Risk management protocol for gastrostomy and jejunostomy insertion in ventilator dependent infants

• Published in: Neuromuscular disorders : NMD 2013-04, Vol.23 (4), p.289-297
• Main Authors: Chatwin, M, Bush, A, Macrae, D.J, Clarke, S.A, Simonds, A.K
• Format: Article
• Language: English
• Subjects: Adolescent; Airway clearance; Aspiration; Child; Child, Preschool; Clinical Protocols; Cough augmentation; Down Syndrome - complications; Enteral Nutrition - instrumentation; Enteral Nutrition - methods; Failure to Thrive - etiology; Failure to Thrive - surgery; Gastro-oesophageal reflux; Gastroesophageal Reflux - complications; Gastroesophageal Reflux - surgery; Gastrostomy - methods; Humans; Infant; Jejunostomy - methods; Lung Diseases - complications; Nervous System Diseases - complications; Neurology; Neuromuscular disease; Neuromuscular Diseases - complications; Non invasive ventilation; Noninvasive Ventilation - methods; Postoperative Care - methods; Postoperative Complications - prevention & control; Preoperative Care - methods; Respiration, Artificial - methods; Retrospective Studies; Spinal muscular atrophy; Treatment Outcome; Trisomy 21
• ISSN: 0960-8966; 1873-2364
• DOI: 10.1016/j.nmd.2013.01.006

Abstract Gastrostomy, gastrojejunostomy and anti-reflux surgery in infants and children who are chronically ventilator dependent are associated with significant risk of morbidity and mortality. We report outcomes of 22 high risk children who underwent these procedures at our centre. Pre-operative investigations included: overnight oxygen and carbon dioxide monitoring and subsequent optimisation of ventilatory support, echocardiography, video fluoroscopy, and assessment of gastroesophageal reflux. We carried out 24 procedures under general anaesthesia. Twenty-one children used ventilatory support pre-operatively. Median age of first surgical procedure was 18 months (range 3–180). Supplementary feeding was commenced in 20 children prior to procedure, median age 9 months (1–31). Median PICU length of stay was 1 (1–8) days. No children died in the post-operative period. Extubation was possible within 24 h in 87% of cases. Complications included; atelectasis ( n = 2), ileus ( n = 2), abdominal distension ( n = 4) and loose stools ( n = 1). We conclude that, in this high risk cohort of ventilator dependent children with predominantly neuromuscular disorders, with careful assessment, operative intervention can be carried out under general anaesthesia, with the child being extubated early back onto their routine ventilatory support and aggressive airway clearance. Additionally this protocol can minimise post-operative complications and is associated with a good outcome in the majority.