DIAGNOSIS AND MANAGEMENT OF PYLORIC STENOSIS IN CHILDREN CLINICAL GUIDELINE V3.0

Transcription

1 DIAGNOSIS AND MANAGEMENT OF PYLORIC STENOSIS IN CHILDREN CLINICAL GUIDELINE V3.0

2 1. Aim/Purpose of this Guideline This guideline is relevant to all medical and nursing staff caring for children with Pyloric Stenosis. 2. The Guidance Pyloric stenosis is due to hypertrophy of the pyloric sphincter, leading to narrowing of the gastric outlet. It occurs in 2 in 1000 live births and is the most common cause of gastric outflow obstruction in children under 3 months of age. Risk factors include: Sex (4:1 male-female ratio) 1st born infants Parental history of pyloric stenosis (higher if mother affected) Term infants Caucasian families 2.1. Presentation Pyloric stenosis typically presents between 3 6 weeks of age with forceful nonbilious vomiting which is occasionally blood stained. There may also signs of reduced absorption such as failure to thrive, dry nappies, dry mucous membranes, tachycardia and depressed fontanelle. Jaundice may also be present. It is rare for the condition to present with diarrhoea. (BMJ 2009) Differential diagnoses to consider are GORD, over feeding, infectious diarrhoea and small bowel atresias. (BMJ 2009) Assessment Assess degree of dehydration Observe for visible gastric peristalsis (waves of muscular contraction across abdomen from left upper quadrant to right lower quadrant; requires 2-3 minutes observation) Palpate for pyloric mass (typically olive sized in right upper quadrant) (BMJ 2009) Test feeds can be a useful aid if clinical diagnosis is uncertain, infant if given full strength feed and observed for mechanism of any vomiting e.g. projectile or posset; bilious or non-bilious. Abdominal ultrasound should be arranged in all babies where the diagnosis is suspected. The US is diagnostic if pylorus is greater than 4mm thickness and greater than 17mm in length. Page 2 of 9

3 2.3. Management Plot weight on growth chart and compare to previous measurements Blood gas (venous or capillary): hyperchloraemic hypokalaemic metabolic alkalosis is often present Bloods: FBC, U/E, Glucose, LFT (if jaundiced) NBM Discuss with the surgeons at RCHT initially who may advise further discussion with surgical team at Bristol children s Hospital. Regular BM monitoring 4-6 hourly via heel prick Strict fluid monitoring and correct dehydration NG tube on free drainage with hourly aspirations Replace NG losses ml for ml with 0.9% NaCl + 10mmol KCl per 500mls of intravenous fluid Also give maintenance intravenous fluids 0.45% NaCl + 5% dextrose + 10mmol KCl per 500mls of fluid Serum bicarbonate and potassium are almost always corrected prior to surgery. Families may need to be warned that this correction will usually happen locally before transfer to the surgical centre Surgery Pyloromyotmy is the gold standard surgical procedure. This involves longitudinal splitting of the pylorus muscle by either open or laparoscopic methods Post-operative care Feeding is usually recommenced 4-6 hours after surgery. This will be at the discretion of the surgical team. Vomiting may continue but should resolve within 48 hours. The main complications of the procedure are continued vomiting, infection and bowel perforation. Page 3 of 9

4 3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Compliance with section 2.4 of the guideline Audit lead Patient review, notes audit. At point of patient occurrence as low numbers. Paediatric consultant Child Health Directorate audit and guidelines meeting Paediatric consultants Directorate audit and guidelines meeting Required actions will be identified and completed in 3-6 months. Change in practice and lessons to be shared Required changes to practice will be identified and actioned within 3-6 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 4 of 9

5 Appendix 1. Governance Information Document Title Date Issued/Approved: 10 th Nov 2017 Diagnosis and Management of Pyloric Stenosis in Children Clinical Guideline V3.0 Date Valid From: 10 th Nov 2017 Date Valid To: 10 th Nov 2020 Directorate / Department responsible (author/owner): Chris Williams Paediatric Consultant Contact details: Brief summary of contents Clinical Guideline for the diagnosis and management of pyloric stenosis in children. Suggested Keywords: Target Audience Executive Director responsible for Policy: Child Children Pyloric stenosis RCHT CPFT KCCG Medical Director Date revised: 10 th Nov 2017 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: CLINICAL GUIDELINE FOR THE DIAGNOSIS AND MANAGEMENT OF PYLORIC STENOSIS IN CHILDREN V2.0 Child health audit and guidelines meeting Divisional Manager confirming approval processes Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings David Smith Not Required {Original Copy Signed} Name: Caroline Amukusana Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Page 5 of 9 {Original Copy Signed} Internet & Intranet Intranet Only

6 Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? Clinical / Paediatric none Guner YS., Aranda A. and Upperman YS. British medical journal : Best practice Pyloric Stenosis. NO Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) December 2011 January 2014 V1.0 Initial Issue V2.0 Review and reformat Dr Fiona Briant & Dr James Mallen Dr.N.Venkata paediatric consultant and Tabitha Fergus deputy ward manager- (reformat only) Nov 2017 V3.0 Minor Changes to wording in assessment and management sections Chris Williams, Paediatric Consultant All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 6 of 9

7 Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. Name of Name of the strategy / policy /proposal / service function to be assessed DIAGNOSIS AND MANAGEMENT OF PYLORIC STENOSIS IN CHILDREN CLINICAL GUIDELINE V3.0 Directorate and service area: Child Health Name of individual completing assessment: Chris Williams Is this a new or existing Policy? Existing Telephone: Policy Aim* Clear guidance for medical staff caring for child with pyloric stenosis. Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* Clear guidance for medical staff caring for child with pyloric stenosis. 3. Policy intended Outcomes* Evidenced based and standardised practice. 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. Audit and review Children and families Workforce Patients Local groups x Please record specific names of groups Clinical Guideline Group Child Health Directorate External organisations Other Page 7 of 9

8 What was the outcome of the consultation? Guideline agreed 7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development Page 8 of 9

9 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. No areas indicated Signature of policy developer / lead manager / director Chris Williams Date of completion and submission 10/11/17 Names and signatures of members carrying out the Screening Assessment 1. Chris Williams 2. Human Rights, Equality & Inclusion Lead Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Chris Williams Date 10/11/17 Page 9 of 9