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.

Keywords

infantile hypertrophic pyloric stenosis - preoperative care - resuscitation policy - cutoff value - pyloromyotomy

Publikationsverlauf

Eingereicht: 02. August 2019

Angenommen: 04. November 2019

Artikel online veröffentlicht:
20. Januar 2020

• References

• 1 To T, Wajja A, Wales PW, Langer JC. Population demographic indicators associated with incidence of pyloric stenosis. Arch Pediatr Adolesc Med 2005; 159 (06) 520-525
• 2 Peters B, Oomen MW, Bakx R, Benninga MA. Advances in infantile hypertrophic pyloric stenosis. Expert Rev Gastroenterol Hepatol 2014; 8 (05) 533-541
• 3 Jobson M, Hall NJ. Contemporary management of pyloric stenosis. Semin Pediatr Surg 2016; 25 (04) 219-224
• 4 Yanchar NL, Rangu S. Corrected to uncorrected? The metabolic conundrum of hypertrophic pyloric stenosis. J Pediatr Surg 2017; 52 (05) 734-738
• 5 Tutay GJ, Capraro G, Spirko B, Garb J, Smithline H. Electrolyte profile of pediatric patients with hypertrophic pyloric stenosis. Pediatr Emerg Care 2013; 29 (04) 465-468
• 6 Kamata M, Cartabuke RS, Tobias JD. Perioperative care of infants with pyloric stenosis. Paediatr Anaesth 2015; 25 (12) 1193-1206
• 7 Kelay A, Hall NJ. Perioperative complications of surgery for hypertrophic pyloric stenosis. Eur J Pediatr Surg 2018; 28 (02) 171-175
• 8 Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pediatr Surg 2007; 16 (01) 27-33
• 9 Andropoulos DB, Heard MB, Johnson KL, Clarke JT, Rowe RW. Postanesthetic apnea in full-term infants after pyloromyotomy. Anesthesiology 1994; 80 (01) 216-219
• 10 Pappano D. Alkalosis-induced respiratory depression from infantile hypertrophic pyloric stenosis. Pediatr Emerg Care 2011; 27 (02) 124
• 11 Tigges CR, Bigham MT. Hypertrophic pyloric stenosis: it can take your breath away. Air Med J 2012; 31 (01) 45-48
• 12 Patel RV, Wockenforth R, Milliken I, Marshall D. Infantile Hypertrophic pyloric stenosis (IHPS): it can take away your breath, alertness, wee and poo. BMJ Case Rep 2013;
• 13 Cartabuke RS, Tobias JD, Rice J, Tumin D. Current perioperative care of infants with pyloric stenosis: comparison of survey results. J Surg Res 2018; 223: 244-250
• 14 Wilkinson DJ, Chapman RA, Owen A, Olpin S, Marven SS. Hypertrophic pyloric stenosis: predicting the resolution of biochemical abnormalities. Pediatr Surg Int 2011; 27 (07) 695-698
• 15 Goh DW, Hall SK, Gornall P, Buick RG, Green A, Corkery JJ. Plasma chloride and alkalaemia in pyloric stenosis. Br J Surg 1990; 77 (08) 922-923
• 16 Shanbhogue LK, Sikdar T, Jackson M, Lloyd DA. Serum electrolytes and capillary blood gases in the management of hypertrophic pyloric stenosis. Br J Surg 1992; 79 (03) 251-253
• 17 Dalton BG, Gonzalez KW, Boda SR, Thomas PG, Sherman AK, St Peter SD. Optimizing fluid resuscitation in hypertrophic pyloric stenosis. J Pediatr Surg 2016; 51 (08) 1279-1282
• 18 Dalkey N, Helmer O. An experimental application of the Delphi method to the use of experts. Manage Sci 1963; 9: 458-467
• 19 Fitch K, Bernstein SJ, Aguilar MS. et al. The RAND/UCLA Appropriateness Method User's Manual. Santa Monica, CA: RAND; 2001
• 20 Hsu CC, Sandford BA. The Delphi technique: making sense of consensus. Pract Assess, Res Eval 2007; 12: 1-8
• 21 Sinha IP, Smyth RL, Williamson PR. Using the Delphi technique to determine which outcomes to measure in clinical trials: recommendations for the future based on a systematic review of existing studies. PLoS Med 2011; 8 (01) e1000393
• 22 McNab S, Ware RS, Neville KA. et al. Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Cochrane Database Syst Rev 2014; (12) CD009457
• 23 Arieff AI, Ayus JC, Fraser CL. Hyponatraemia and death or permanent brain damage in healthy children. BMJ 1992; 304 (6836): 1218-1222
• 24 Halberthal M, Halperin ML, Bohn D. Lesson of the week: acute hyponatraemia in children admitted to hospital: retrospective analysis of factors contributing to its development and resolution. BMJ 2001; 322 (7289): 780-782
• 25 Pandya S, Heiss K. Pyloric stenosis in pediatric surgery: an evidence-based review. Surg Clin North Am 2012; 92 (03) 527-539
• 26 Neilson J, O'Neill F, Dawoud D, Crean P. Guideline Development Group. Intravenous fluids in children and young people: summary of NICE guidance. BMJ 2015; 351: h6388
• 27 Lee LK, Burns RA, Dhamrait RS. et al. Retrospective cohort study on the optimal timing of orogastric tube/nasogastric tube insertion in infants with pyloric stenosis. Anesth Analg 2019; 129 (04) 1079-1086
• 28 Elanahas A, Pemberton J, Yousef Y, Flageole H. Investigating the use of preoperative nasogastric tubes and postoperative outcomes for infants with pyloric stenosis: a retrospective cohort study. J Pediatr Surg 2010; 45 (05) 1020-1023
• 29 Flageole HH, Pemberton J. Post-Operative Impact of Nasogastric Tubes on length of stay in infants with pyloric Stenosis (POINTS): a prospective randomized controlled pilot trial. J Pediatr Surg 2015; 50 (10) 1681-1685
• 30 Banieghbal B. Rapid correction of metabolic alkalosis in hypertrophic pyloric stenosis with intravenous cimetidine: preliminary results. Pediatr Surg Int 2009; 25 (03) 269-271
• 31 Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs 2000; 32 (04) 1008-1015