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 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 https://www.cdc.gov/hai/pdfs/bsi-guidelines-2011.pdf (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 https://www.uptodate.com/contents/gastrostomy-tubes :-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 Available at https://emedicine.medscape.com/article/939455-clinical ... College of Emergency Physicians Pediatric Emergency Medicine Committee Policy statement? ?emergency information forms and emergency preparedness for children with special health care needs Pediatrics... 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... 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