Evaluation of a fluid resuscitation protocol for patients with hypertrophic pyloric stenosis

Optimizing throughput of babies with infantile hypertrophic pyloric stenosis

BACKGROUND

Definitive surgical care is often delayed in hypertrophic pyloric stenosis (HPS). Our aim is to evaluate the effect modifiable factors in preoperative HPS management have on efficiency of care.

METHODS

A retrospective review of all patients undergoing pyloromyotomy for HPS at two US children's hospitals between 2008 and 2018 was performed.

RESULTS

406 patients were included in the study. The majority (310, 76 ​%) were adequately resuscitated and ready for surgery upon diagnosis in the ER. However, only 133 patients (43 ​%) had surgery on the day of admission. Patients diagnosed between 12pm and 6pm were more likely to have surgery the next day than those diagnosed before noon (67 ​% vs 33 ​%, p ​< ​.001), which correlated with a longer length of stay (32 vs 47 ​h, p ​< ​.001).

CONCLUSION

The majority of patients presenting with HPS can safely undergo same day surgery. Delaying surgery due to an afternoon diagnosis is common, and leads to a modifiable increased total length of stay.

Hypertrophic Pyloric Stenosis Protocol: A Single Center Study

BACKGROUND

Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes.

METHODS

We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate.

RESULTS

The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5 hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9 hours (IQR 1.2,2.7) and 11.2 hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8 hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% (n = 12) with 2.7% of re-admissions occurring within 72 hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy.

DISCUSSION

This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention.

Does Presenting Facility and Race Impact Outcomes and Management of Pyloric Stenosis?

Hypertrophic Pyloric Stenosis (HPS) is a common surgical disease in infants. Traditionally, patients present with projectile emesis and severe dehydration with metabolic alkalosis. We looked to assess if patients presenting as a transfer vs directly to our facility as well as race affected patients' initial presentation and outcomes. We performed a retrospective analysis of 131 patients who presented to with a diagnosis of HPS from 2015 to 2021 assessing how transfer status and patient race affected presenting electrolyte levels and length of stay (LOS). We found no statistically significant difference in patients' presenting electrolyte levels and hospital LOS based on transfer status or patient race. We believe this reflects availability and widespread utility of ultrasound. We suggest that this could be used as a model for standardizing care to equalize outcomes in other pediatric diseases which currently show large disparities in care based on race and geographical location.