Pyloric Stenosis
Considerations
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Medical but not surgical emergency
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Infant considerations
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High aspiration risk
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Resuscitation of metabolic derangements:
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Hypovolemia
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Metabolic alkalosis
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Hypochloremia
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Hyponatremia
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Hypokalemia
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Post-op dispostion & apnea monitoring
Goals
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Correction of volume deficit & acid/base & electrolyte abnormalities prior to pylormyotomy
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Prevent aspiration (OG/NG, RSI)
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Appropriate post-operative apnea monitoring
Conflicts
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Resuscitation vs. surgical timing
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RSI vs. hypovolemia
Optimization & management
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Restore intravascular volume:
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NS 10-20ml/kg IV boluses
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Maintenance D5/NS + KCl 20-40 mEq/L
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Clinical signs to assess (HR, BP, fontanelles, mucous membranes, skin turgor, urine output, capillary refill)
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Correct electrolyte & acid/base disturbances:
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Na > 130 mEq/L
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K > 3 mmol/L
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Cl > 90 mEq/L
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HCO3 < 27 mmol/L
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Urine output > 1cc/kg/hr
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Vital signs normal for age (HR ~150, SBP >/= 60 mmHg)
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Empty stomach: OG/NG in supine, lateral x2
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RSI or awake intubation, suggested RSI method with cricoid applied:
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NG suction in supine/R+L lateral
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Atropine 20mcg/kg
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Propofol 3mg/kg & succinylcholine 2mg/kg
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Post-op analgesia
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Avoid narcotics post-op
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Preop PR acetaminophen 40 mg/kg
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Local anesthetic infilitration (BPV 0.25% 1cc/kg)
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Post-op apnea monitoring