Pyloric Stenosis 

 

 

Considerations

 

  • Medical but not surgical emergency

  • Infant considerations 

  • High aspiration risk

  • Resuscitation of metabolic derangements:

    • Hypovolemia

    • Metabolic alkalosis

    • Hypochloremia

    • Hyponatremia

    • Hypokalemia

  • Post-op dispostion & apnea monitoring

 

 

Goals

 

  • Correction of volume deficit & acid/base & electrolyte abnormalities prior to pylormyotomy

  • Prevent aspiration (OG/NG, RSI)

  • Appropriate post-operative apnea monitoring

 

 

Conflicts

 

  • Resuscitation vs. surgical timing

  • RSI vs. hypovolemia

 

 

Optimization & management

  • Restore intravascular volume:

    • NS 10-20ml/kg IV boluses 

    • Maintenance D5/NS + KCl 20-40 mEq/L

    • Clinical signs to assess (HR, BP, fontanelles, mucous membranes, skin turgor, urine output, capillary refill)

  • Correct electrolyte & acid/base disturbances:

    • Na > 130 mEq/L

    • K > 3 mmol/L

    • Cl > 90 mEq/L

    • HCO3 < 27 mmol/L

    • Urine output > 1cc/kg/hr

  • Vital signs normal for age (HR ~150, SBP >/= 60 mmHg)

  • Empty stomach: OG/NG in supine, lateral x2

  • RSI or awake intubation, suggested RSI method with cricoid applied: 

    • NG suction in supine/R+L lateral 

    • Atropine 20mcg/kg 

    • Propofol 3mg/kg & succinylcholine 2mg/kg  

  • Post-op analgesia

    • Avoid narcotics post-op

    • Preop PR acetaminophen 40 mg/kg

    • Local anesthetic infilitration (BPV 0.25% 1cc/kg) 

  • Post-op apnea monitoring