A Delphi Analysis to Reach Consensus on Preoperative Care in Infants with Hypertrophic Pyloric Stenosis

Abstract

Introduction Infantile hypertrophic pyloric stenosis (IHPS) is a common gastrointestinal condition that can lead to metabolic alkalosis and, if uncorrected, to respiratory complications. A standardized approach to correct metabolic derangements and dehydration may reduce time until pyloromyotomy while preventing potential respiratory complications. Such an evidence-based policy regarding preoperative care is absent. We aim to formulate a recommendation about preoperative care for infants with IHPS using the Delphi technique. Materials and Methods The RAND/UCLA appropriateness method was used to reach international consensus in a panel of pediatric surgeons, pediatric anesthetists, and pediatricians. Statements on type and frequency of blood sampling, required serum concentrations before pyloromyotomy and intravenous fluid therapy, were rated online using a 9-point Likert scale. Consensus was present if the panel rated the statement appropriate/obligatory (panel median: 7–9) or inappropriate/unnecessary (panel median: 1–3) without disagreement according to the interpercentile range adjusted for symmetry formula. Results Thirty-three and twenty-nine panel members completed the first and second round, respectively. Consensus was reached in 54/74 statements (73%). The panel recommended the following laboratory tests and corresponding cutoff values prior to pyloromyotomy: pH ≤7.45, base excess ≤3.5, bicarbonate <26 mmol/L, sodium ≥132 mmol/L, potassium ≥3.5 mmol/L, chloride ≥100 mmol/L, and glucose ≥4.0 mmol/L. Isotonic crystalloid with 5% dextrose and 10 to 20 mEq/L potassium should be used for fluid resuscitation. Conclusion Consensus is reached in an expert panel about assessment of metabolic derangements at admission, cutoff serum concentrations to be achieved prior to pyloromyotomy, and appropriate intravenous fluid regime for the correction of dehydration and metabolic derangements in infants with IHPS.

Fluid therapy in pyloric stenosis – assessment of the implementation of hospital guidelines

“…The preoperative preparation is essential to optimal outcome. 14 Proper hydration and stable electrolyte levels cause the organism to return to normal functioning faster. The hospitalization time after surgery, of the patients who were treated with the appropriate iv fluids, was shorter.…”

Perioperative fluid and electrolyte management in surgical neonates

“…[44] Adequate fluid resuscitation should be done using, isotonic crystalloids with 5% dextrose and 10-20mEq/l of potassium after establishing diuresis. [45] Subsequently, potassium should be adequately replaced as potassium ions are exchanged for hydrogen in the kidney to correct alkalosis and total body potassium is usually depleted in these patients. It may be better to wash the stomach with saline and remove the NG tube, to further stall the loss of gastric acids and electrolytes.…”

Perioperative Hypoxemia and Postoperative Respiratory Events in Infants with Hypertrophic Pyloric Stenosis

“…3,6,[8][9][10][11] In a recent Delphi analysis, we obtained consensus among an international expert panel that recommended, among others, pH less than 7.45, bicarbonate less than 26 mmol/L, and chloride more than or equal to 100 mmol/L as cutoff values before safe pyloromyotomy. 12 Two recent studies showed a positive association between preoperative serum bicarbonate and preoperative respiratory events and increased time to extubation post-surgery respectively. 13,14 Both studies suggested that a lower cutoff value of bicarbonate than used nowadays should be considered.…”