Pyloric stenosis is caused by hypertrophy of the pylorus to the point the gastric outlet becomes obstructed and leads to intense vomiting. Etiology is unclear but risk factors for pyloric stenosis include; being a male, maternal smoking during pregnancy, bottle feeding, genetic history and macrolide antibiotics. Pyloric stenosis most often is manifested between the third and sixth weeks of life with projectile vomiting after feeding.
Disease Specific Considerations:
Pyloric Stenosis is a Medical Emergency, not a Surgical Emergency
Vomiting leads to hypochloremic, hypokalemic metabolic alkalosis.
Patients may be very dehydrated at presentation
Superimposed metabolic acidosis reflects severe hypovolemia and is an ominous sign
Metabolic alkalosis predisposes to post-op apnea
Patient must be appropriately resuscitated preoperatively. OU Anesthesia guidelines:
Bicarbonate ≤ 29
Chloride ≥ 100
Potassium ≥ 3.0
Young patients are prone to heat loss
Pre-warm the room and place an underbody bair hugger or K-Thermia
Airway: must have supplies to perform awake gastric suctioning prior to induction. Most use either 10fr OG or 18fr red rubber (*latex).
Suction should be performed with patient:
Drugs/Infusions: these patients are NOT given narcotic intra-op.
Blood Availability: N/A
PICU Bed Availability: N/A
Induction: RSI with cricoid pressure
Evacuate the stomach prior to induction by passing an OG (awake) and suctioning in the supine, left/right lateral and prone positions.
Technique varies with attending; some use succinylcholine/atropine; some use Propofol bolus; some use Cisatracurium or rocuronium and reverse with Sugammadex.
Glycopyrrolate/Neostigmine may be used if twitches have returned by end of case
RN will provide CC pressure.
Place OG after anesthesia induction for intra-op gastric air push with 60cc Toomey syringe.
OG must be clamped after insufflation or the air will escape
Positioning: you will turn patient caddy corner on OR bed.
Maintenance of Anesthesia
Maintain with volatile anesthetic
No case-specific hemodynamic goals
This procedure is frequently brief (<30 min)
Patients should be fully reversed if neuromuscular blockade was given
Patients are a full stomach
Post-Op Pain Management
Local per surgeon
Consider IV Acetaminophen
Patients are full stomach
Have a high degree of suspicion for post-operative apnea