Pyloric Stenosis Fluid Resuscitation
Timestops (6)
Tools Used
Topic Overview
Key Takeaways
- Chloride <85 requires 3 NS boluses (20cc/kg each); Cl 85-97 needs 2 boluses before rechecking labs
- Bicarbonate-driven protocol: HCO3 >40 gets 3 boluses, HCO3 33-40 gets 2 boluses with recheck
- Maintenance fluid during resuscitation: 1.5cc/kg/hr D5 half-NS with 20mEq KCl (if K abnormal and adequate urine output)
- Algorithm eliminates guesswork by stratifying fluid needs based on severity of metabolic alkalosis at presentation
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Transcript
This is Todd Pansky reviewing another article for the Journal of Pediatric Surgery. Today, we're going to review an article entitled Optimizing Fluid Resuscitation for Hypertrophic pyloric stenosis. First author is Dr. Brian Dalton, the senior author is Dr. Sean St. Peter. Yet another fantastic paper from the group at Kansas City. I love this article. This article is a retrospective review that helps to define how much fluid we should be giving patients with abnormal electrolytes. The purpose is to try to avoid the problem of randomly guessing how much fluid to give, rechecking electrolytes and then giving more fluid. What they did is retrospectively look at 505 patients, 202 of which had abnormal electrolytes. They defined abnormal as a chloride less than 100, a bicarb greater than 30 and a potassium greater than 5.2 or less than 3.1. The boluses they gave in this study were 20 cc per kilo boluses of normal saline. While the patients were not receiving a bolus, they were held on maintenance fluid of 1.5 cc per kilo of D5 half normal saline. 20 of KCL was added to that maintenance fluid depending on if their potassium was abnormal and based on their urine output. And what they did is they looked to see how much fluid ended up being required to resuscitate patients and they did this by the severity of their electrolyte abnormalities. So here's what they found. The first thing they did is always look at just the chloride. If the chloride was abnormal and less than 85, they gave three normal sailing boluses of 20 cc per kilo. Then they rechecked the labs. If the chloride was less than or equal to 97, they gave two normal sailing boluses and then rechecked the labs. If the chloride was greater than 97, but the bicarb was less than 33, they gave one bolus of normal sailing. If the chloride was normal, then they look at the bicarb. If the bicarb was greater than 40, then they gave three normal sailing boluses. If the bicarb were greater or equal to 33, then they gave two normal sailing boluses and rechecked the electrolytes. So if the chloride and the bicarb are normal, but the potassium is abnormal, then they gave one normal sailing bolus and recheck the electrolytes. If the electrolytes were normal, then they just took the patient to the operating and when the patient was physiologically appropriate. I thought this was a great study. We hope you enjoy this review. I want to thank Ian Glenn for helping putting this review together. Please leave comments below and let us know any other studies you'd like us to review. Thanks.