Pyloric Stenosis Guideline Recap

Hi, my name is Mira Kotagal and I'm a pediatric surgeon here at Cincinnati Children's. Today we're going to be talking about a guideline for the management of children with pyloric stenosis. Pyloric stenosis is incredibly common in pediatric surgery, and ensuring that we effectively manage patients preoperatively is a key to their safety intraoperatively. If a patient has a history and a physical exam consistent with pyloric stenosis, meaning they have progressive nonbilious emesis, and sometimes you can palpate an olive in the epigastrium, then we get laboratory tests and an ultrasound to confirm their suspected diagnosis. The labs most often demonstrate a hypochloremic, hypokalemic metabolic alkalosis, and the ultrasound should demonstrate a muscle width greater than 3 millimeters and a length greater than 14 millimeters. Once the diagnosis has been confirmed, the patient is admitted to the hospital and resuscitated. We use the framework created by Dalton et al. out of Kansas City to guide our resuscitation. In their study, they found that the amount of fluid boluses necessary could be predicted by the original chloride level. So labs didn't have to be rechecked between each bolus in kids who are likely to require two or three saline boluses for resuscitation. In addition to fluid boluses guided by this schematic, we start patients on a maintenance IV fluid at one and a half times their maintenance rate and add potassium to their fluids once urine output has been confirmed. There is a trend in the literature emerging that isotonic fluids should be used in lieu of hypotonic fluids in pediatric patients. Although the evidence is still developing in this age population and may change over time. Patients then go to the OR for a pyloromyotomy once their bicarb level is less than 30, their chloride is greater than 100, and their potassium is normal. Postoperatively, our pathway focuses on a short period of NPO after the OR, usually around two hours, and then ad lib feeding with either breast milk or formula. Ad lib feeding is supported by randomized controlled trials by Markel et al. and Adebe et al. And those studies found that compared to protocolized feeding, ad lib feeding is associated with equivalent or shorter hospital stays, and although patients may have more emesis, there were no complications associated with that emesis. Thanks so much for joining us and if you have any questions, please feel free to contact us. Keep checking back for more guidelines and have a great day.