Protocol for Management of a Neonate Requiring a Colostomy

This knowledge module allows medical officers (non-specialist physicians) and general surgeons to become confident and competent in the pre-operative management protocol for neonatal colostomy procedures performed in low to middle income countries (LMICs).

Important Aspects of Newborn Anatomy and Physiology[edit | edit source]

The newborn should never be considered a miniature adult as he or she has a distinct physiology and anatomy. In addition, peculiarities due to recent transition from fetal life make them unique. Key aspects to bear in mind for a neonate requiring colostomy include the following:^[1]

• Alveolar expansion and development progresses rapidly in the newborn period and is related to production of surfactant which occurs in late fetal life. Pre-term neonates are therefore at high risk of respiratory challenges.
• Newborns have a higher body surface area and body water composition which places them at risk of rapid fluid shifts and dehydration when normal fluid metabolism is impaired such as in intestinal obstruction. Fluid resuscitation should therefore be prompt and exact.
• Their total blood volume of 80 - 90 ml/kg for term neonates and 90 - 100 ml/kg for preterm infants is a small volume. Hence, small amounts of blood loss can cause significant changes to their cardiovascular homeostasis.
• Additionally, 24% of neonates with anorectal malformation may have an associated cardiac anomaly. This worsens morbidity and impacts outcome. Such anomalies should be anticipated and early supportive therapy instituted.
• They have difficulty maintaining their body temperature due to their large body surface area, poor thermoregulation, and small size. Thermoregulation improves metabolic and physiologic function.
• Surgical neonates are at risk of hypoglycemia. Therefore, a 10% glucose infusion is typically started on admission. During the first 48 hours following surgery, it is also not unexpected to note wide variations in serum glucose levels.
• Although the newborn abdomen is relatively wide and protuberant, access needed for a colostomy is usually small. The colon has a short average length of 35 cm and only the transverse and sigmoid colon which hang free on a long mesentery are ideal for colostomies.

Clinical Considerations[edit | edit source]

A colostomy is a surgically created opening between the colon and the abdominal wall. Most colostomies in neonates are performed for acute intestinal obstruction due to anorectal malformations and Hirschsprung's disease. Other rarer conditions in which colostomy may be required in neonates include: colonic atresia, congenital pouch colon, cloacal extrophy, hydrometrocolpos and following abdominal trauma.^[2]

Several techniques are available to surgeons treating these babies. The commonest however, are divided and loop colostomies. Whereas loop colostomies are quicker and easier to perform, divided colostomies completely defunction the distal bowel, preventing rectal dilatation with feces and continuous soilage of the urinary tract if there is a recto-urinary fistula. They are also less notorious for prolapse.^[3]

Most colostomies created in neonates are temporary and will be reversed after definitive correction of the primary pathology. Though a life-saving procedure, a lack of proficiency in creating a colostomy in a newborn may result in serious complications and sometimes mortality.^[4]

Surgical procedures in children, especially neonates are best undertaken by qualified pediatric surgeons or under their supervision. However, in LMICs, the population of pediatric surgeons may be so sparse that it becomes unfeasible for a pediatric surgeon to attend all pediatric surgical cases. Such situations are more common for those living in rural areas where the highest level of medical care available may be from a medical officer. Patients may then require to travel miles in order to access specialist healthcare and for a neonate with intestinal obstruction, such delays may become quickly life-threatening. Hence, the provision of essential surgical skills to medical officers may prove to be life-saving.^[5]

Protocol for Management of a Neonate Requiring a Colostomy[edit | edit source]

Most neonates requiring colostomies present as an emergency. In order to perform a life-saving colostomy and obtain good outcomes, the following key steps are crucial and must be carefully and meticulously followed.

Resuscitation[edit | edit source]

Airway[edit | edit source]

Due to early splinting of the diaphragm by a distended abdomen, the newborn in obstruction is at risk of frequent vomiting and aspiration. Hence, the mouth and oropharynx should be cleared of secretions and vomitus by gentle low pressure suctioning. Respiratory support with supplementary oxygen is commenced at 2 - 4L/min while regular monitoring of oxygen saturation to maintain a saturation above 90% is undertaken.

Nasogastric Decompression[edit | edit source]

Use an 8F – 10F nasogastric tube to decompress the distended bowel of fluid, hence improving respiration and eliminating the risk of aspiration from recurrent vomiting. The tube should be frequently aspirated at least every 2 hours and aspirated volume replaced with equal volumes of normal saline or Ringers lactate.

Fluid and Electrolyte Replacement and Maintenance[edit | edit source]

The presence of intestinal obstruction will result in significant fluid and electrolyte shifts and loss through third spacing, which is worsened by delay in presentation. Intravenous access should quickly be placed and electrolyte-rich fluid urgently replaced. In situations where intravenous access is difficult or not immediately achievable, an intraosseous access can be placed using the lower 1/3 of the femur or upper 1/3 of the tibia. Bolus correction of deficit with normal saline (20 ml/kg) is administered to rapidly expand the intravascular space for patients in shock. Shock in the newborn is characterized by tachycardia > 160/min, reduced cry and responsiveness, hypothermia and a urine output < 1 ml/kg per hr. Hypotension is a late feature of shock and appropriate sized cuffs may be unavailable in most centers in LMICs. It should therefore not be relied upon for diagnosis of shock.

Maintenance fluid and ongoing losses should concurrently be administered through a separate intravenous access. Initial maintenance fluid is achieved with 5 -10% dextrose in 0.18% saline. The hourly fluid volume is dependent on the patient's age and weight. Table 1 below provides a guide to maintenance fluid volumes in neonates. Fluid overload can quickly lead to pulmonary edema, worsening morbidity. As such, maintenance fluid should be administered on an hourly basis. To achieve this, intravenous fluid should be administered using a calibrated burette rather than by directly hanging the drip bag. The burette is refilled every hour with only the amount of fluid to be administered over that one-hour interval. In addition, the volume of any other fluid given such as blood should be subtracted from the daily maintenance fluid.

Table 1: Maintenance Fluid Therapy in a Neonate Requiring Colostomy by Age and Weight^[6]

Age(volume ml/kg)	Day 1	Day 2	Day 3	Day 4	≥ Day 5
Preterm term	80 - 100 mL/kg	90 - 110 mL/kg	110 mL/kg	130 mL/kg	150 - 160 mL/kg
Full term	70 - 90 mL/kg	80 - 100 mL/kg	100 mL/kg	120 mL/kg	130 - 140 mL/kg

Ongoing losses are replaced volume for volume using normal saline or Ringers Lactate. Rapid correction of huge fluid losses should be avoided. This is attained by assessing and replacing the losses hourly to every 2 hours.

A urine output of at least 2 ml/kg/h is targeted. A urethral catheter is passed to monitor fluid input. As soon as adequate urine output is established, potassium replacement should be added to fluid. This should include the daily requirement of 1 - 2 mmol/kg until electrolyte results are available to guide replacement of deficits.

Following provision of serum electrolyte values and establishment of adequate urine output, electrolytes are added to fluid based on daily requirements as summarized in Table 2 below:

Table 2: Daily Electrolytes Requirements in the Surgical Neonate^[7]

Sodium (Na)	Potassium (K)	Chloride (Cl)	Calcium (Ca)	Magnesium (Mg)	Phosphate (PO4)
3 - 5 mmol/kg/24hrs	2 - 3 mmol/kg/24hrs	2 - 4 mmol/kg/24hrs	0.5 - 1 mmol/kg/24hrs	0.25 - 0.5 mmol/kg/24hrs	0.25 - 1 mmol/kg/24hrs

Hypoglycemia[edit | edit source]

This is quickly assessed and corrected using 4 ml/kg of 10% dextrose water once blood glucose level is determined to be ≤2.2 mmol/L. If hypoglycemia has been corrected, hourly monitoring of serum glucose is continued until 3 consecutive normal values are recorded before the frequency of glucose monitoring can be decreased. However, it is important to closely monitor serum glucose levels in all neonates. Use of glucometer strips for glucose monitoring is not only fast but also safe as it minimizes venipunctures and blood loss.

Thermoregulation[edit | edit source]

Warming should be provided through the use of preferably woollen blankets or hot water bottles wrapped in a cloth (this can be improvised with wrapped hot intravenous fluid bags wrapped in cloth). In the absence of any of these, and if feasible, the Kangaroo method could be deployed using the caregiver. Also, warm intravenous fluids and radiant warmers are used where available. Preterm neonates should be nursed in an incubator if available.

Analgesia[edit | edit source]

Mild analgesics may be necessary once a diagnosis is made as pain may impede respiration. This should not exceed acetaminophen intravenous injection at 10 mg/kg every 8 hours.

Antibiotics[edit | edit source]

Empirical broad spectrum antibiotics is important as micro-organisms tend to quickly translocate the wall of the obstructed intestine, resulting in sepsis. Parenteral combinations of amoxicillin-clavulanate plus metronidazole plus amikacin or ceftazidime plus metronidazole are safe and effective.

Bleeding Prevention[edit | edit source]

Intravenous vitamin K is administered at a dose of 1 mg daily to all surgical neonates due to a yet poorly developed liver and risk of clotting abnormalities (hemorrhagic disease of the newborn).

Monitors[edit | edit source]

It is important to closely monitor oxygen saturation, pulse and respiratory rates, temperature, blood pressure and fluid input/output. Pulse oximeters are low-budget tools that can be reliably used here.

Initial Evaluation[edit | edit source]

History[edit | edit source]

• Age of the neonate
• Duration of ongoing symptoms
• Cause of the obstruction may help guide placement of the colostomy
• Presence of other abnormalities will give insight to possible etiology and anesthesia risk
• Presence of complications such as sepsis (fever, jaundice), acute renal failure and shock (decreased or absent urine)
• Gestational age at delivery
• History of similar abnormalities in the family
• Care undertaken so far may expose practices that increase the risk of onset of sepsis, tetanus, and other complications

Physical Examination[edit | edit source]

A thorough general examination for pallor, jaundice, cyanosis, fever and dehydration.

Weight and length are determined and compared to the standard for age.

A quick review of vital signs will guide resuscitation. This should then be monitored continuously if possible or at least frequently. Table 3 below provides the normal range for these values.

Table 3: Normal Ranges for Pulse Rate, Respiratory Rate, Blood Pressure and Temperature in a Neonate^[7]

	0 - 28 Days	< 1 Kg	3 Kg	96 hrs - 28 days
Pulse Rate	110 - 160 beats per minute
Respiratory Rate	30 - 60 breaths per minute
Systolic Blood Pressure		39 - 59 mm Hg	60 - 76 mm Hg	67 - 84 mm Hg
Diastolic Blood Pressure		16 - 36 mm Hg	31 - 45 mm Hg	35 - 50 mm Hg
Temperature	36.4 - 37.5 °C

Examination of the abdomen for the degree of distension, whether bowel markings are visible, if peristalsis is visible on the abdominal wall, whether there is tenderness and what the nature of the bowel sounds may be. They are likely to be hyperactive for cases of obstruction but will be absent if there has been an associated perforation.

Examination of the perineum will determine the presence or absence of an anal opening, its location and shape or if there is fecal staining along any part of the midline raphe. Where there is an anal opening, its patency should be determined and the rectum above it characterized with the clinician's well-lubricated smallest digit.

A thorough examination of the systems will reveal other abnormalities which may be congenital, features of decompensation or shock and also, guide further care. Abnormalities with the cardiovascular system especially, such as congenital heart disease may greatly affect outcome of surgery.

Investigations[edit | edit source]

Once the likely diagnosis is made, investigations will be guided along the lines of confirming diagnosis, guiding resuscitation and work up for surgery. This will include the following:^[8]

Babygram[edit | edit source]

Obtain erect and supine views. Multiple air-fluid levels and bowel dilatation will indicate intestinal obstruction. Ground glass opacity may suggest a perforation. Chest is reviewed for evidence of pulmonary hypoplasia, position, size and shape of the cardiac silhouette are also noted.

Cross-Table Lateral X-Ray[edit | edit source]

Where there is anorectal malformation with no obvious fistula, this will show if it is a high or low anomaly and helps determine whether a colostomy is required. A distance of the rectal gas lucency from an opaque material placed over the position of a normal anal verge, greater than 1 cm implies a high anomaly which will require an initial colostomy.

Abdominal Ultrasound Study[edit | edit source]

There may be associated congenital anomalies like hydronephrosis. Fluid collections may be seen within the peritoneal cavity if perforation has occurred and this will guide the approach to surgery.

Complete Blood Count[edit | edit source]

Anemia (hematocrit < 40%) and thrombocytopenia (platelets < 150,000/L) should be corrected with fresh whole blood where specific blood products are not available. Presence of leukocytosis (white blood cell counts above 17,000/L) should serve as baseline and inform decision for a blood culture and antibiotic therapy but should not deter surgery.

Electrolytes, Urea, Creatinine, and Albumin[edit | edit source]

Serum sodium levels of 135 - 150 mmol/L, potassium of 3.5 – 5.0 mmol/L, calcium level > 1.75 mmol/L, bicarbonate of 20 - 30 mmol/L, and chloride of 90 -110 mmol/L are normal. Abnormal values should be corrected. Serum albumin may also be determined as baseline.

Type and Cross[edit | edit source]

Blood group determination and cross-match are done in preparation for provision of blood for surgery.

Preoperative Preparation[edit | edit source]

Patient resuscitation should be completed within the shortest possible time (< 6 hours is ideal but may require more time). When the patient is assessed to be well resuscitated, that is, saturating up to and above 90%, vital signs within normal values, urine output and concentration adequate, acidosis corrected and other serum electrolytes and blood parameters optimized to levels acceptable for surgery (packed cell volume – 40%, platelet count ≥50,000/L) then surgery can proceed.

It is imperative that the indication for a colostomy should be ascertained before a neonate is exposed to the risks of surgery.^[9]

Blood should be provided as intra-operative blood losses should be replaced volume for volume and immediately.

A preoperative anesthetic review will determine the neonate's fitness for surgery and preempt possible anesthetic challenges that may be encountered during the surgery. Availability and adequacy of anesthetic equipment and drugs are also confirmed/ optimized.

Patient should be labelled and the surgery site marked.

Informed consent should be obtained from the parents or caregiver.

Perioperative medications should be confirmed available.

Patient Transport to Operating Room[edit | edit source]

The neonate should be transferred to the theatre in warm wrappings, preferably using a resuscitaire. This may, however, be likely unavailable in rural parts of LMICs. Warm blankets with hot water bottles folded in-between the sheets may suffice.

Oxygen support should be provided also especially if there is respiratory distress. This will be available usually in gas cylinders. But where this is unavailable, manual ventilation may be provided while transporting the patient.

References[edit | edit source]