Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee

and we got feedback that several hospitals have changed their gastro schesis protocols based on recent publications so with us we have beth romeski jason frazier and stephen lee who are going to talk about updates in gastro schesis great thanks todd so i have the easy part i'm just going to put up the full question welcome everyone so uh we are going to address three topics the first will be when to start feedings using a feeding protocol and what to do when you start feeding and your baby with gastro schesis starts vomiting so our first question is you just performed a sutureless abdominal wall closure in a newborn with gastro schesis the bedside nurse and family asks you when you want to start feedings you reply so we'll put up the question all right so go ahead so you have four choices immediately after sutureless dressing is placed when the og output is clear when the og output is less than 10 mls per kilo per day when the abdomen is completely closed defect is covered by skin and fascia all right guys you're not off the hook i'm going to be calling on you when do you feed a gastro schesis baby when do you feed right away you put the tape on do you wait or you just start feeding right away what'd you say what'd you say when the output's going down when the output's going down says miguel justin we have a protocol i don't remember the exact number it's not based on what the og looks like or ng it's just volume and then so it's ng volume mirth nodding her head ng volume same thing 20 per kilo once it's less than 20 per kilo you start beads take out the ng anyone different all right steve okay wait wait wait what are the questions say sorry steve it's split between that when the og output is clear that's about half and then the next step is um when the og output is less than 10 per kilo okay i'm going to go out on a limb i would have said b myself because we use we do consider quality and quantity but i think we're going to hear something different so jason so why why do you do 20. for those that said like miguel what what does it mean by you with decreasing uh and then it's going to 60 the third day i must start doing something okay so do you pull the ng then no i keep it close though and then then you do when do you sure yeah every four hours okay why to see how it's going okay so i mean again there get much more of that out of him he's so i mean there's trying to go back up how do you go there go okay so me we start and we're pretty aggressive uh so we start feeding essentially you have to put the dressing on uh as long as the baby's not sick not having horrible output not puking or anything like that there's been several protocols that have been published on this um it's kind of all over the place you know some say 20 uh some say when the babies had a bowel movement some say when the output's kind of clear uh you know some say when they you know clamp it or you stop it and then there's output then it's doing okay okay immediately and in whatever means if the ng goes to you know 100 in one time completely very dark green feeders brain so we'll start essentially the you know we don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it uh if we if it'll tolerate it can i can i interrupt you for one second before we keep going on this you've already put the dressing on yeah i want to ask a question about the dressing for two seconds i'm going to be the outlier here you're going to throw tomatoes at me because i don't know why are we so why is everyone pushing for no sedation when we put the dressing on what what's the i think it's going to hurt us i think we're going to have better outcomes with more sedation but like huh you intubate who who intubates just miguel cecilia i would love to dan threw his hands down i i i i think it's much harder for me to get everything down for you or for the baby yes what's that is this for you or for the baby we're both well in order to put the dressing on you need to reduce right so i'm pushing it in and the baby's crying and it's popping back out and i'm pushing it in the baby's crying and it's popping back out is that i might maybe i'm the only one that has that issue and i when they're sedated it's like easy it does and i think what we've learned by doing this more and more often is that if you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit so they do a question and bindi hold on wait one second hold on i have the microphone right now you have to come grab it from me yeah okay but well yeah real real quick question bindi do you sedate an ind at your hospital do you do them awake or sedated oh fully general anesthesia so you do a general anesthesia for an ind but shoving bowel inside a newborn baby no we're not going to give them any sedation i don't think there's any nerves nerves oh they're going crazy it's just the pressure that bothers them yeah it's it's j receptors it hurts you're anyways all right keep going so this this is an important good thing because everybody's so different on the way they do this so i mean even the way that people use feeding protocols is different ours is pretty aggressive we just started this one recently so we'll have some data on this probably in the next year or so um but it's really just based upon patient tolerance and it's kind of based upon some of the data that's out there from the rest of the world where they don't have tpn and so they just you have to feed the kid if the kid does okay then they keep going whereas you know in the us we were such privileged that we have pic lines we have tpn and things like that and so this is our ours is really kind of based upon that as well i mean beth talk about kind of what your protocol looks like ours is yours but more complicated so um i think we have the slide thing so our feeding protocol came about by looking at outcomes and and i think maybe that's the next slide you know well we'll get to that but ours is talking about the same thing so it's basically once the dressing is on or the abdomen is surgically closed which almost never happens then it goes by volume um and talks through some things and then the we have a standardized increase for the feeds um and then i i think we have also on here we introduced sham feeding because what we realized is a lot of our gastroschesis babies have very poor oral feeding skills from you know delayed access to feeding etc so we introduced sham feedings and we advance sort of per protocol before this we had trialed a system of just ad-lib feeding um it was not successful i think there were a number of reasons for that part of it was that there was no standardized plan for when to get the ng tube out so there was i think we started feeding these babies too late and what we did for two weeks was we just let them ad-lib feed and we filled in the rest with tpn but we abandoned that after about a year or so after we looked at the results and realized that wasn't working so this is the the practice change and and protocol that we've had in place for i think the past four years or so so i think the next question we had was um does your institution have a gastroschisis feeding protocol it's going to get a sense of worldwide um you know what the practices it are so a yes and i follow it b yes but i don't follow it no or unsure so in the room how many people have a gastroschisis feeding protocol at their institution so it's like two-thirds of people are how many of those people follow the gastroschisis feeding protocol so it looks like we have a lot of you know followers in this room so that's maybe good i don't know if we've had enough time to comments so beth i think that this is a general statement but the reason these protocols at least in my opinion are important is because there's not variation in care generally speaking they've been tried and true and work all right but the nurses know what it is and you know you don't need to call a doctor every time you want to increase by 10 cc's or whatever so that's why i think all these protocols whether it's gastroschisis or anything are important so that your nurse practitioners and your nurses and your residents just know know what what's going on and how to feed or manage these patients yeah i think that's a really good point ellen what does the poll tell us yeah it's uh most people half of them are saying over half yes and they follow the protocol well there we go lots of followers so does it really matter so uh jason was the lead author i guess i'm going to present this for him uh of a study that we recently published out of the mwpsc about outcomes of patients who were and were not fed by protocol where it was roughly two-thirds by protocol one-third not um the protocol fed infants had fewer surgical site infections which um and then we but we weren't really sure there was a lot of differential variations i don't know if you want to comment on yeah i think a lot of the a lot of the inconclusivity from the the study showed that you know most likely due to the fact that there was lots of different feeding protocols that were used uh across our member institutions um and i think the the ssi thing was probably just because patients that were fed via protocol were cared for via protocol and so that they actually had less variability and less uh less changes uh in the way that these these patients are not you know look for and i think this kind of speaks to the fact that number one there's a lot of variability within gastroschisis in and of itself when you get cohorts that large uh but then number two uh you know even if you have difficult different protocols there's significant variation within and of itself that in that too so i think just one of the things and i alluded to this before the reason that we were started looking at these is our length of stay for gastroschisis and cincinnati was astronomically higher than like any other nick micu in the cooperative network that we worked with so we sat down we're like what is going on here so our average length of stay was 49 days and it was comparing to other nicu's like kansas city and and other places that are taking care of very similar babies it wasn't like it was comparing to a different type of nicu so we instituted this uh a feeding protocol we spent a lot of time trying to get people to follow it and and making some adjustments and over two years we dropped the length of stay by 10 days and the mix of patients is not different so i think it can work uh there's a lot of other things obviously going on here that we're working on we're finally starting to see a decrease in time to first first feed to full feed uh we haven't really seen the number of days from admission to first feed change although 2020 we did really well and then bounced back but so we're working on that but i think it can it can you know sort of standardize care and and make things smoother sure uh third question after two days of successful feeding advancement the baby has one bout of bilious emesis now what what do you do with your feedings now npo for 24 hours npo for six to eight hours keep feeding at the current rate and volume decrease feedings um the the volume and rate so as this is coming up i'd love to hear from the uh room here what people would do keep going so keep going npo over there justin put a chest tube in is that what i heard justin i have a question so i love the protocol because it allows us to sort of fade into the distance and the nick you can mostly run it but the downside of what i've seen from doing that of us not being that involved is there's like this tendency of the neonatologist some of them love like continuous feeds and then they're not taking anything orally and then a lot of them get uh oral aversion and that prolongs their length of stay do your guys's protocols say how to feed bolus when they get oral that kind of thing because that also significantly contributes to length of state not just getting the gold feeds you're right and that's why we we do try to do both uh intermittent feeds to start but it doesn't specifically say you have to uh but i think that's where the sham feeds are hopefully we'll see it's too too early we've only been doing that for like a year to see if maybe that is going to make a difference because our rate of sending gastroschisis babies home with an ng or a g tube it's like two thirds of them go home with some sort of tube to help them continue feeding which is crazy um but yeah i think that's true ours ours does include how to feed when to feed how to advance all of those things uh we actually took it for the prenatal care for our whole gastroschisis protocol including uh our um you know ob-gyns our new and then with the neonatologist to help post-operatively so we continue to follow i think it is key that we we do continue to follow these patients throughout the duration okay what did the pulse show um it's been changing a lot but it's pretty divided currently it's about equal between um a c and d so it's so if it's equal between a c and d probably b also so so it's all all over the map so who's uh is it jason you're going to tell us what we do next so steve is the question about bilious emesis or is it about emesis because i think that's i mean i think that that may or may not be impactful on what the answer is right right so i i just didn't know if that was why there was variation in um in in the answers yeah i put that bilious to stimulate this because some people will ignore bilious emesis completely you know some people check residuals and that's going to be bilious a lot of the time too and some people will just completely ignore that uh and i think that's the important you know we were talking about miguel was shaking his head just keep feeding keep feeding keep feeding um but i think that's an important thing to say too but the most important thing i think about all of this is like justin was talking about how you kind of start fading away is actually not fading away you know a lot of the protocols that are out there talk about you know there's this one study from new zealand talks about the you know the attitudes towards feeding and it's a little bit different but the most important thing that kind of keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing you know yes you can have a protocol yes you know you need to follow it but the most really you really need to continually evaluate the patient as they continue to go to make sure that you know yes your protocol is working but also to the patient does okay throughout that's essentially what this does i mean for us we'll you know if the patient really has significant issues in complete intolerance we'll stop for six hours but again that's you know necessarily this isn't clearly evidence-based at this point because there's still so much variation in literature as regards to that but we did put in our protocol for that for our nursing college as well as our families that emesis is expected we put that within our written protocol to make that expectation known that it's okay it's okay they're going to throw up we'll just keep working through it how quick do you get to uh quickly how quickly do you get to goal feeds on average yeah good question so with our new protocol we've been we started just really instituting that unless last may and so we've had very few patients with that i can talk about our last one of our last patients that we got primarily reduced you know day of life zero he's probably the hot out of hospital about two weeks and i just saw him back in clinic and you know i have two weeks after that and still doing okay that's probably an outlier in the quicker side uh you know gastroschisis length of stays has probably been about 30 to 34 days or so and so hopefully you mentioned that down and so we really try to push oral feeds quickly to get rid of that oil aversion issue and i think the quicker you can get to that quicker it's going to be able to get them home and do you start with a tube in place at any point or just like for reduction with the tube but then try to get to oral feed either both with the tube or without it if you're early feeding um i'm sorry i missed how quickly you start once they reduce is it one or two days right away have you seen any aspirations we have not seen any aspirations with regards to that yet but we'll still we're still pretty early within that and i think that's the importance of continue to monitor the data yeah and i think this is really important also also for low resource countries all right because they don't have tpn and this is i think this is where a lot of this data came from is started in cham feeds and early feeds in those kids but um having tried that in africa a few times it is it is very hard for those kids to tolerate that so it's just interested to know what your um your approach how it leads and we have we would be very helpful yeah what are you doing with the patient you do you cannot reduce so if we can't reduce it right away probably at least two-thirds of them we can't reduce right away we put them in a silo and reduce there and then do suture this gastric closure after that and then you start and then we start feeds yeah okay all right uh this was a great session i'm actually i love this it's short it's to the point i think that we've seen to bindi's point this is a big problem internationally and the more we can figure out how best to treat these the better we have really great sessions coming up we're going to be talking about the most cutting edge new technology in the past year in pediatric surgery or surgery as a whole we're going to be talking about uh the which patients i know i they tease me because i'm not good at this which patients can you send home from the emergency room because i admit everybody uh so who can we send home and feel okay about it and then we're going to be talking about new ways of managing esophage leaks uh we've all done it the same way for years so we're going to get to that but i want to make one plug to tell people about all this talk of protocols so the state current app um i want to give credit to miracodigal who came up with this idea of creating a private space to keep these protocols in your hospital um it's all with your hospital videos your hospital protocols your lectures all in one place but the cool thing that just happened and probably most of you here already have done this with us is the idea of creating your hospital space and a sharing network so that if you're part of the network you can share protocols and see what all the other hospitals are using ask questions move them into your list your playlist of protocols and get updated when other hospitals are making changes because i feel like we're all kind of on islands and we do things different so hopefully this will end that um so let us know if you're interested in that for your hospital um so we're going to take a quick break talk about oshate buffalo children's hospital uh who has again been with us from the very beginning for 10 years now uh matt carmen is the chairman of surgery there so let's roll that video and then we will uh come back