Possible cause(s)

The technique was applied during or immediately following a meal

What to do?

• Stop the technique immediately unless your child is really congested with secretions.
• Avoid applying the technique within 2 hours before or after a meal.
• If needed, suction the secretions.

Possible cause(s)

• Sore chest or abdominal muscles
• Too much air in the lungs

What to do?

• It is normal that your child feels a slight pulling of the chest muscles when the therapy is first started. This discomfort will gradually disappear.

If he feels pain:

• Stop the technique immediately.
• Contact the healthcare team as soon as possible.

Possible cause(s)

• Less than 10 minutes between each session
• Session is too long

What to do?

• Let your child rest.
• Wait 10 minutes between each session.

If the dizziness is severe:

• Stop the technique immediately.
• If the symptoms reappear again, contact the healthcare team.

Possible cause(s)

Air is entering the stomach instead of the lungs

What to do?

• Remind your child to relax during the insufflations of air; he must not resist air entry.

If the discomfort persists:

• Stop the technique immediately.
• Quickly contact the healthcare team.

Possible cause(s)

• Poor technique
• Thicker secretions
• More secretions than usual

What to do?

• Review the technique.
• Combine more than one technique at a time (ex, pulmonary hyperinflation with abdominal thrusts) in order to increase the efficacy of secretion clearance.
• Make sure that the humidity level is adequate.
• If the problem persists, contact the healthcare team as soon as possible.

Possible cause(s)

Poor seal around the mouthpiece

What to do?

• Make sure that your child closes his mouth firmly around the mouthpiece.
• Make sure that the mouthpiece is properly inserted in the modified ventilatory bag.
• If needed, use a facial mask.
• If the problem persists, contact the healthcare team.

Possible cause(s)

The air is leaking through the nose rather than going to the lungs

What to do?

• Use a nose clip.
• If the problem persists, use a facial mask.
• If the problem continues to persist, contact the healthcare team.

Possible cause(s)

• Poor technique
• Lack of collaboration by your child

What to do?

• Review the technique.
• Make sure that there is no leak (mouthpiece, facial mask, tubing).
• Make sure that your child is relaxed.
• If the problem persists, contact the healthcare team.

Possible cause(s)

• Respiratory tract infection
• Incorrect placement of the tracheal cannula

What to do?

• Suction the secretions if required.
• Rapidly contact your child’s health care team.
• Observe your child attentively in order to detect any sign of respiratory distress (see next problem).
• In this case, call 911 immediately.
• If required, begin manual ventilation and CPR as instructed.

If your child has increased secretions without respiratory distress, then:

• Suction the secretions if required.
• Raise the head of the bed at night and during naps.
• Keep your child in a sitting and semi-sitting position if more comfortable this way.
• Take your child’s temperature every 4 hours and give the medication recommended by your child’s health care team.
• Increase liquid intake to help liquify the secretions.
• Increase the humidity level.

Possible cause(s)

• Obstruction of the tracheal cannula by a foreign object or by secretions (mucus plug)
• Accumulation of secretions or water in the artificial nose
• Respiratory tract infection (eg, tracheitis, pneumonia)
• Granulation tissue around the tracheal cannula site (thick soft scar tissue that sometimes forms around the tracheostomy)
• Bronchospasm (eg, allergic reaction, exposure to smoke, dust, cold air)

What to do?

• Remain calm and reassure your child.
• Immediately identify the cause of the blockage (eg, secretions, mucus plug).

If the tracheal cannula is obstructed

• by a foreign object: change the cannula.
• by secretions:
  • Try suctioning the secretions and,
  • Instill a few drops of normal saline, if recommended by your healthcare team.
  • Repeat suctioning.

If the obstruction persists:

• Change the cannula.
• If needed, suction secretions.
• If needed, repeat instillation and suction up to 2 more times maximum.

If the problem is resolved:

• Verify your child’s breathing to detect any signs of respiratory distress.
• Inform your child’s health care team.

If the symptoms persist:

• Call 911 immediately.
• If required, begin manual ventilation and CPR as instructed.

If there is an accumulation of secretions,
in the tracheostomy:

• Try suctioning the secretions.
• Instill a few drops of normal saline, if recommended by your healthcare team.
• If you are able to suction the secretions: repeat instillation and suction up to 2 more times maximum, if needed.
• If you are unable to suction the secretions (blockage of the tracheal cannula):
  • Change the cannula.
  • Suction tracheal secretions if needed.
• If the problem is resolved:
  • Verify your child’s breathing to detect any signs of respiratory distress.
  • Inform your child’s health care team.
• If the symptoms persist:
  • Call 911 immediately.
  • If required, begin manual ventilation and CPR as instructed.

in the artificial nose:

• Remove the artificial nose.
• Suction tracheal secretions.
• Replace the artificial nose.
• If the problem is resolved:
  • Verify your child’s breathing to detect any signs of respiratory distress.
  • Inform your child’s health care team.
• If the problem persists: re-evaluate the cause of the obstruction.

If your child has difficulty breathing that is not related to the issues above:

• Contact your child’s healthcare team immediately.
• If your child has medications that have been previously prescribed for these symptoms (eg, Ventolin), administer them as prescribed or according to your child’s health care team.

Possible cause(s)

• Spasm, irritation or inflammation of the trachea
• Complete or partial obstruction of the trachea (eg, laryngospasm)
• Incorrect positioning of your child’s head
• Granulation tissue around the tracheal cannula site

What to do?

• Do not force insertion of the cannula into the trachea.
• Remain calm and reassure your child, he may still be able to breathe through his tracheostomy.
• If the new cannula is partially inserted:
  • hold the cannula in place and remove the obturator;
  • allow your child to calm down and breathe through the cannula;
  • reposition your child’s head so that it is slightly tilted backwards by replacing the rolled towel under the shoulders;
  • try again to insert the rest of the cannula without forcing, as your child takes a breath in, while gently pulling on the  neck skin just below the tracheostomy;
  • if you are able to insert the cannula completely, secure it with ties and immediately contact your child’s health care team to inform them of the situation.
• If the cannula is impossible to insert:
  • remove the cannula and lubricate it again;
  • try re-inserting the cannula with the obturator in place;
  • if this does not work: try again with a smaller size cannula with the obturator;
  • if this also does not work: try again by replacing the obturator with a suction catheter to serve as an insertion guide;
  • observe your child’s breathing to detect any signs of respiratory distress;
  • if you are able to insert the cannula completely, secure it with ties and immediately contact your child’s health care team to inform them of the situation.
• If you are unable to insert the new cannula call 911 immediately.
• While waiting for help, if your child is not breathing on his own, begin manual ventilation and CPR as instructed.
• While waiting for help, if your child is breathing on his own through the tracheostomy and if you have been trained to do so by your child’s health care team:
  • insert a suction catheter into the tracheostomy to maintain an open airway;
  • hold on to the catheter so that it does not slide into the trachea;
  • verify if your child is in respiratory distress (see that specific problem);
  • if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

Possible cause(s)

• Accident
• Incorrect manipulation of the cannula
• Tracheostomy ties (ribbons or Velcro® band) are too loose or poorly secured around the neck
• Excessive cough

What to do?

• Remain calm and reassure your child, he may still be able to breathe through his tracheostomy.
• If the cannula has come out partially:
  • gently push it back down even if the conditions are not ideal;
  • immediately contact your child’s health care team to inform them of the situation.
• If the cannula has come out completely:
  • undo the tracheostomy ties;
  • insert a new cannula if available or reinsert the old one in the meantime;
  • replace the tracheostomy ties;
  • suction tracheal secretions;
  • once the cannula has been inserted, contact your child’s health care team to inform them of the situation.
• If the cannula is impossible to insert:
  • remove the cannula and lubricate it again;
  • try re-inserting the cannula with the obturator in place;
  • if this does not work: try again with a smaller size cannula with the obturator;
  • if this also does not work: try again by replacing the obturator with a suction catheter to serve as an insertion guide;
  • observe your child’s breathing to detect any signs of respiratory distress;
  • if you are able to insert the cannula completely: secure it with ties and immediately contact your child’s health care team to inform them of the situation.
• If you are unable to insert the new cannula: call 911 immediately.
• While waiting for help, if your child is not breathing on his own, begin manual ventilation and CPR as instructed.
• While waiting for help, if your child is breathing on his own through the tracheostomy and if you have been trained to do so by your child’s health care team:
  • insert a suction catheter into the tracheostomy to maintain an open airway;
  • hold on to the catheter so that it does not slide into the trachea;
  • verify if your child is in respiratory distress (see that specific problem);
  • if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

Possible cause(s)

• Irritation of the trachea by:
  • incorrect suctioning technique (too frequent, too deep or using a suction pressure that is too high)
  • injury due to the rubbing of the tracheal cannula
• Respiratory tract infection
• Granulation tissue around the tracheal cannula site
• Insufficient humidification
• Insufficient hydration

What to do?

If fresh blood in the secretions:

• remain calm and reassure your child;
• if bleeding continues, immediately contact your child’s health care team;
• observe your child’s breathing to detect any signs of respiratory distress (see that specific problem);
• if your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

If blood streaks or pink secretions:

• observe your child’s breathing to detect any signs of respiratory distress;
• check the pressure of the suction device;
• review suctioning technique; be sure to respect the length and the depth of insertion of the suction catheter that is recommended;
• gently suction tracheal secretions;
• increase the level of humidity;
• contact your child’s health care team.

Possible cause(s)

• Irritation of the trachea
• Ulceration of the trachea
• Granulation tissue around the tracheal cannula site
• Infection
• Insufficient humidity
• Cannula replacement

What to do?

• Immediately contact your child’s health care team.
• Increase the level of humidity.

Possible cause(s)

• Accident during a bath, while washing hair or splashing
• Accumulation of water in the tubing of a heated humidifier or air compressor humidifier system

What to do?

• Suction tracheal secretions.
• Immediately contact your child’s health care team.
• Observe your child’s breathing to detect any signs of respiratory distress.

Possible cause(s)

• Dysphagia (difficulty in swallowing)
• Gastric reflux (stomach contents rise up through esophagus)

What to do?

• Stop feeding your child food and liquids immediately.
• Suction tracheal secretions.
• If solid food or thick liquid bits are present in the secretions:
  • instill a few drops of saline solution according to the recommendations of your child’s health care team;
  • try suctioning the tracheal secretions again.
• Rapidly contact your child’s health care team.

Possible cause(s)

Various

What to do?

• Turn your child’s head to the side so as to avoid vomit from entering the tracheostomy.
• If you think that vomit has entered the tracheostomy, suction tracheal secretions.
• Clean your child’s mouth.
• Observe your child’s breathing to detect any signs of respiratory distress (see that specific problem).
• Rapidly contact your child’s health care team.

Possible cause(s)

• Infection
• Dampness of the skin (from secretions, or a soiled tracheostomy dressing)
• Use of products that irritate the skin

What to do?

• The skin around the tracheostomy site should look the same as the skin on the rest of your child’s neck.
• Review the technique for cleaning of the skin around the tracheostomy.
• Keep the tracheostomy site clean and dry by increasing the frequency of cleaning around the tracheostomy and by changing the tracheostomy dressing.
• There are many types of products that can be used to protect the skin such as foam dressings and liquid skin protectors; speak with your child’s health care team.
• Contact your child’s health care team for more recommendations if the skin is irritated (eg, application of an antibiotic cream).

Possible cause(s)

Tracheostomy ties are too tight

What to do?

• The space between the skin of your child’s neck and the tracheostomy ties (Velcro® or cotton ribbons) should be the thickness of the tip of a finger. Individuals with large fingers should use their small finger. This space can sometimes be reduced particularly when the child is overweight.
• Verify the space between the neck and the tracheostomy tie and adjust, if needed.
• Contact your child’s health care team for more recommendations regarding skin protection under the tracheostomy ties.

Possible cause(s)

• Mucous plug in the tracheal cannula: may be caused by insufficient humidity, excess secretions and/or insufficient frequency of suctioning
• Foreign body in the tracheal cannula
• Incorrect insertion of catheter for aspiration

What to do?

• Never force the insertion of the catheter in the tracheal cannula.
• Gently but rapidly, attempt to suction tracheobronchial secretions.
• Instill saline drops into the tracheal cannula, as you have been taught by your healthcare team.
• If you are unable to suction secretions (the tracheal cannula is obstructed), then:
  • change the cannula;
  • suction tracheal secretions if needed.
• If the problem is resolved:
  • observe your child’s breathing to detect any signs of respiratory distress;
  • inform your healthcare team.
• If you are still unable to suction secretions and your child IS in respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If you able still unable to suction secretions and your child IS NOT in respiratory distress, immediately contact your child’s healthcare team.
• If you are able to aspirate secretions, then:
  • repeat the aspiration, using installation of saline drops, up to 2 more times, as needed;
  • review methods to prevent mucous plugs with your healthcare team.

Possible cause(s)

• Mucous plug or foreign body in the nostril
• Inflammation inside the nose, causing blockage of the nostril (eg, due to infection or allergy)
• Septum deviation of the nose
• Incorrect insertion of the catheter into the nose

What to do?

• Clean the nose, using saline drops, as taught to you by the healthcare team.
• Never force the insertion of the catheter into the nose.
• Review the method of nasal aspiration.
• Ensure that you are using the correct equipment and materials for nasopharyngeal suctioning.
• Rapidly contact your child’s healthcare team.

Possible cause(s)

• Equipment malfunction including any of the following:
  • suction device battery charge depleted
  • suction regulator pressure too low
  • suction device broken
  • canister containing secretion overfilled
  • canister cover incorrectly closed
  • suction tubing bent or pinched
  • suction equipment incorrectly assembled
  • suction catheter blocked
• Excess or very thick secretions are obstructing the airway

What to do?

• Quickly verify that the suction device is plugged into a working electrical outlet or that the battery is correctly charged.
• If no power is available, use the manual mucous trap device, as instructed by your healthcare team.
• If the power supply is adequate, quickly verify that the suction equipment is in working order:
  • verify that the pressure on the suction; regulator is set to the correct value
  • empty the canister if full;
  • verify that the canister cover is closed correctly;
  • verify that the suction tubing is correctly installed and not blocked, pinched, bent or damaged in any way;
  • verify that that all parts of the suction circuit are correctly installed;
  • verify that the suction valve or port is working correctly;
  • verify that the suction catheter is not blocked.
• After these steps, if you are unable to suction secretions (obstruction of the tracheal cannula):
  • change cannula;
  • suction tracheal secretions if needed.
• If the problem is resolved:
  • observe your child’s breathing to detect any signs of respiratory distress;
  • inform your healthcare team.
• If you are still unable to suction secretions and your child IS in respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If you able still unable to suction secretions and your child IS NOT in respiratory distress, immediately contact your child’s healthcare team.
• If you are able to aspirate secretions, then:
  • repeat the aspiration, using installation of saline drops, up to 2 more times, as needed;
  • review methods to prevent mucous plugs with your healthcare team.

Possible cause(s)

• Irritation of the trachea by:
  • incorrect suctioning technique (too frequent, too deep or using a suction pressure that is too high)
  • excessive cough
• Respiratory tract infection
• Insufficient humidification
• Insufficient hydration

What to do?

If fresh blood in the secretions:

• Remain calm and reassure your child;
• If bleeding continues, immediately contact your child’s healthcare team;
• Observe your child’s breathing to detect any signs of respiratory distress (see next problem);
• If your child is in respiratory distress, remove the suction catheter and begin manual ventilation and CPR as instructed.

If blood streaks or pink secretions:

• Observe your child’s breathing to detect any signs of respiratory distress.
• Check the pressure of the suction device.
• Review suctioning technique; verify that you are inserting the catheter to the correct depth.
• Aspirate secretions gently.
• Avoid excessive aspiration which can damage the delicate lining of the airways.
• Increase the level of humidity.
• Contact your child’s healthcare team.

Possible cause(s)

• Mucous plug moved further down the airways towards the lungs
• Bronchospasm: narrowing or constriction of the airways (eg, due to irritation, inflammation and/or secretions in the airways)
• Pneumothorax (a puncture in the lining of the lungs)

What to do?

• Remain calm and reassure your child.
• Stop suctioning.
• Remove the suction catheter.
• Give prescribed medication, such as a bronchodilator (eg, Ventolin®) and/or oxygen if available and recommended by the healthcare team.
• If your child IS NO LONGER in respiratory distress, contact your child’s healthcare team.
• If your child REMAINS in respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.

Possible cause(s)

• Aspiration too soon after the last meal
• Incorrect aspiration technique (eg, insertion of the suction device such as Yankauer suction tip too far back in the throat)
• Stimulation of the gag reflex during oral or nasopharyngeal suctioning
• Incorrect insertion of the catheter

What to do?

• Turn your child’s head to the side to avoid choking or passage of vomit into the lungs.
• If the secretions were aspirated during a meal, pause your child’s feeding.
• Clean your child’s mouth.
• Closely observe your child’s breathing to detect any signs of respiratory distress (see previous problem).
• Rapidly contact your child’s healthcare team.

To avoid vomiting:

• Minimize aspiration of secretions immediately after meals.
• Review the correct technique for aspiration of secretions.
• Gently insert the suction catheter to avoid stimulating the gag reflex.

Possible cause(s)

• Agitated child, moving a lot during the aspiration procedure
• Incorrect insertion of the suction catheter
• Irritation of the nostril
• Excessive suctioning of the nose
• Suction pressure too high

What to do?

• Reassure your child.
• Apply direct pressure to the bridge of your child’s nose for a few minutes to stop bleeding; if possible put your child in the upright or sitting position.
• If the bleeding persists, rapidly contact your child’s healthcare team.

To avoid nosebleeds:

• Review the correct technique for nasopharyngeal aspiration of secretions.
• Verify that the suction pressure regulator is correctly set, as recommended by the healthcare team.
• Verify that the catheter is well lubricated prior to insertion.
• Gently insert the catheter into the nose.

Possible cause(s)

• Incorrect insertion of the suction catheter
• Bronchospasm: narrowing or constriction of the airways
• Respiratory tract infection

What to do?

• Stop suctioning.
• Remove the suction catheter.
• Reassure your child.
• Assess your child’s breathing and colour.
• If your child calms and stops coughing, gently re-insert the catheter to aspirate secretions.
• If the cough persists, consider administration of a bronchodilator such as Ventolin® and/or oxygen if available and recommended by the healthcare team.
• If your child shows signs of respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If the cough persists, rapidly contact your child’s healthcare team.

To prevent this problem: Review the correct technique for aspiration of secretions.

Possible cause(s)

Low level of oxygen in the blood (desaturation or hypoxia)

What to do?

• Stop aspiration of secretions.
• Remove the suction catheter.
• Administer oxygen, if available.
• Closely observe your child.
• If your child is mechanically ventilated, reconnect your child to the ventilator.
• If your child remains in respiratory distress:
  • call 911 immediately;
  • if required, begin manual ventilation and CPR as instructed.
• If your child improves, immediately contact your child’s healthcare team.

Possible cause(s)

Vagal stimulation

What to do?

• Stop aspiration of secretions.
• Verify the general and respiratory status of your child, following the training provided by your healthcare team.
• If your child is in respiratory distress, call 911 immediately and begin manual ventilation and CPR as instructed.

Possible cause(s)

• Break or leak in the suction device system (eg, cover not secured, catheter or filter incorrectly connected)
• Defective suction device

What to do?

• Verify that the suction device is correctly installed and connections are secured.
• If necessary, use the manual mucous trap device to aspirate secretions from the tracheal cannula
• If the problem persists, rapidly contact your healthcare team.

Possible cause(s)

• Canister is overfilled
• Battery depleted
• Defective suction device

What to do?

• Verify that the suction device is plugged into a working electrical outlet or that the battery is correctly charged.
• Empty the canister if full.
• If the problem persists, rapidly contact your child’s healthcare team.

Possible cause(s)

• The body has difficulty in absorbing water
• Reaction of the body to certain foods or medications
• Infection

What to do?

• The stool of an ileostomy may be liquid or pasty, and that of a colostomy may be semi-formed or formed.
• Talk with the nutritionist about foods that can change the consistency of your child’s stool.
• You can put a few cotton balls or an absorbent tampon into the collection bag to absorb the excess liquid and this will also make emptying easier.
• Powdered fibers (eg, “Metamucil”) can be added to the bag so that the content can become jelly-like.
• It is particularly important if your child has an ileostomy, that you ensure your child drinks more than usual in order to prevent dehydration.
• If liquid stool is not normal for your child, or if  there are more than usual, it is important to consult your healthcare team immediately.

Possible cause(s)

• Certain medications/foods can constipate
• Low fluid intake

What to do?

• Children with colostomies may be constipated, ie, no bowel movement for 2 or more days.
• Ensure that your child drinks enough as recommended by the healthcare team.
• See the nutritionist or a member of the healthcare team if necessary.

Possible cause(s)

• Leakage around the collection device
• Injury caused by an ill-fitting device
• Use of products irritating to the skin
• Watery stool
• Sweating

What to do?

• The skin around the stoma of your child should look the same as the skin over the chest and abdomen.
• It is important that the skin barrier fits closely to the stoma but without touching it.
• Do not use products such as powder, lotion, ointment that may prevent the skin barrier from sticking well.
• It can be challenging to avoid stoma irritation in the young child who is active and growing; speak with your enterostomal therapy nurse or your healthcare team as soon as possible as there are many special products that can be tried to solve your child’s specific problem.

Possible cause(s)

Incorrect installation of the collection device

What to do?

• Odor should not be a problem if the collection bag is closed properly and if the opening is kept clean after the bag has been emptied.
• Certain foods can cause more gas. Speak to the nutritionist about this.
• If the odor is strong, or it persists after emptying the bag, or while changing the collection device you can:
  • use a bag with a filter.
    
  • use an odor eliminator for toilets (put 1 drop in the water before you empty the contents of the bag there).
  • clean the inside and outside of the bag opening with toilet paper or a damp washcloth.
  • for bags that have a clasp, roll the edge of the bag down (creating a rolled edge like a turtleneck) before emptying.
    
  • use an odor eliminator in the bag after emptying it, according to the manufacturer’s instructions.

• Discuss other possible “home remedies” as needed with your enterostomal therapy nurse.

Possible cause(s)

• Too much stool in the collection bag
• Skin around the stoma is oily or wet
• Improper fit of the skin protector for the stoma

What to do?

• Empty the bag when it is 1/3 full or almost 1/3 full if you anticipate going out with your child.
• Consult your enterostomal therapy nurse or your healthcare team if the skin around the stoma is irritated (eg, red, red bumps, small wounds).

• Do not clean the skin around the stoma with products that might be oily or leave a residue (creams, soap). Use only those recommended in the section Everyday tips, Bathing.
• Always dry the skin around the stoma after cleaning.
• Use the appropriate equipment for your child, adjusted to the length of the stoma to ensure that the skin barrier sticks well to the skin.
• Warm the skin barrier well in your hands before applying it.
• Change the collection device.

Possible cause(s)

• Collection bag too full
• Collection bag poorly attached to the collar
• Excessive movement of collection bag

What to do?

• Empty the bag when it is 1/3 full or almost 1/3 full if you anticipate going out with your child.
• If the bag fills with gas quickly, you can use bags with filters that permit the passage of air.

• Check whether the portion of the bag that fits the ring of the collar is secure.
• Secure the bag under snug but not tight clothing, especially if your child is young and active.

Possible cause(s)

• Friction between the stoma and the skin barrier
• Bleeding from the stoma itself or from inside the intestine

What to do?

• The skin on the inside of the stoma is fragile; it is normal that it bleeds very slightly (a few pinpoint drops) when touched.
• If appropriate, review how to cut the opening of the skin barrier, ensuring that the cut opening is smooth.
• If there is significant bleeding, apply firm pressure to the site of the bleeding with a clean cloth or gauze; contact your healthcare team immediately.

Possible cause(s)

Causes vary: may happen with increased activity, coughing, etc.

What to do?

• The intestine can sometimes slide out through the stoma, like a hernia. Usually this does not cause pain.
• Contact your healthcare team immediately.

Possible cause(s)

• Infection or inflammation at the catheter entry site
• Phlebitis (irritated vein)

What to do?

• If the pump is running:
  • press the “STOP / START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Contact your healthcare team quickly.

Possible cause(s)

• Contact dermatitis (ie, irritation of the dressing on the skin)
• Allergy to the adhesive of the dressing
• Allergy to disinfectant solution
• Reaction of the skin to the disinfection technique

What to do?

• Contact your health care team who may suggest:
  • a change in dressing materials,
  • use of a topical corticosteroid,
  • a change in disinfection technique.

Possible cause(s)

Phlebitis (irritated vein)

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and of the tubing of the pump.
• Contact your healthcare team quickly.

Possible cause(s)

• Infiltration (the nutrition solution is leaking out of the vein and into the skin)
• Phlebitis of the vein (irritated vein)

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your healthcare team.
• If your child’s arm with the catheter is swollen, lift it as much as possible.

Possible cause(s)

• Disconnection from the implantable chamber of the catheter
• Displacement of the catheter
• Displacement of the noncoring needle

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If during irrigation:
  • close the clamp of the catheter tubing,
  • stop attempting to flush the line.
• Immediately contact your healthcare team.

Possible cause(s)

• Breakage or disconnection of the catheter or tubing
• Recent catheter insertion
• Child’s underlying health condition

What to do?

• If there is continuous bleeding, put a compress over the dressing and apply firm pressure.
• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your healthcare team.

Possible cause(s)

• Breakage or disconnection of the catheter or tubing
• Blockage of the catheter
• Displacement of the catheter
• Displacement of the needle if the child has an implantable chamber device
• Infection
• Contact dermatitis
• Child’s underlying health condition

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your healthcare team.
• If the dressing is falling off, put another dressing over it while waiting for the advice of your care team.
• If the dressing is partially detached, do not remove it as you might remove the catheter by mistake.

Possible cause(s)

Various causes

What to do?

• If the dressing is falling off, tape the sides down.
• If it is punctured or torn, install another clear adhesive dressing over the old one.
• If the dressing is partially detached, do not remove it as you can remove the catheter by mistake.
• Immediately contact your health care team.

Possible cause(s)

Return of blood (reflux)

What to do?

• Irrigate the catheter with the saline solution. Refer to steps 5 and 8 to 12 of the “Catheter irrigation” care method.
• If this happens more than once or twice a week, contact your healthcare team.

Possible cause(s)

Pump malfunction

What to do?

Contact your pharmacy or healthcare team quickly.

Possible cause(s)

• Contamination of the solution
• Problems in preparing the solution
• Heat-exposed bag

What to do?

• Do not administer the medication.
• Contact your pharmacy or healthcare team quickly.

Possible cause(s)

• Contamination of the solution
• Problems in preparing the solution

What to do?

• Do not administer the solution.
• If during the administration: press the “STOP/START” button on the pump and close the catheter tubing clamp and the pump tubing clamp.
• Contact your pharmacy or healthcare team quickly.

Possible cause(s)

Various

What to do?

• Close the clamp of the catheter tubing and the tubing of the pump.
• Press the “SILENCE” button to stop the alarm tone.
• Look at the message on the screen.
• Follow the instructions accordingly.
• If a help screen is available for the alarm, follow the instructions provided.
• If necessary, consult the pump instructions that you have been given.
• If you still can not resolve the problem, contact your healthcare team.

Possible cause(s)

• Blockage or displacement of the catheter
• Blockage of the tubing
• Clamps are closed
• Displacement of the needle in children with an implantable chamber device (PORT)

What to do?

• Do not push the plunger of the syringe with saline solution or locking solution forcefully.
• Make sure tubing clamps are fully open.
• Check that the tubing is not pinched or bent.
• Ask your child to:
  • move the arm on the side of the catheter,
  • turn on each side,
  • cough,
  • turn the head towards the opposite side of the catheter or to bear down (as if they were going to have a bowel movement).
• If your child has an implantable chamber catheter (eg, Port-a-Cath®): check if the needle has moved out of the correct position.
• If the problem persists:
  • close the clamp of the catheter tubing,
  • stop attempting to flush the line,
  • contact your healthcare team immediately.

Possible cause(s)

• Accident
• Mishandling

What to do?

• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your healthcare team.

Possible cause(s)

• Mishandling
• Catheter or other defective equipment
• Blocked catheter

What to do?

• You may notice a flow of blood or fluid at the point where the catheter or other piece of equipment is broken.
• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If you can see where the equipment is broken or where the leakage is coming from:
  • close the clamp between the catheter and the point of leakage.
  • if there is no clamp, use the hemostat clamp, as your healthcare team has taught you, or bend the catheter in half and keep it folded in place with tape.
• If you do not see where the leakage is coming from or where the equipment is broken: put a gauze compress on the dressing to absorb the leakage.
• Immediately contact your care team.

Possible cause(s)

• Accidental displacement of the catheter
• Mishandling of the catheter
• Improperly adjusted dressing
• Child has moved excessively and displaced the catheter

What to do?

• Never push the catheter back into the vein.
• If the pump is running:
  • press the “STOP/START” button on the pump in order to stop the infusion,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If the catheter has been completely pulled out, put a clear dressing over the previous entrance site.
• Immediately contact your healthcare team.

Possible cause(s)

Displacement of the internal (inside the body) portion of the catheter

What to do?

• Close the clamp of the catheter tubing.
• Stop attempting to flush the line.
• Immediately contact your healthcare team.

Possible cause(s)

Contact between the saline solution and the plastic of the syringe may activate your child’s sense of taste and smell

What to do?

• This is commonly reported. There is no danger to your child’s health.
• If the taste is very intense, contact your healthcare team.

Possible cause(s)

• Signs of hypoglycemia (low blood sugar)
• Rapid termination of solution administration
• Infection

What to do?

• Take your child’s blood glucose, if possible.
• Quickly give your child extra glucose (ask your child’s healthcare team for specific guidelines).
• Immediately contact your healthcare team.

Most hypoglycemia can be avoided by gradually decreasing the rate of the infusion in the last hour of delivery. Ask your child’s healthcare team for more specific instructions.

Possible cause(s)

• Signs of hyperglycaemia (high blood sugar)
• Infection

What to do?

• Take your child’s blood glucose, if possible.
• Immediately contact your healthcare team.

Possible cause(s)

Dehydration

What to do?

• Contact your healthcare team quickly.
• Give oral rehydration solutions to your child (eg, Pedialyte™, Gastrolyte™), if recommended by your healthcare team.

Possible cause(s)

• Fluid overload in the body
• Lack of protein in the blood
• Infection

What to do?

• Immediately contact your healthcare team.

Possible cause(s)

• Infection at the catheter entry site
• Blood infection
• Other infection

What to do?

• Note the other discomforts of your child (eg, pain, chills, difficulty breathing, blood in the stool, vomiting with blood, drowsiness, etc).
• Contact your healthcare team quickly.

Possible cause(s)

• Phlebitis of the vein (irritated vein)
• Blood clot in the vein with the catheter

What to do?

Immediately contact your healthcare team.

Possible cause(s)

• Infection or inflammation at the catheter entry site
• Phlebitis (irritated vein)

What do to?

• If your child uses an elastomeric infusion pump:
  • stop the infusion by closing the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump to stop the infusion or shut the pump off as you have been shown by your healthcare team,
  • close the clamps of the catheter tubing and the tubing of the pump.
• Contact your health care team quickly.

Possible cause(s)

• Contact dermatitis (ie, skin irritation due to the dressing)
• Sensitivity to the adhesive of the dressing
• Sensitivity to disinfectant solution
• Reaction of the skin to the disinfection technique

What to do?

• Contact your health care team who may suggest:
  • a change in dressing materials,
  • use of a topical corticosteroid,
  • a change in disinfection technique.

Possible cause(s)

Phlebitis (irritated vein)

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Contact your health care team quickly.

Possible cause(s)

• Infiltration (medication is leaking out of the vein and into the skin)
• Phlebitis of the vein (irritated vein)

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your care team.
• If your child’s arm with the catheter is swollen, elevate it as much as possible.

Possible cause(s)

• Disconnection from the implantable chamber of the catheter
• Displacement of the catheter
• Displacement of the noncoring needle

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If during irrgation:
  • close the clamp of the catheter tubing,
  • stop attempting to flush the line.
• Immediately contact your care team.

Possible cause(s)

• Breakage or disconnection of the catheter or tubing
• Recent catheter insertion
• Child’s underlying health condition

What to do?

• If there is continuous bleeding, put a compress over the dressing and apply firm pressure.
• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your care team.

Possible cause(s)

• Breakage or disconnection of the catheter or tubing
• Blockage of the catheter
• Displacement of the catheter
• Displacement of the needle if the child has an implantable chamber device
• Infection
• Contact dermatitis
• Child’s underlying health condition

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP / START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your care team.
• If the dressing is falling off, put another dressing over it while waiting for the advice of your care team.
• If the dressing is partially detached, do not remove it as you might remove the catheter by mistake.

Possible cause(s)

• Various causes

What to do?

• If the dressing is falling off, tape the sides down.
• If it is punctured or torn, install another clear adhesive dressing over the old one.
• If the dressing is partially detached, do not remove it as you can remove the catheter by mistake.
• Immediately contact your health care team.

Possible cause(s)

Return of blood (reflux)

What to do?

• Irrigate the catheter with the saline solution. Refer to steps 5 and 8 to 12 of the “Catheter Irrigation” care method.
• If this happens more than once or twice a week, contact your healthcare team.

Possible cause(s)

• Medication too cold
• If using an elastomeric infusion pump and it is placed lower than the catheter insertion site
• Malfunction of ambulatory infusion pump
• Displacement of the catheter
• Partial obstruction of the catheter

What to do?

• A cold solution can also cause headaches or chills.
• Irrigate the catheter with the saline solution. Refer to steps 5 and 8 to 12 of the “Catheter irrigation” care method.
• If your child uses an elastomeric infusion pump:
  • make sure the medication is at room temperature. A solution that is too cold increases the time it takes for the drug to flow.
  • place the elastomeric infusion pump at the same height as the catheter insertion site.
•  If the problem persists, contact your healthcare team promptly.

Possible cause(s)

• Breakage of the portable infusion device
• Technical defect of the device

What to do?

• Close the clamp of the catheter tubing and the tubing of the pump.
• Disconnect the catheter from the infusion pump.
• Irrigate the catheter with the saline solution. Refer to steps 5 and 8 to 12 of the “Catheter irrigation”.
• Contact your health care team quickly.

Possible cause(s)

• Contamination of the solution
• Problems in the preparation

What to do?

• Do not administer the medication.
• Contact your pharmacy or healthcare team quickly.

Possible cause(s)

Various

What to do?

• Close the clamp of the catheter tubing and the clamp of the pump tubing.
• Press the “STOP/START” button to stop the alarm or as indicated.
• Look at the message displayed on the screen.
• Follow the instructions accordingly.
• If necessary, consult the pump instructions you have been given.
• If you still can not resolve the problem, contact your healthcare team.

Possible cause(s)

• Blockage or displacement of the catheter
• Blockage of the tubing
• Clamps are closed
• Displacement of the needle in children with an implantable chamber device (PORT)

What to do?

• Do not push the plunger of the syringe with saline solution or locking solution forcefully.
• Make sure tubing clamps are fully open.
• Check that the tubing is not pinched or bent.
• Ask your child to:
  • move the arm on the side of the catheter,
  • turn on each side,
  • cough,
  • turn thir head towards the opposite side of the catheter or to bear down (as if they were going to have a bowel movement).
• If your child has an implantable chamber catheter (eg, Port-a-Cath®): check if the needle has moved out of the correct position.
• If the problem persists:
  • close the clamp of the catheter tubing,
  • stop attempting to flush the line,
  • contact your healthcare team immediately.

Possible cause(s)

• Accident
• Mishandling

What to do?

• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• Immediately contact your care team.

Possible cause(s)

• Mishandling
• Catheter or other defective equipment
• Blocked catheter

What to do?

• You may notice leakage of blood or fluid at the point where the catheter or other piece of equipment is broken.
• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If you can see where the equipment is broken or where the leakage is coming from: close the clamp between the catheter and the point of leakage. If there is no clamp, use the hemostat clamp, as your healthcare team has taught you, or bend the catheter in half and keep it folded in place with tape.
• If you do not see where the leakage is coming from or where the equipment is broken: put a gauze compress on the dressing to absorb the leakage.
• Immediately contact your care team.

Possible cause(s)

• Accidental displacement of the catheter
• Mishandling of the catheter
• Improperly adjusted dressing
• Child has moved excessively and displaced the catheter

What to do?

• Never push the catheter back into the vein.
• If your child uses an elastomeric infusion pump:
  • close the catheter tubing clamp and the pump tubing clamp.
• If your child uses an ambulatory infusion pump:
  • press the “STOP/START” button on the pump or close the pump as indicated,
  • close the clamp of the catheter tubing and the tubing of the pump.
• If the catheter has been completely pulled out, put a clear dressing over the previous entrance site.
• Immediately contact your healthcare team.

Possible cause(s)

Displacement of the internal (inside the body) portion of the catheter

What to do?

• Close the clamp of the catheter tubing.
• Stop attempting to flush the line.
• Immediately contact your care team.

Possible cause(s)

Contact between the saline solution and the plastic of the syringe may activate your child’s sense of taste and smell

What to do?

• This is commonly reported. There is no danger to your child’s health.
• If the taste is very intense, contact your healthcare team.

Possible cause(s)

• Phlebitis of the vein (irritated vein)
• Blood clot in the vein with the catheter

What to do?

Immediately contact your care team.

Possible cause(s)

• Ongoing infection for which your child is being treated
• Infection of the skin at the catheter entry site
• Blood Infection
• Other infection

What to do?

• Note any other symptoms that your child may have including: pain, irritability, loss of appetite, drowsiness, etc.
• Contact your health care team quickly.

Possible cause(s)

• Urinary tract infection
• Catheterization not frequent enough
• Malfunctioning Mitrofanoff valve

What to do?

• Identify the time of the last catheterization.
• Contact your healthcare team quickly.

Possible cause(s)

• Too frequent catheterization: therefore little urine in the bladder
• Insufficient hydration
• Inadequate functioning of kidneys
• Mechanical blockage of the catheter (eg, kinked)
• Catheter too small
• Blockage of the Mitrofanoff stoma (eg, presence of mucus)
• Poor technique

What to do?

• Identify the time of the last catheterization.
• Check how well your child is hydrated:
  • review the amount of liquid drunk by your child in the last 2 days,
  • look for the signs of dehydration: dry mouth and lips, sunken eyes, headache, weakness, dizziness.
• Make sure the catheter is not stuck, bent or kinked.
• Use a larger catheter after discussing it with your healthcare team.
• Review the steps of catheterization and make sure to follow them well.
• Contact your healthcare team quickly if the problem lasts for a longer period than what is agreed with your healthcare team.
• Mitrofanoff: if your child has had surgery to enlarge the bladder, deposits can form and build up thus making the emptying difficult. To avoid this problem, the bladder must be irrigated regularly. Talk to your healthcare team.

Possible cause(s)

• Resistance at the level of the sphincters
• Mechanical blockage of the catheter (eg, kinked)
• Mitrofanoff: injury at the level of the tunnel

What to do?

Natural ways: You may feel a slight resistance at the level of the urethral sphincter when trying to insert the catheter:

• encourage your child to relax and breathe slowly,
• roll the catheter itself with your fingers and push gently, but not forcefully,
• ask your child to change position (eg, roll to the side).

If the resistance persists:

• try a smaller catheter,
• if this is not effective, remove the catheter to avoid hurting your child,
• contact your healthcare team immediately.

Mitrofanoff:

• follow the path of the canal between the stoma and the bladder with the catheter,
• if there is some resistance at the entrance of the bladder proceed gently,
• do not force the catheter in.

If the resistance persists:

• remove the catheter,
• contact your healthcare team immediately.

Possible cause(s)

• Urinary tract infection
• Insufficient hydration
• Bladder not completely emptied

What to do?

• Make sure the bladder completely empties during catheterization.
• If the problem is new, repeat the catheterization.
• Check if your child has other symptoms that may indicate a urinary infection:
  • change in the color of urine
  • need to empty the bladder more often
  • pain in the urethra or abdomen
  • nausea, vomiting
  • fever: rectal  ≥ 38⁰C, oral or armpit ≥  37.5⁰C
  • chills
  • irritability
  • tiredness, lack of energy
• If the problem persists after catheterization or if your child has other symptoms, quickly contact your healthcare team.

Possible cause(s)

• Irritation caused by frequent catheterizations
• Urinary tract infection

What to do?

• 1 or 2 small blood drops may be seen during catheterization: it is not worrying if it happens infrequently. Nevertheless, discuss it with your healthcare team.
• If there is more bleeding or if it is more frequent:
  • check if your child has a fever (rectal ≥ 38⁰C or oral/armpit ≥ 37.5⁰C),
  • contact your healthcare team quickly.

Possible cause(s)

In rare cases, the catheter may have rolled up on itself

What to do?

• Do not forcibly remove the catheter. Leave it in place.
• Contact your healthcare team quickly.

Possible cause(s)

• Skin irritation around the stoma
• Infection of the skin around the stoma

What to do?

• The skin around the stoma your child should have the same appearance as that of the rest of the belly.
• Contact your healthcare team quickly.

Possible cause(s)

Various causes

What to do?

Contact your healthcare team immediately.

Possible cause(s)

• Urinary infection
• Irritation

What to do?

Contact your healthcare team quickly.

Possible cause(s)

• Urinary infection
• Other infection

What to do?

• Record your childs other symptoms: pain, irritability, loss of appetite, fatigue, etc.
• Contact your healthcare team quickly.