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
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.
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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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 dont.
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
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
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
You will be expected to return
to your surgeons office within 2 to 3 weeks after discharge
from the hospital.
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WHAT IS PYLORIC
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
Normally, the contents of the
stomach (food, fluids, formula, or the stomachs 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 stomachs 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
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 babys 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 babys 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 cant 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
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
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WHAT IS AN 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
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.
DURING AND AFTER SURGERY?
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.
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?
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).
AND WHAT'S NOT?
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 shouldnt worry. If
youre not sure, call us.
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
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
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 (Childrens 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
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.
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
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.
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.
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.
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)
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
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
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
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
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
· Your Doctor will tell you when your child may begin
to take a tub bath.
· Avoid overly warm water because this can irritate tender
· 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
· 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
To let the feeding back up into
an empty syringe instead of vomiting
· Catheter tip syringe tied with string to keep it above
· 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.
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
· Signs of feeding
Vomiting, diarrhea, discomfort, distention or continuous backup
in the tube greater than one quarter (1/4) of the feeding volume
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