal pain. When the bowel relaxes, in between contractions, the pain goes away, and the child will typically be very restful, and sometimes even sleepy or lethargic.

HOW DO I KNOW THAT MY CHILD HAS INTUSSUSCEPTION?


Abdominal pain in young children can be due to a large number of conditions, but some features are typical of intussusception. In addition to the above-mentioned cramp-like, episodic type of pain, whereby the child often draws up his legs, there may be other signs of intestinal obstruction: the abdomen may become distended with gas, as the air that is normally swallowed cannot find its way past the blockage; As fluid backs up as well, the child may start to vomit, not only food, but greenish bile as well. Diarrhea, which is a common finding in viral infections (intestinal flu), is usually not present, but stools may be blood-tinged and contain clear mucus. As noted above, the episodes of severe pain often alternate with long periods of sleepiness and lethargy, a finding that is typical of intussusception. If some or all of these signs and symptoms are present, intussusception should be suspectded and the child should be seen by a physician.


WHY DOES INTUSSUSCEPTION HAPPEN?


Although the condition is well known to pediatricians and pediatric surgeons, and its treatment is very effective (see below), the cause of most cases of intussusception is still unknown. It almost always occurs in children between the ages of 4 months and 2 years (sometimes a little older, rarely younger) and will not happen later in life. While a lesion, tumor or polyp inside the small intestine can act as a ?lead point? and cause an intussusception (the most common type of such lesions is a Meckel?s diverticulum), this mechanism is only responsible for 10% of all cases. In all others, the condition is so-called ?idiopathic,? meaning that the true cause of it is not (yet) known. Much research has been done to discover the cause of idiopathic intussusception, and several theories exist, but none has proved to be satisfactory.



HOW IS INTUSSUSCEPTION TREATED?


Intussusception is a true intestinal obstruction, and requires immediate attention. If left untreated, it will progress to bowel distention, damage, necrosis and rupture, followed by peritonitis (inflammation of the abdominal cavity), severe infection and shock. However, this is one of the few forms of obstruction that do not always require an operation. In about 70% of the cases, the intussusception can be pushed back by running liquid (typically, barium) or air under tightly controlled pressure, while the child?s abdomen and intestines are being monitored by X-rays. Performing a barium enema in a child suspected of having intussusception therefore helps to establish the diagnosis (the blockage can be seen on X-ray) and treat the condition (ultrasound will sometimes be used to diagnose (or rule out) intussusception, but a barium (or air) enema will still be necessary to treat it).

The longer the intussusception has been present, the more difficult reduction by barium or air enema will be. Sometimes, the child will be so sick that the surgeon or the radiologist will judge this technique to be too dangerous. Even if a reduction under X-ray monitoring can be attempted, it may not succeed in relieving the obstruction. In both these situations (which occur 20 to 30% of the time), the obstruction will have to be corrected surgically.



WHAT HAPPENS IF MY CHILD NEEDS SURGERY?



If X-ray reduction is too dangerous or unsuccessful, your child will need to be operated on emergently to relieve the intestinal obstruction. As for the X-ray technique, your child will first have to be hydrated (between the vomiting, the poor appetite and the obstruction itself, your child will have become moderately to severely dehydrated). This will be done intravenously.

Your child will then undergo an operation under general anesthesia. An incision will typically be made in the child?s right lower abdomen, not unlike what is done for appendicitis. The obstruction will be found and corrected, by gently separating the telescoped loops of bowel. Rarely, a portion of the bowel will be so diseased that it is safer to remove it.



WHAT HAPPENS AFTERWARDS?



Once the intussusception is reduced (with X-ray or surgically), your child will gradually recover. He will be kept without food initially, to allow his intestines to rest. Depending on whether or not your child required an operation, feeding will be started within hours or the following day(s). As soon as a regular diet is tolerated, your child will be discharged home.

Intussusception can sometimes occur again (approximately 10% of the time); not uncommonly, this will happen within the first day or two after the initial attack (often while your child is still in the hospital). If X-ray reduction was successful the first time, it is very likely that the same treatment will be successful again. Ultimately, your child will outgrow the risk of intussusception, and there should be no lasting effects.

 

 

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MORE INFORMATION ON GASTROSTOMY TUBES



Click here for a comprehensive review of G-tubes, put together by the parents of a patient. If the tube just fell out, see the instructions below.

 

HOW DO I CARE FOR A GASTROSTOMY ("G"-)TUBE?


High Profile (Pezzar, PEG & Foley)

SITE CARE
1. Gather and set-up equipment
a. Warm tap water
b. Mild soap only if needed
c. Cloth adhesive tape unless patient skin becomes red from the tape
d. Q tips
2. Wash hands
3. Clean skin (twince a day, or as instructed
4. Remove old tape gently. Do not pull the tube away from the belly
5. Check the skin and tube for changes
a. Skin: Redness, drainage, tenderness, open areas, bleeding or skin temperature changes
b. Tube: For Cracks, leakage (Be sure it is pulled against the stomach wall)
c. IF CHANGES SEEN PAGE: Neil Ead, CPNP at 350-1757 or Pediatric Surgeon on call at 444-5611( ask operator to call Pediatric Surgical Resident)
6. Wash the site with circular motion from the center of the tube toward the outside of the belly using the q-tips
7. Tape the tube to keep it in place. Be sure it is fixed firmly to the skin and it is taped downward
8. Be sure the GT is hidden away from your child's hand & feet so it is not accidentally pulled out (For example-under clothes)

BATHING
· Your Doctor will tell you when your child may begin to take a tub bath.
· Avoid overly warm water because this can irritate tender skin
· Use only mild soaps and soft washcloths
· While the GT is vented, do not let water get into the tube. (The tube should not be clamped, even in the tub.)
· After the bath, do site care.

 

 What to do if the G-tube falls out?  

Cover the site with a 4x4 gauze until a new one is in


· Call your Surgeon to come to the office or Emergency room


· The G-tube needs to be replaced within 2 hours

Travel with a 14Fr. Foley Catheter, luberfax, paper towels or, better yet, make sure that you always carry a replacement tube or button of the same size.


·

 

Gastrostomy Tube Feeding

· The child should be sitting or positioned on right side with the head of bed elevated
· Set-up tube feeding on feeding pump as per home care company

Vented System:

To let the feeding back up into an empty syringe instead of vomiting
· Set-up:
· Catheter tip syringe tied with string to keep it above stomach level.
· Be careful that the tube is not pulling on the belly.
· Flush the tube with tap water before and after feeds and every 4 hours.
· This helps to make sure that tube will not clog .
· The feeding tube from the pump is placed inside the syringe and run
· If the feeding backs up try to flush it with water. If this does not work, check the position of the tube, milk the tube and then flush it again.

· This set-up is kept even if the feeding is done or when traveling.
· (Be sure to pin strings higher than the stomach (e.g., to your shirt).
· The tubing is only clamped with the surgeon's instruction.
· This will be done slowly, when changing from vented to direct feeds.

Giving medications

Give ½ hour before feedings or 1 hour after feeds.
· Draw up the medications in syringes. If pills must be used, crush them up and mix them with water before putting them in the syringe.
· Put medications into the large syringe
· Flush with 15 cc ( 1 tablespoon) of water

· Formula, which is too hot or too cold or given too quickly, can cause vomiting, diarrhea or cramping.

· Signs of feeding intolerance:
Vomiting, diarrhea, discomfort, distention or continuous backup in the tube greater than one quarter (1/4) of the feeding volume

 

 

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