Abstract
Background
Hypertrophic pyloric stenosis (HPS) is the most common diagnosis requiring surgery
in infants. Electrolytes are used as a marker of resuscitation for these patients
prior to general anesthesia induction. Often multiple fluid boluses and electrolyte
panels are needed, delaying operative intervention. We have attempted to predict the
amount of IV fluid boluses needed for electrolyte correction based on initial values.
Methods
A single center retrospective review of all patients diagnosed with HPS from 2008
through 2014 was performed. Abnormal electrolytes were defined as chloride <100 mmol/L, bicarbonate ≥30 mmol/L or potassium >5.2 or <3.1 mmol/L. Patients with abnormal electrolytes were resuscitated with 20 ml/kg saline boluses and continuous fluids at 1.5 times maintenance rate.
Results
During the study period 542 patients were identified with HPS. Of the 505 who were
analyzed 202 patients had electrolyte abnormalities requiring IV fluid resuscitation
above maintenance, and 303 patients had normal electrolytes at time of diagnosis.
Weight on presentation was significantly lower in the patients with abnormal electrolytes
(3.8 vs 4.1 kg, p < 0.01). Length of stay was significantly longer in the patients with electrolyte abnormalities,
2.6 vs 1.9 days (p < 0.01). Fluid given was higher over the entire hospital stay for patients with abnormal
electrolytes (106 vs 91 ml/kg/d, p < 0.01). The number of electrolyte panels drawn was significantly higher in patients
with initial electrolyte abnormalities, 2.8 vs 1.3 (p < 0.01).
Chloride was the most sensitive and specific indicator of the need for multiple saline
boluses. Using an ROC curve, parameters of initial Cl−80 mmol/L and the need for 3 or more boluses AUC was 0.71. Modifying the parameters to
initial Cl− ≤97 mmol/L and 2 boluses AUC was 0.65. A patient with an initial Cl−85 will need three 20 ml/kg boluses 73% (95% CI 52–88%) of the time. A patient with an initial Cl− ≤97 will need two 20 ml/kg boluses at a rate of 73% (95% CI 64–80%).
Conclusion
Children with electrolyte abnormalities at time of diagnosis of HPS have a longer
length of stay; require more fluid resuscitation and more lab draws. This study reveals
high sensitivity and specificity of presenting chloride in determining the need for
multiple boluses. We recommend the administration of two 20 ml/kg saline boluses separated by an hour prior to rechecking labs in patients with
initial Cl− value ≤97 mmol/L. If the presenting Cl− <85 three boluses of 20 ml/kg of saline separated by an hour are recommended. If implemented these modifications
have potential to save time by not delaying care for extraneous lab results and money
in the form of fewer lab draws.
Key words
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Article info
Publication history
Published online: February 11, 2016
Accepted:
January 21,
2016
Received in revised form:
December 21,
2015
Received:
October 5,
2015
Identification
Copyright
© 2016 Elsevier Inc. All rights reserved.
