Gastric secretions following neonatal surgery

Gastric secretions following neonatal surgery

Gastric Secretions Following Neonatal Surgery By GEORGEA. HYDE, JR. I N 1960, Gutierrez, Sukarochana, and Kiesewetterl suggested that in the postope...

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Gastric Secretions Following Neonatal Surgery By GEORGEA. HYDE, JR.


N 1960, Gutierrez, Sukarochana, and Kiesewetterl suggested that in the postoperative period very young infants produced more dilute gastric secretions than infants over 6 months of age. Since our initial findings failed to confirm this, we collected and studied postoperative gastric drainage in babies who had undergone surgery in the newborn period. PROCEDURE Gastric secretions were collected for 24-hour periods during the postoperative course of 24 infants who were being maintained on parenteral fluids. Either a nasogastric or gastrostomy tube, which was irrigated only with air, was utilized for gastric drainage. Only 6 of the 87 aspirates were obtained later than the sixth day after surgery, and all operations were performed in the first 4 weeks of life. Volumes varied from 5 to 210 ml. The collected fluid was refrigerated immediately until analyzed. Sodium and potassium concentrations were determined (in duplicate) by flame photometry; most chloride concentrations were determined by the Schales and Schales” titration method; the rest were determined by a BuchlerCotlove Chloridometer (in duplicate). The pH was measured in 61 specimens with a model 96 Beckman pH meter. (The pH determinations were repeated on 9 specimens without any change over 4 days.) The extent of reflux of duodenal fluid into the stomach was estimated in 64 specimens by noting the degree of greenness of the collected fluid. RESULTS Table 1 summarizes the mean electrolyte concentrations present in the total series and compares this mean with various subgroups. All subgroup means lie within one standard deviation of the total series. The premature and fullterm infants in the subgroups were selected because of known birth weight. Operations correcting duodenal atresia were excluded from these two groups, as was one infant with biliary atresia. Table 2 correlates the electrolyte concentration and pH with the degree of greenness in the aspirate. As expected, the pH fell with the decrease in the amount of bile evident, and as the pH fell, the sodium concentration fell.” From the Department of Surgery, Children’s Hospital of San Francisco, San Francisco, California. GEORGE A. HYDE, JR., M.D.: Attending Surgeon Children’s HospitaZ of San Francisco and Clinical Instructor in Surgeq, University of California San Francisco Medical Center. Thisinvestigation was supported by the Little Jim Club, Children’s Hospital of San Francisco. JOUIWAL OF PEDIATRICSURGERY,VOL. 3, No. 6 (DECEMBER), 1968



GEORGE A. HYDE, JR. Table 1.-Electrolyte


No. of Specimens Total Series

Nonfibrocytic, premature Infants (3 infants, 3 operations) Nonfibrocystic, full-term Infants (12 infants, 12 operations)




0 to 48 hours postoperatively (21 infants, 24 operations)


50 ml. or more of aspirate (9 infants, 9 operations)

K (mEq./L.) (Range)

100 +22 (47-140)

11.7 k4.16 (4-22.4)

130 f 17.57 (68-174)

118 (93-l 31)

9.8 (6.1-13.6)

137 (120-148)


13.2 (6.9-22.4)

122 (68-153)

103 (60-140)

10.8 (5.8-18.7)

138 (107-174)


11.4 (5.1-18.7)

125 (68-146)


12.2 (5.1-22.4)

130 (90-167)

108 (93-140)

10.3 (6.0-17.4)

125 (100-160)


12.8 (8.9-16.8)

144 (126-145)


15.5 (7.2-18.7)

137 (127-148)




Na (mEq./L.) (Range)


Fibrocytic infants (4 Infants, 6 operations)

48 to 96 hours postoperatively (20 infants, 22 operations)

Mean : 1 SD: Range :

of Gastric

Cl (mEq./L.) (Range)

2 operations in neonatal period (3 infants, 6 operations) 1st Operation 2nd Operation

11 10

very green fluid in some specimens was associated with low pH and high sodium. Table 3 is an example of an individual study. It demonstrates the tendency found in some infants to produce an electrolyte concentration which is relatively stable from day to day, except for a falling sodium associated with a falling PH.~ There was a tendency in the overall study for decreasing pH, as in this patient, in the postoperative period. Unlike the patient in this table, the greenness of the aspirate tended to decrease following operation in the overall study. However,


The study of Gutierrez et al. was undertaken to indicate the electrolyte composition of intravenous fluid used to replace losses from postoperative




Table 2.-Eflect




of Bile Reflex into the Gastric Drainage

Color of Gastric Aspirate

No. of specimens Mean pH Per cent pH 2.5 or below

Dark Green

Medium Green

Light or No Green

28 3.6 52%(13/25)

12 3.3 58%‘,(7/12)

24 2.3 83%‘,(20/24)

Mean electrolyte concentration in mEq./L. Sodium Potassium Chloride

107 10.1 131

106 9.2 133

79 15.4 134

gastric drainage. Rightfully, they maintained that this would become a problem only if the postoperative aspiration of gastric contents was prolonged and copious. They suggested that % N saline would be sufficient since the mean concentrations of sodium, potassium, and chloride were 53, 10.7, and SO.3 mEq./L.-considerably lower than our values of 100, 11.7, and 130 mEq./L. Our studies suggest that infants with prolonged gastric drainage would be depleted by this replacement fluid. The consequence of l/z N saline replacement would result in a slight but definite sodium loss and, more importantly, a rapid and marked loss of chloride. Howe alld LeQuesne,4 in England, and Kassirer and Schwartz,s in the ITnited States, emphasized the importance of chloride deficit in the production and correction of metabolic alkalosis due to loss of gastric juice. Our figures suggest that replacement intravenous fluid for loss from gastric aspiration should contain, volume for volume, 100 mEq./L. sodium chloride (2/3 N) saline to which 30 mEq./L. potassium chloride is added when urine liow is established. While this replaces more potassium than is lost in the gastric aspirate, the renal correction of metabolic alkalosis often involves a marked urinary loss of potassium.5 An attempt was made to explain our values by the reflux of bile and duodenal secretions into the stomach because the initial high electrolyte concentrations in the gastric aspirate reported in this study did not agree with thr


3 .-Volume

and Electrolyte Day of Operation

\‘olume Na Concentration Ii Concentration Cl Concentration PH Degree of greenness of fluid aspirated

21 ml. 124 mEq./L. 8.6 mEq./L. 140 mEq./L. 3.6 Dark green ____ ~~

Concentration 1

in an lnfant Postoperative 2

with Jejunal Atresia Days

35 ml. 196 mEq./L. 8.4 mEq./L. 146 mEq./L. 2.3

32 ml. 110 mEq./L. 10.8 mEq./L. 147 mEq./L. 1.6

Dark green

Dark green -~~

3 18ml. 93 mEq./L. 12.8 mEq./L. 148 mEq./L. 1.5 Dark green

~~ ~~~




values of Gutierrez et al. The amount of the reflux was estimated by the degree of greenness in the gastric aspirate. There was a tendency toward increased sodium concentration and elevated pH in heavily bile-stained fluid; however, this did not explain the continued difference in electrolyte concentration. In addition, the degree of greenness did not reflect electrolyte concentration accurately and was not useful clinically; it did not imply lack of danger of aspirating fluid of pH 2.5 or less. Interestingly, Colle and Paulsen6 found a mean sodium concentration of 93 mEq./L. in 7 babies; however, their mean chloride concentration was 104 mEq./L. Avery et al. found a higher mean chloride in gastric juice of small infants-133 mEq./L. The pH values reported here are unexpected in view of Miller’s oft-quoted study,s where free acid was found to be usually absent after the second day of life. Our data are compatible with the Polacek and Ellison finding of a high parietal cell mass in the stomach of the newborn and with Avery, Randolph and Weaver’s7 recent study of low gastric juice pH in some stressed infants. Measurements of pH correlated poorly with electrolyte concentrations; the measurement of pH was not useful clinically. Its importance lies in an appreciation of the dire effects of pulmonary aspiration. Severe pneumonia is the inevitable consequence of aspiration of fluid with a pH of 2.5 or less.lO This degree of acidity was present in 66 per cent of our analyzed samples. SUMMARY

Eighty-seven postoperative gastric aspirates were obtained from 24 infants in the neonatal period. Measurements indicated mean concentrations of 100 mEq./L. sodium, 11.7 mEq./L. potassium, and 130 mEq./L. chloride in the gastric drainage. A pH of less than 2.6 was present in 66 per cent of the specimens measured. On the basis of these data, intravenous fluid containing 100 mEq./L. sodium chloride and 30 mEq./L. potassium chloride would be optimal as parenteral replacement fluid. SUMMARIO



Un serie de 87 postoperatori aspiratos gastric esseva obtenite ab 24 infantes durante lo period0 neonatal. Le analyse de1 aspiratos revelava concentrationes medie de natrium de 100 &q/L, de kalium de 11,7 mEq/L, e de chloruro de 130 mEq/L. Un pH de minus que 2,6 esseva presente in 66 pro cento de1 specimens examinate. A base de iste datos, fluidos intravenose continente 100 mEq/L chloruro de natrium e 30 mEq/L chloruro de kalium pare esser le optime coma fluid0 de reimplaciamento parenteral. REFERENCES 1. Gutierrez, I. Z., Sukarochana, K., and Kiesewetter, W. B.: Electrolyte replacement of gastric drainage in pediatric surgery patients. Surgery 48:610. 1960. 2. &hales, 0. and Schales, S. S.: A simple and accurate method for determination of chloride in biological fluids. J. Biol. Chem. 1#:879, 1941. 3. Riddell, M. J., Strong, J. A., and Cam-

eron, D.: The electrolyte concentration of human gastric secretion. Quart. J. Expzr. Physiol. 45:1, 1960. 4. Howe, C. T., and LeQuesne, L. P.: Pyloric stenosis: the metabolic effects. Brit. J. Surg. 51:923, 1964. 5. Kassirer, J. P., and Schwartz, W. B.: The response of normal man to selective depletion of hydrochloric acid. Amer. J. Med.





40:10, 1966. 6. Colle, E., and Paulsen, E. P.: Response of the newborn infant to major surgery. Pediatrics 23: 1063, 1959. 7. Avery, G. B., Randolph, J. G., and Weaver, T.: Gastric response to specific disease in infants. Pediatrics 38~674, 1966. 8. Miller, R. A.: Observations on the gastric acidity during the first month of life.



Arch. Dis. Child. 1622, 1941. 9. Polacek, M. A., and Ellison,



Gastric acid secretion and parietal cell mass in the stomach of a newborn infant. Amer. J. Surg. 111:777, 1966. 10. Vandam, L. D.: Aspiration of gastric contents in the operative period. New Eng. J. Med. 273:1206, 1965.