Investigating the use of preoperative nasogastric tubes and postoperative outcomes for infants with pyloric stenosis: a retrospective cohort study

Elanahas, Ahmad; Pemberton, Julia; Yousef, Yasmin; Flageole, Hélène

doi:10.1016/j.jpedsurg.2010.02.026

Cited by 10 publications

(6 citation statements)

References 23 publications

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“…It has been proposed that constant drainage of gastric secretions worsens the electrolyte imbalance and, in the absence of milk feeds, is unnecessary in the preoperative period. 9 Consequently, depending on institutional practice, a patient may arrive in the operating room without an NG tube; these patients still require insertion of a NG or orogastric tube to empty the stomach before induction of anaesthesia. In a small prospective randomised trial of the effects of preoperative NG tubes on emesis rates, patients were randomised to receive a gastric tube at diagnosis or only immediately before anaesthesia.…”

Section: Anaesthesiamentioning

confidence: 99%

Anaesthesia for pyloromyotomy

Craig

Deeley

2018

BJA Education

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By reading this article you should be able to:Describe the electrolyte and acid-base abnormalities associated with infantile hypertrophic pyloric stenosis. Explain why these electrolyte and acid-base abnormalities need to be corrected before surgery. Describe the technique for ultrasound examination of the gastric antrum and qualitative assessment of stomach contents before induction of anaesthesia for pyloromyotomy. Discuss the options for induction of anaesthesia including choice of drugs and techniques.Pyloric stenosis is the result of hypertrophy of the smooth muscle of the pylorus, which forms the gastric outlet. Its aetiology is uncertain, although a number of environmental and hereditary contributory factors have been identified. The reported incidence varies between 0.9 and 5.1 per 1000 live births. 1 In England and Wales it is 1.5 per 1000 live births and has remained static in recent years. 2 The risk of the disease is four to five times higher in boys than girls. 3 There is a decline in risk with increasing birth order with an odds ratio of 1.9 for first-born children. 3 The genetic element is evidenced with higher rates of concordance in monozygotic than dizygotic twins and a number of susceptibility loci have been identified.Babies with infantile hypertrophic pyloric stenosis present most commonly in the 2nd and 3rd months of life. 2 However, a recent review of surgical outcomes for 9686 infants who underwent pyloromyotomy in England over a 10-year period, found that 30% of patients were aged 7e28 days at the time of surgery. 2 The classic presentation is projectile vomiting of non-bilious stomach contents, loss of weight or failure to gain weight (crossing centiles on the growth chart), and dehydration. Abdominal examination may reveal a palpable 'olive'; however, modern developments mean that the majority of patients are being diagnosed earlier with ultrasound and this physical finding is becoming less common. Pathophysiology and electrolyte changesVomiting is the principal symptom of pyloric stenosis, classically described as being projectile in nature. The vomitus in pyloric stenosis consists of gastric secretions. These secretions are high in hydrogen and chloride ions with some sodium and potassium, all of which are lost along with water. The electrolyte losses result in a hypokalaemic, hypochloraemic metabolic alkalosis. The water loss causes dehydration and a reduction in plasma volume; this results in the secretion of aldosterone. Aldosterone causes sodium and water retention Key pointsVomiting results in hypochloraemic, hypokalaemic metabolic alkalosis and dehydration; these must be corrected before general anaesthesia and surgery. The stomach should be emptied using a nasogastric or orogastric tube before induction of anaesthesia. Ultrasound can be used to identify fluid in the gastric antrum. Ensuring adequate depth of anaesthesia with complete neuromuscular block before laryngoscopy minimises the risk of regurgitation and pulmonary aspiration. Options for analgesia include rectus sheath ...

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Section: Anaesthesiamentioning

confidence: 99%

Anaesthesia for pyloromyotomy

Craig

Deeley

2018

BJA Education

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“…On the other hand, OGT/NGT placement on admission is thought to be associated with increased postoperative length of stay and longer time to electrolyte correction, because gastric suctioning could exacerbate metabolic derangements. 27,28 Although some studies reported no demonstrable effect on postoperative emesis, others stated an adverse effect on postoperative vomiting. [27][28][29] More research using controlled trials is needed to compare the effects of using OGTs/NGTs.…”

Section: Discussionmentioning

confidence: 99%

“…27,28 Although some studies reported no demonstrable effect on postoperative emesis, others stated an adverse effect on postoperative vomiting. [27][28][29] More research using controlled trials is needed to compare the effects of using OGTs/NGTs. In a relatively small study in African infants with IHPS who, due to delay in diagnosis, often presented with profound metabolic alkalosis and severe dehydration, the effect of cimetidine, an H2 receptor antagonist, was investigated.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2020

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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.

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“…Furthermore, the NGT constitutes a foreign body that disrupts the stomach's motility, causes discomfort to the patient, and obstructs the upper airways. The results of some studies suggest that NGT placement in HPS is disadvantageous and might increase the duration of treatment prior to surgery [2][3][4]. Here, we sought to evaluate the effects of avoiding NGT placement in patients treated for HPS.…”

Section: Purposementioning

confidence: 99%

Hypertrophic Pyloric Stenosis: Why Are We Still Using a Nasogastric Tube at Diagnosis

Delforge,

Carolina,

Lachambre

et al. 2023

Preprint

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Purpose: In patients presenting with hypertrophic pyloric stenosis, the placement of a nasogastric tube (NGT) before surgery is supposed to prevent the aspiration of gastric fluid into the lungs. The objective of the present study was to determine whether or not a NGT prevents respiratory complications. Methods: A cohort of 87 patients from a prospectively maintained database were retrospectively included in the study; we compared patients with vs. without NGT placement before surgery. The primary endpoint was the occurrence of respiratory complications. Results: Three patients (two patients in the no-NGT group and one in the NGT group) presented severe respiratory complications; even though there was no evidence of lung aspiration, these adverse events obliged us to discontinue the study.There were no differences between the NGT and no-NGT groups with regard to the time to correction of the electrolyte imbalance, the time to complete oral refeeding, the length of hospital stay, and the incidence of other complications. The level of pre-operative discomfort appeared to be higher in the NGT group. Conclusion: In patients with hypertrophic pyloric stenosis, avoiding pre-operative NGT placement is potentially unsafe in some circumstances. Although our results did not argue in favor of NGT placement overall, more evidence is required.

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Investigating the use of preoperative nasogastric tubes and postoperative outcomes for infants with pyloric stenosis: a retrospective cohort study

Cited by 10 publications

References 23 publications

Anaesthesia for pyloromyotomy

Anaesthesia for pyloromyotomy

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

Hypertrophic Pyloric Stenosis: Why Are We Still Using a Nasogastric Tube at Diagnosis

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