• Gatorade 20 oz 4 hours preop for PONV
• Gabapentin 600mg pills
• Tylenol 1000mg with Gatorade for PONV and Pain Scope
• Patch on admission for PONV

Prophylaxis

• Pneumatic compression boots for DVT
• Heparin 5000IU sq preop for DVT
• Ancef 2-3 grams IV on induction for Infection

Using adjusted body weight for weight-based dosing of obese patients:

1. Estimate Ideal body weight in (kg)
   1. Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.
2. Calculate adjusted body weight AjBW = adjusted body weight:
   1. AjBW = IBW + 0.4(ABW - IBW)

These meds recommended

1. Dexmedetomidine
   1. Administer a minimum of 0.5 mcg/kg (using the adjusted body weight) Do not administer >1 mcg/kg
2. Ketamine
   1. Administer a minimum of 30 mg or 0.5 mg/kg (using the adjusted body weight)
   2. Do not administer >1 mg/kg
3. Dexamethasone
   1. Administer >0.1 mg/kg (up to 12 mg, using the adjusted body weight)
4. Ketorolac
   1. 30mg IV(0.5-1 mg/kg (maximum 30mg)) for Pain
5. Ondansetron 8mg IV

Surgeons to perform bilateral laparoscopically guided Tap Blocks

Mix 20ml EXPAREL (266mg) and 20ml 0.25% bupivacaine (2.5mg/ml) is 316mg (maximum dose 3mg/kg). Inject 20ml of mixture on either side subcostal, transverses abdominus plane May use additional 10cc local 0.25% bupivacaine in incisions if weight allows.

MEDS:

For pain

1. Tylenol po 650mg pills q6 hours RTC - USE IV POD#0
2. Ketorolac 15mg IV q6 hours RTC 
3. Gabapentin 600mg BID RTC (pill form)
   1. PRN
4. Oxycodone 5mg-10mg po q6 prn pain
5. Hydromorphone 0.005-0.15mg/kg/dose PRN in severe pain

For PONV

1. Ondansetron 8mg IV q8 RTC
2. Scopolamine Patch
   1. PRN
3. Ativan 0.5mg IV q 6 hours PRN nausea
4. Reglan 15mg IV q8 PRN severe nausea

FLUIDS:

IV LR at 125cc/hour until discharge. (DO NOT STOP until discharge)

ACTIVITY:

Out of bed and ambulate within 4 hours of surgery with PT Ambulate every 2-4 hours while awake

For DVT

SCD’s while in bed

Heparin 5000mg sq BID or (TID if >150kg)

Discharge on Extended prophylaxis if personal or family history of blood clots or travel by plane or >4 hours by car in first 2 weeks postop.

DIET:

NPO except meds POD #0.

No postop swallow unless ordered

Advance per new protocol:

1. POD#1 1oz (30cc) every 30 min
   1. Includes: water, sugar free non-carbonated beverage or sugar free jello No juice or soda
2. POD#2 2oz (30cc) every 30 min
   1. Include protein shakes, milk, other sugar free full liquids or sugar free pudding.

1. Afebrile
2. Able to perform ADL’s same as preop Pain and Nausea controlled with meds
3. Tolerates water – intake of 500 cc over one shift (protein shakes not required)

Discharge Medications:

For PAIN:

1. Tylenol 650mg QID
2. Celebrex 200mg BID as needed for pain
3. Only offer oxycodone if taking in hospital regularly

For PONV:

1. Odansetron 8mg po TID prn

For Prophylaxis:

1. Ursodiol 600mg po BID 6 month supply Prilosec 20mg po qD 6 month supply Lovenox x2-4 weeks postop if indicated Vitamins:
2. Pediatric chewable with iron (not gummy) MVI 1 po BID Calcium with vitamin D chews take for 1000mg calcium per day
3. Vitamin B1 100mg po qD 6 month supply and Vitamin B12 1000ug sublingual qD

Or

1. Neurobion Classico Vitamin B complex 1 tablet per day.

1.   J. Ingrande, H. J. M. Lemmens, Dose adjustment of anaesthetics in the morbidly obese, BJA: British Journal of Anaesthesia, Volume 105, Issue suppl_1, December 2010, Pages i16–i23, https://doi.org/10.1093/bja/aeq312

2.   Vaughns JD, Ziesenitz VC, van den Anker JN. Clinical Pharmacology of Frequently Used Intravenous Drugs During Bariatric Surgery in Adolescents. Curr Pharm Des. 2015;21(39):5650-9. doi: 10.2174/1381612821666150901105736. PMID: 26323414.

3.   Samuels PJ, Sjoblom MD. Anesthetic Considerations for Pediatric Obesity and Adolescent Bariatric Surgery. Curr Opin Anaesthesiol Jun:29(3):327-36 2016

4.   Zhu A, Benzon HA, Anderson TA. Evidence for the Efficacy of Systemic Opioid-Sparing Analgesics in Pediatric Surgical Populations: A Systematic Review. Anesth Analg. 2017 Nov;125(5):1569-1587. doi: 10.1213/ANE.0000000000002434. PMID: 29049110.

5.   Egan TD. Are opioids indispensable for general anaesthesia? Br J Anaesth. 2019 Jun;122(6):e127-e135. doi: 10.1016/j.bja.2019.02.018. Epub 2019 Mar 28. PMID: 31104756.

6.   Gobble RM, Hoang HL, Kachniarz B, Orgill DP. Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials. Plast Reconstr Surg. 2014 Mar;133(3):741-55. doi: 10.1097/01.prs.0000438459.60474.b5. PMID: 24572864.

7.   Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LH, Hahnenkamp K, Hollmann MW, Poepping DM, Schnabel A, Kranke P. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev. 2018 Jun 4;6(6):CD009642. doi: 10.1002/14651858.CD009642.pub3. PMID: 29864216; PMCID: PMC6513586.

8.   Lauren K. Dunn, Marcel E. Durieux; Perioperative Use of Intravenous Lidocaine. Anesthesiology 2017; 126:729–737

doi: https://doi.org/10.1097/ALN.0000000000001527

9.   Grady P, Clark N, Lenahan J, Oudekerk C, Hawkins R, Nezat G, Pellegrini JE. Effect of intraoperative intravenous lidocaine on postoperative pain and return of bowel function after laparoscopic abdominal gynecologic procedures. AANA J. 2012 Aug;80(4):282-8. PMID: 23251997.

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Congenital hypertrophic pyloric stenosis is a common cause of gastric outlet obstruction in the newborn period.  It is characterized by projectile non-bilious vomiting after feeding. The universal accepted treatment is either an open or a laparoscopic pyloromyotomy.  Despite successful completion of the pyloromyotomy, postoperative emesis is common.  Postoperative vomiting has been attributed to the delayed return of normal gastric peristalsis following surgery and the inability of the support to support frequent feeding.  A survey including 34 North American pediatric surgery training programs demonstrated a wide range of feeding plans (1).  Significant debate and variability exist on postoperative NPO time, type of feeding (e.g. Pedialyte, breastmilk, formula), and rapidity of feeding advancement (2).

In a retrospective of 227 post-pyloromyotomy patients, Adibe et al. (3), demonstrated that infants fed ad libitum were able to tolerate full feed sooner without increase in frequency of postoperative emesis. A subsequent study from Kansas City suggested that lower body weight at admission and worsening preoperative electrolyte abnormality was more likely to lead to postoperative vomiting than the actual feeding regimen (4).  Two recent randomized prospective trials confirmed the retrospective results demonstrating ad libitum feeding compared to a strict feeding protocol allowed for faster advancement to goal feeding and reduced length of stay (5, 6).  Of note while there was no difference in vomiting episodes in the Markel trial (6), the number of patients with emesis was significantly higher in the ad libitum group compared to protocol feeding in the Adibe trial (41% vs. 15%, p<0.001, [5]).

Based on these studies as well a consensus meeting among all pediatric surgeon in our division the following feeding guidelines for post-pyloromyotomy patients have been proposed:

1.  Juang D, et al. Eur J Pediatr Surg 2012; 22: 409-411
   1. PubMed
2.  Sullivan K, et al. Pediatrics 2015; 137 (1): 1-10
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3.  Adibe O, et al. J Lap Adv Surg Tech 2007; 17(2), 235-237
   1. PubMed
4.  St. Peter S, et al. Journal Pediatric Surgery 2008; 43(11): 2038-2041
   1. PubMed
      
5.  Adibe O, et al. JPS 2014; 49: 129-132
   1. PubMed
6.  Markel T, et al. JPS 2017; 52: 534-539
   1. PubMed