Mucous Fistula Refeeding Protocol

Pathway for Mucous Fistula (MF) Refeeding •Intestinal resection but not a good candidate for primary anastomosis?•Is infant stable to allow for extra operative time to create MF? •Distal bowel assessed for patency?◦Either in OR or with contrast study•Tolerating enteral nutrition for at least 2 days?•Has >5 mL of stoma output/day? Refeed proximal stoma effluent into mucous fistula to create an artificial ‘continuity’◦Max refeed bolus push = 10 mL.If >10 mL, run refeeds over a pump with max rate of 30 mL/hr. Can extend infusion time as needed to 3 hours maximum.◦If thick stoma effluent, strain to prevent MF tube clogging. May also dilute w/small amount of warm water PRN. 1)Place MF refeeding order in EPIC◦Day 1: Refeed 5 mL q12h ◦Day 2: Refeed 5 mL q6hr (if on enteral bolus feeds) or q8H (if enteral continuous feeds)◦Day 3: Refeed 10 mL q6hr (or q8H if on continuous feeds)◦Day 4: Refeed 10 mL q3hr (or q4H if on continuous feeds) ◦Beginning Day 5, refeed all stoma output q3 or q4 hours (depending on type of feeds) 2) Ensure that patient continues to tolerate enteral nutrition Intra-Operative: Ready to begin refeeding? How to initiate refeeding : v2 Updated 5/20 •Line up mesenteries of proximal and distal bowel (Fig. 1)•Tunnel MF tube through abdominal wall & away from stoma•Place 5-8 French feeding tube into distal bowel (MF) with purse string suture (Fig. 2)•Stamm MF tube to abdominal wall (Fig. 3)•Stoma and MF should be far enough apart for placement of separate ostomy bags (Fig. 4) Place MF tube intra-operatively Is patient a candidate for MF refeeding? If yes, create MF After post-op ileus has resolved Figure 1. Figure 2. Figure 3. Figure 4.Technical Key Steps: If yes to all 3, then can start refeeding MF tube fell out•Alert PedSurg Fellows to replace MF tube on morning or evening rounds Leakage around MF•Check tube placement •Order contrast study to r/o distal obstruction Troubleshooting Refeeding Challenges: MF tube is clogged •Instill warm water; if that doesn’t work then try carbonated waterPatient is acidotic (bicarb < 20)•Rule out other causes of metabolic acidosis •Stop MF refeeding, then resume refeeds slowly after bicarb has normalized Refeeding: 1 2 3 4 Figure 1.Figure 2. Figure 3.Figure 4.