Update Course Rewind - Who to send home from the OR #3 - Pyloromyotomy

Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm Cecilia Hina, a research fellow from Cincinnati Children's Hospital Medical Center. In August 2023, we held our annual update course in pediatric surgery. In this session, the surgeons discussed in round table fashion who can go home from the OR on the same day of their procedure. Let's hear what they thought about laparoscopic pylloromyotomy at less than 37 weeks gestation and more than 37 weeks. This is a three-week old male born at 36 weeks who has normal electrolytes and bicarbonate, who undergoes straightforward laparoscopic pylloromyotomy at noon after receiving fluids overnight. So would you plan to Hey. Does everyone do adlib feeds or do people do feeding protocols? Who here sends them home the same day? So that kids technically 36 weeks. So can't go home same day because of apnea bradycardia. Dr. Russell brings up an important point here. If an infant is less than 37 weeks gestation at the time of birth, current guidelines suggest that they should be admitted overnight following anesthesia for additional monitoring. This age group is more likely to have apnic and bradycardic episode that those born after 37 weeks gestation. But what does recent research recommend for protocols regarding monitoring? There's a paper where basically from anesthesia perspective, they made the recommendation that each institution develops their own institutional protocols, and so they avoided a a general guideline, but I think most will either do 12 to 24 hours of apnea bradycardia monitoring for premature babies less than choose your number 55 or 60 weeks. I still have to factor in institution specific apnea guidelines in this particular patient. The anesthesia paper suggests on a review of multiple other papers that it's different based on different institutions, and so your own institution should decide. Dr. Talu pulled the audience to see what their institutions use as their gestational age cutoff for overnight monitoring. Hey, I'm just curious, how many people do 60 weeks post conception, 55 weeks in at your institution, is it? Is everybody 60 weeks if it's premature? I think we're 55. We do 55. 55. Yeah. Because I think that data, I don't know. Is there regional variation in the incidence of apnea or is there a regional variation in how we do anesthesia and make decisions? This is an interesting question that we don't know yet the answer to. Further research might be needed to determine why the variation still exists. Let's move on to the next case scenario. This baby is a six week old born at 40 weeks gestation with pyc stenosis who undergoes a straight forward laparoscopic pymyotomy. Who has sent a patient home same day after tolerating feeds? So it's one hand. Lots of nos. We have this um 12hour observation thing after anesthesia sometimes for the babies that they that's like a protocol in our hospital which so sometimes if it's 12 hours you do the pilomy first case then you they tolerate a couple feeds and could go home but they still need to be obs by anesthesia. So that's sometimes is a barrier to us discharging them same day. Well I think that goes back to if they're 60 weeks gestational age then they can go home or 55 weeks gestational age they can go home. I say that if they're full term and more than four weeks old then they don't have to be observed for 12 hours but it it will be institution specific. They each have to come up with their own. So most hospitals look at the current data and determine specific protocols for discharge. The majority of surgeons poll keep their pymy patients overnight which is based on age and feeding tolerance. But is it safe to discharge them home the same day if they are tolerating feeds? How many feeds do they need to tolerate? Mark, you and Justin both raised your hands that you've sent home pyorics right after surgery. Not commonly. So two feeds? Yeah ours is two feeds in a row. I obviously am the one that admits longer because I think coming back to the hospital is really bad. I think for our patients that live really far away to come back again. Py take time. And I don't see the rush in why you would send them home the same day. Because you Because it's safer at home than at the hospital. Being in the hospital is dangerous, right? You you you're exposed to medication airs, you're exposed to other things that can happen. if you don't really need to be there, you don't want to be there. While hospitals are the appropriate setting for a patient requires surgical intervention, if that intervention was successful, the general consensus is to get them home as soon as possible to avoid exposure to additional illness. As it turns out, the question of discharge timing was initially studied following an accidental early discharge. A stable patient was sent home from the PAQ by the surgical resident who upon realizing this was not common practice, called the family to have them come back. The mother noted the child's to be doing well and did not feel the need to return for monitoring. The patient did well and did not require readmission. and so David Rostine and a couple others and I looked at this and looking at Nquip data, only 1.5% of pyx were discharged on the day of surgery. Um and there was no difference in the odds of readmission and then no difference in complication for them. And then since the original Nquip data analysis that showed the 1.5% same day discharge, um it's now up to 4.5% same day discharge in the more recent time period. Additionally, there are published protocols that show if you do an early case, 7 to 9 a.m. and the patient feeds and live post operatively, then tolerates three feeds, they can be safely discharged as early as 11 hour post off. So I think people are probably doing if you tolerate three feeds that live okay to go home a little more commonly than they were a few years ago and there may be a certain select uh population of pyx that can go home same day. So in summary, surgeons from around the globe discussed appropriate discharge timing for those who undergo an uncomplicated laparoscopic pymyotomy. They decided that patients who are less than 37 weeks gestation or 55 weeks post conception at the time of procedure should be kept overnight for additional monitoring according to current guidelines. Patients that are older than 37 weeks of gestation or 55 weeks post conception at the time of the procedure can be safely discharged after they tolerate two to three feeds post operatively. Don't forget to subscribe to the Staycurrent MD YouTube channel. Follow our social media channels and download the Staycurrent MD app for tons of content in pediatric surgery.