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necessitates a workup for pyelonephritis. Stomal stenosis can also lead to the
formation of urinary calculi. In this setting, surgical revision of the ileal stoma
must be undertaken.
Urinary Undiversions
As the child with a vesicostomy or ileal loop grows older, the social stigma of a
diaper motivates many of these patients to seek urinary continence. For patients
with spina bifida or exstrophy, this goal may be achieved by the use of an
intestinal segment to augment bladder capacity (enterocystoplasty). In addition, a
procedure to tighten the bladder neck and create resistance to leakage and
creation of a channel through which the patient can perform intermittent
catheterization is indicated. For all patients with spina bifida and most patients
with exstrophy, continence comes at the expense of daily clean intermittent
catheterization (CIC) for the rest of their lives. Careful patient and family
selection is necessary for this procedure; compliance with CIC is crucial.
Nevertheless, the enhanced self-esteem and improved quality of life these patients
report are gratifying.
Perforation is the worst complication of intestinal augmentations to create
neobladders. Most bladder perforations result from overdistention of the
augmented bladder, which then diminishes perfusion to the bowel segment. In
addition, the urine in these neobladders is chronically colonized because of the
use of intermittent catheterization. Patients may present anywhere from 1 month
to many years after surgery with a history of acute abdominal pain. Fever may be
present within a few hours of perforation. Because many patients with spina
bifida have decreased or absent abdominal sensation, peritonitis may be fairly
advanced before pain is experienced. The presence of abdominal pain in a patient
with a urinary diversion should prompt an immediate call to the patient’s
urologist. The urologic evaluation generally consists of a fluoroscopic gravity
cystogram with views during filling and emptying, or a CT cystogram. Small
perforations may be obscured with the full bladder and become apparent only
during bladder emptying. Prophylactic antibiotics should be administered before
the cystogram. Once this diagnosis is established, the patient should be prepared

for emergency laparotomy.
Patients may present to the ED with a sudden inability to pass a catheter into
their neobladder. This situation may be because the appendiceal conduit through
which they pass their catheter contains a false passage. A fluoroscopic study is
warranted to delineate the passage and allow catheterization under radiographic
control. The same situation is often true for patients catheterizing per urethra. In


some cases, the urologists may opt to take a patient to the operating room for
emergency endoscopy in order to define the obstruction point. When all else fails
and the patient’s bladder continues to distend, it is safest to pass a suprapubic
drainage catheter into the neobladder.
Because the creation of a neobladder is an intraperitoneal operation, these
patients are at risk for developing small bowel obstructions. A patient with
abdominal pain and a neobladder merits radiographic evaluation.
Up to 30% of patients with a neobladder develop stones within their pouch and
require either endoscopic or open surgical removal. These stones rarely cause
pain by obstruction, but rather they produce foul urine that can be so irritating to
the neobladder that the patient presents with a vague lower abdominal pain. These
stones are calcified and show up on an abdominal radiograph. Treatment with
antibiotics is palliative until surgical removal is undertaken.
The insertion of bowel segments into the urinary tract carries with it certain
fluid and electrolyte complications that may not be a problem under normal
circumstances. However, with GI viral infection and superimposed diarrhea and
dehydration, the patient may not be able to compensate. For example, a patient
with a gastric augmentation who presents with diarrhea and lethargy may have a
severe, hypochloremic, hyponatremic, metabolic alkalosis. Thus, any patient with
a bladder augmented with bowel who is obtunded requires careful consideration
of an electrolyte disturbance as the underlying cause.
Suggested Readings and Key References

Approach to the Care of the Technology-Assisted Child
Alpern E, Clark A, Alessandrini E, et al. Recurrent and high-frequency use of the
Emergency Department by pediatric patients. Acad Emerg Med 2014;21:365–
373.
American Academy of Pediatrics, Committee on Pediatric Emergency Medicine
and Council on Clinical Information Technology, American College of
Emergency Physicians Pediatric Emergency Medicine Committee. Policy
statement—emergency information forms and emergency preparedness for
children with special health care needs. Pediatrics 2010;125(4):829–837.
Tracheostomy Care
Brook I, Graf J, Stein F. Tracheitis in pediatric patients. Semin Pediatr Infect Dis
2006;17(1):11–13.


Joseph RA. Tracheostomy in infants: parent education for home care. Neonatal
Netw 2011;30(4):231–242.
Kallis JM. Replacement of a tracheostomy cannula. In: Henretig FM, King C,
eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Baltimore, MD:
Lippincott Williams & Wilkins; 2007:792–798.
Kohn J, McKeon M, Munhall D, et al. Standardization of pediatric tracheostomy
care with “Go-bags.” Int J Pediatr Otorhinolaryngol 2019;121:154–156.
Posner JC. Acute care of the child with a tracheostomy. Pediatr Emerg Care
1999;15:49–54.
Cerebrospinal Fluid Shunts
Hatlen TJ, Shurtleff DB, Loeser JD, et al. Nonprogrammable and programmable
cerebrospinal fluid shunt valves: a 5-year study. J Neurosurgery Ped
2012;9(5):462–467.
Riva-Cambrin J, Kestle JR, Holubkov R, et al. Risk factors for shunt malfunction
in pediatric hydrocephalus: a multicenter prospective cohort study. J Neurosurg
Pediatr 2016;17(4):382–390.

Sarda S, Simon HK, Hirsh DA, et al. Return to the emergency department after
ventricular shunt evaluation. J Neurosurg Pediatr 2016;17(4):397–402.
Simon TD, Butler J, Whitlock KB, et al. Risk factors for first cerebrospinal fluid
shunt infection: findings from a multi-center prospective cohort study. J
Pediatr 2014;164(6):1462–1468.e2.
TuanTJ, Thorell EA, Hamblett NM, et al. Treatment and microbiology of
repeated cerebrospinal fluid shunt infections in children. Pediatr Infect Dis J
2011;30(9):731–735.
Yue EL, Meckler GD, Fleischman RJ, et al. Test characteristics of quick brain
MRI for shunt evaluation in children: an alternative modality to avoid
radiation. J Neurosurg Pediatr 2015;15(4):420–426.
Zorc J, Krugman SD, Ogborn J, et al. Radiographic evaluation for suspected
cerebrospinal fluid shunt obstruction. Pediatr Emerg Care 2002;18(5):337–
340.
Indwelling Catheters
Gorski L, Hadaway L, Hagle M, et al. Infusion therapy standards of practice. J
Infus Nurs 2016;39(1S):S1–S158. ISSN 1533-1458.
Marschall J, Mermel LA, Fakih M. Strategies to prevent central line–associated
bloodstream infections in acute care hospitals: 2014 update. Infec Control Hosp
Epidemiol 2014;35(7):753–771.


Pai MP, Pendland SL, Danziger LH, et al. Antimicrobial-coated/bonded and impregnated intravascular catheters. Ann Pharmacother 2001;35:1255–1263.
Safdar N, O’Horo JC, Ghufran A, et al. Chlorhexidine-impregnated dressing for
prevention of catheter-related bloodstream infection: a meta-analysis*. Crit
Care Med 2014;42:1703–1713.
United States Centers for Disease Control and Prevention. Guidelines for the
Prevention
of
Intravascular

Catheter-Related
Infections,
2011.
(Accessed on May 3,
2019).
Enteral Feeding Catheters
Acord M, Pollock A. Gastric outlet obstruction from a button-type percutaneous
gastrostomy tube. Pediatr Emerg Care 2017;33(7):522–523.
Baker L, Beres A, Baird R. A systematic review and meta-analysis of
gastrostomy insertion techniques in children. J Ped Surg 2015;50:718–725.
DeLegge M. Gastrostomy tubes: Complications and their management. In:
Robson K, ed. UpToDate. 2019. Accessed May 20, 2019. Available at
/>:-complications-andtheir-management
Fortunato JE, Cuffari C. Outcomes of percutaneous endoscopic gastrostomy in
children Curr Gastroenterol Rep 2011;13(3):293–299.
Fuchs S. CME Review Article. Pediatric Emerg Care 2017;33(12):792–793.
doi:10.1097/01.pec.0000526609.89886.37.
Graneto JW. Gastrostomy tube replacement. In: King C, Henretig FM, eds.
Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2008:829–834.
Wong K, Leonard H, Pearson G, et al. Epidemiology of gastrostomy insertion for
children and adolescents with intellectual disability. Eur J Pediatr
2019;178(3):351–361.
Gastrointestinal Diversion
Garvin G. Caring for children with ostomies. Pediatr Surg Nurs 1994;29:645–
654.
Hellman J, Lago C. Dermatologic complications in colostomy and ileostomy
patients. Int J Dermatol 1990;29:129–133.
Minkes RK. Stomas of the small and large intestine in children clinical
presentation. In: Grewal H, ed. Medscape. 2019. Accessed May 25, 2019.

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