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QUICK GUIDE - DRAFT

Caring for Patient with a Flourish™ Pediatric Esophageal Atresia Device (Magnamosis)

|Date: 12 April 2019 revised Oct 8/19 |Written by : Tanya Redecopp, Nurse Educator |

|Reviewed by: Cindy Holland RN,MN Nurse Practitioner, Pediatric General Surgery |

|Stephanie Mardakis, RN, MSc(A), NPDE MCH NICU |

|Supporting documents: Cook Medical Flourish™ Pediatric Esophageal Atresia Instructions for Use |

|Clinical Practice Guideline (EIPT): Management of an Infant with Unrepaired Esophageal Atresia |

1. The Flourish device is used to repair a child with esophageal atresia using a non-surgical technique. In esophageal atresia the esophagus is disconnected creating a proximal and distal pouch. The device uses magnets to draw the two pouches together resulting in a spontaneous anastomosis. Anastomosis, or joining of the two pouches is expected to take 3-13 days.

1. The device has two parts - an esophageal (oral/nasal) catheter, and a gastric catheter placed into a mature gastrostomy.

• The oral/nasal catheter is secured in place using tape to the infant’s cheek – similarly to typical Replogle securement.

• The oral/nasal catheter has a luer-lock suction port – this port will not be used for suction

NOTE: Do NOT flush or inject enteral feeds or medications through the oral catheter as doing so could result in aspiration.

• The gastric catheter is held in place by a balloon with sterile water (inflation port).

• The bolster helps anchor the tube in place. It should rest close to the skin surface. (it should not piston)

• The gastric catheter has a port for administration of medications and feeds. The feeding port is an Enfit connection.

2. Both the oral/nasal catheter and the gastric catheter contain a wire guide lumen which connects to the respective magnets. The float freely within the lumen as the magnets draw the ends together. DO NOT PULL OR PLACE TRACTION ON WIRES.

3. Maintain patient with head of bed raised 15-30 degrees. Before any necessary movement of the infant, the magnet wires in the oral/nasal and gastric catheters should be locked so as not to disturb the position of the magnets or pulling of the wires. To lock the magnet wire, turn the Connecting Cap (oral/nasal catheter) and Tuohy Borst Adapter (gastric catheter) until they are tight. Supervision, arm restraints and socks should be used to prevent patient from dislodging catheters.

4. Stoma site should be inspected and GT site care provided as per patient’s usual care.

5. Assess patient for signs of secretion accumulation in the oral cavity at least every 30 mins. Gurgling or respiratory distress, desaturation or bradycardia may indicate the tube is not draining and may be blocked.

6. To ensure adequate removal of secretions from the upper esophageal pouch, a 10Fr Replogle should be inserted into the patient’s nose or mouth (insertion location determined by placement of magnet catheter and presence of an ETT). Place the Replogle on continuous suction at 60 mmHg. The insertion depth will be relative to the depth of the oral/nasal catheter placement – insert the Replogle to the depth of oral/nasal catheter and then pull up by 2-5 mm and secure to the patient’s cheek.

If necessary, the suction port of the oral/nasal catheter can be suctioned using a luer-lock syringe (IV syringe). If possible, avoid suction of this port to prevent unnecessary manipulation and potential dislodgement of magnet.

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a. Note the appearance and volume of secretions in the suction collection system. If aspirates show signs feed or gastric fluid, this is an indication that an anastomosis may have formed.

b. Note external length of oral catheter at least every 4 hours. Catheter is marked with black ink at the lip.

7. The gastric tube can be used to provide feeds and medications. The magnet wire needs to be locked in place during administration of feeds or medications to prevent leakage. The magnet is locked by tightening the Tuohy Borst adapter. The Tuohy Borst adapter should be loosened after feeding or administration of medication is complete to allow the magnets to continue to move and approximate.

8. Kangaroo feeding pump bags are already designed to fit Enfit connections. Simply remove the white adaptor and connect purple hub directly to the formula/med port. If necessary to give medications via gastric catheter, give through Kangaroo pump as our syringes are not adapted to the EnFit connectors.

9. When administering feeds or medications:

a. Tighten Tuohy Borst adapter.

b. Flush tube with sterile water through the formula / med port using Enfit connector.

c. Administer feeds and/or medication.

d. Flush port with 5 mL sterile water & recap the port.

e. Loosen the Tuohy Borst adapter.

10. To prevent clogging flush lumen with sterile water (5 mL) before and after the administration of feeds and medications. For patients on continuous feeds, flush a minimum of every 4 hours. Air can be used for flushing if needed to reduce the amount of free water administered to the patient.

Key Points

• The Connector Cap and Tuohy Borst Adapter should always be in the unlocked position to allow the magnets to attract each other and expand the esophageal pouches.

• If the patient must be moved or manipulated (ex: position change, placement for daily x-ray, diaper change), lock both the Connector Cap and Tuohy Borst Adapter to prevent accidental dislodgement of the magnets.

• If either the upper or lower magnets appear to be dislodged (moved outward), call the staff neonatologist to the bedside for assessment. An x-ray will likely be done. The upper magnet can be reinserted at bedside but the lower magnet requires the use of fluoroscopy so the patient must go to the OR. As such, close monitoring and vigilance is essential to the success of this procedure.

• The initial position of both magnet wired should be marked with a permanent marker to allow for observation of movement (specifically to note any movement outward). If the mark should no longer appear because the magnet has moved in, make a new mark.

Patient- specific Instructions:

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Picture source:

Picture source:

Wire connected to magnet

Connecting Cap

suction port

inflation port for balloon

Tuohy Borst Adapter

wire connected to magnet

Formula / med port

“Feed/Med” Port on Flourish device

Remove white adaptor

End of Kangaroo Bag

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