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van den Bunder FAIM, Stevens MF, van Woensel JBM, van de Brug T, van Heurn LWE, Derikx JPM. Perioperative Hypoxemia and Postoperative Respiratory Events in Infants with Hypertrophic Pyloric Stenosis. Eur J Pediatr Surg 2023; 33:485-492. [PMID: 36417975 DOI: 10.1055/a-1984-9803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Normalization of metabolic alkalosis is an important pillar in the treatment of infantile hypertrophic pyloric stenosis (IHPS) because uncorrected metabolic alkalosis may lead to perioperative respiratory events. However, the evidence on the incidence of respiratory events is limited. We aimed to study the incidence of peroperative hypoxemia and postoperative respiratory events in infants undergoing pyloromyotomy and the potential role of metabolic alkalosis. MATERIALS AND METHODS We retrospectively reviewed all patients undergoing pyloromyotomy between 2007 and 2017. All infants received intravenous fluids preoperatively to correct metabolic abnormalities close to normal. We assessed the incidence of perioperative hypoxemia (defined as oxygen saturation [SpO2] < 90% for > 1min) and postoperative respiratory events. Additionally, the incidence of difficult intubations was evaluated. We performed a multivariate logistic regression analysis to evaluate the association between admission or preoperative serum pH values, bicarbonate or chloride, and peri- and postoperative hypoxemia or respiratory events. RESULTS Of 406 included infants, 208 (51%) developed 1 or more episodes of hypoxemia during the perioperative period, of whom 130 (32%) experienced it during induction, 43 (11%) intraoperatively, and 112 (28%) during emergence. About 7.5% of the infants had a difficult intubation and 17 required more than 3 attempts by a pediatric anesthesiologist. Three patients developed respiratory insufficiency and 95 postoperative respiratory events were noticed. We did not find a clinically meaningful association between laboratory values reflecting metabolic alkalosis and respiratory events. CONCLUSIONS IHPS frequently leads to peri- and postoperative hypoxemia or respiratory events and high incidence of difficult tracheal intubations. Preoperative pH, bicarbonate, and chloride were bad predictors of respiratory events.
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Affiliation(s)
- Fenne A I M van den Bunder
- Department of Pediatric surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, the Netherlands
| | - Markus F Stevens
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Job B M van Woensel
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Tim van de Brug
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - L W Ernest van Heurn
- Department of Pediatric surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, the Netherlands
| | - Joep P M Derikx
- Department of Pediatric surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, the Netherlands
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Park RS, Rattana-Arpa S, Peyton JM, Huang J, Kordun A, Cravero JP, Zurakowski D, Kovatsis PG. Risk of Hypoxemia by Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy. Anesth Analg 2021; 132:367-373. [PMID: 31361669 DOI: 10.1213/ane.0000000000004344] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND In patients presenting for pyloromyotomy, most practitioners prioritize rapid securement of the airway due to concern for aspiration. However, there is a lack of consensus and limited evidence on the choice between rapid sequence induction (RSI) and modified RSI (mRSI). METHODS The medical records of all patients presenting for pyloromyotomy from May 2012 to December 2018 were reviewed. The risk of hypoxemia (peripheral oxygen saturation [Spo2], <90%) during induction was compared between RSI and mRSI cohorts for all patients identified as well as in the neonate subgroup by univariate and multivariable logistic regression analysis. Complications (aspiration, intensive care unit admission, bradycardia, postoperative stridor, and hypotension) and initial intubation success for both cohorts were also compared. RESULTS A total of 296 patients were identified: 181 in the RSI and 115 in the mRSI cohorts. RSI was associated with significantly higher rates of hypoxemia than mRSI (RSI, 30% [23%-37%]; mRSI, 17% [10%-24%]; P = .016). In multivariable logistic regression analysis of all patients, the adjusted odds ratio (OR) of hypoxemia for RSI versus mRSI was 2.8 (95% confidence interval [CI], 1.5-5.3; P = .003) and the OR of hypoxemia for multiple versus a single intubation attempt was 11.4 (95% CI, 5.8-22.5; P < .001). In multivariable logistic regression analysis of neonatal subgroup, the OR of hypoxemia for RSI versus mRSI was 6.5 (95% CI, 2.0-22.2; P < .001) and the OR of hypoxemia for multiple intubation versus single intubation attempts was 18.1 (95% CI, 4.7-40; P < .001). There were no induction-related complications in either the RSI and mRSI cohorts, and the initial intubation success rate was identical for both cohorts (78%). CONCLUSIONS In infants presenting for pyloromyotomy, anesthetic induction with mRSI compared with RSI was associated with significantly less hypoxemia without an observed increase in aspiration events. In addition, the need for multiple intubation attempts was a strong predictor of hypoxemia. The increased risk of hypoxemia associated with RSI and multiple intubation attempts was even more pronounced in neonatal patients.
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Affiliation(s)
- Raymond S Park
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sirirat Rattana-Arpa
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Mahidol University, Bangkok, Thailand
| | - James M Peyton
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jia Huang
- New York Eye and Ear Infirmary of Mount Sinai, New York, New York.,Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anna Kordun
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Joseph P Cravero
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Pete G Kovatsis
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Gagey AC, de Queiroz Siqueira M, Desgranges FP, Combet S, Naulin C, Chassard D, Bouvet L. Ultrasound assessment of the gastric contents for the guidance of the anaesthetic strategy in infants with hypertrophic pyloric stenosis: a prospective cohort study. Br J Anaesth 2018; 116:649-54. [PMID: 27106968 DOI: 10.1093/bja/aew070] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Evacuation of gastric content through a nasogastric tube, followed by rapid sequence induction, is usually recommended in infants undergoing pyloromyotomy. However, rapid sequence induction may be challenging, and is therefore controversial. Some anaesthetists regularly perform classical non-rapid induction technique, after blind aspiration of the gastric contents, although this aspiration may have been incomplete. This prospective observational study aimed to assess whether the ultrasound monitoring of the aspiration of the stomach contents, may be useful to appropriately guide the choice of the anaesthetic induction technique, in infants undergoing pyloromyotomy. METHODS Infants undergoing pyloromyotomy were consecutively included. Ultrasound assessment of the antrum was performed before and after the aspiration of the gastric contents through a 10 French gastric tube. The stomach was defined as empty when no content was seen in both supine and right lateral positions. The correlation between antral area and the aspirated gastric volume was also tested. RESULTS We analysed 34 infants. Ultrasound examination of the antrum failed in three infants. The stomach was empty in 30/34 infants (nine before aspiration, 21 after aspiration), allowing to perform a non-rapid induction technique in 88.2% of the infants. There was a significant correlation between antral area measured in right lateral decubitus and the aspirated gastric volume. CONCLUSIONS Our results suggest that the qualitative ultrasound assessment of the antral content may be a simple and useful point-of-care tool, for the choice of the most appropriate anaesthetic technique for pyloromyotomy according to the estimated risk of pulmonary aspiration of gastric contents.
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Affiliation(s)
- A-C Gagey
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France
| | - M de Queiroz Siqueira
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France
| | - F-P Desgranges
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France
| | - S Combet
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France
| | - C Naulin
- Department of Anaesthesia and Intensive Care, Centre Hospitalier de Villefranche-sur-Saône, Plateau d'Ouilly Gleizé, 69655 Villefranche-sur-Saône, France
| | - D Chassard
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France University of Lyon, Claude Bernard Lyon 1 University, 43 boulevard du 11 Novembre 1918, 69100 Villeurbanne, France
| | - L Bouvet
- Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Femme Mère Enfant Hospital, 59, boulevard Pinel, 69500 Bron, France Inserm, U1032, LabTau, 151, cours Albert Thomas, 69003 Lyon, France
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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.e3. [DOI: 10.1016/j.jss.2017.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/26/2017] [Accepted: 10/12/2017] [Indexed: 01/12/2023]
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Sofer M, Schwartz AJ, Cook-Sather SD. Wagering, anesthetic technique, and infants for pyloromyotomy. Paediatr Anaesth 2016; 26:112-3. [PMID: 26644300 DOI: 10.1111/pan.12805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Michale Sofer
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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