Pyloromyotomy
Clinical Procedure
 
Aliases:
Pyloric stenosis surgery
pyloric stenosis repair

Topic aliases are alternate phrasings for a particular topic.


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Pyloromyotomy is a surgical procedure performed in patients with hypertrophic pyloric-stenosis. Patients with this condition present within the first few weeks of birth with persistent vomiting, dehydration, hypochloraemic metabolic alkalosis, and hypokalemia.
Initial medical management involves volume and electrolyte resuscitation over a 24-72 hour period prior to surgery.
Anesthetic considerations include ensuring adequate correction of volume and electrolyte deficits, and minimising risk of pulmonary aspiration for a short procedure with minimal peri-operative pain.

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Is the child ex-preterm? Pyloric stenosis is more common in this population. If so, enquire about related comorbidities. See ex premature

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Dec 04, 2012
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Clinical picture is usually one of dehydration accompanied by a hypochloraemic metabolic acidosis and hypokalemia.

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Oct 19, 2011
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Use the weight of the infant compared to birth weight, in combination with clinical signs, to help estimate volume deficit.

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Oct 11, 2011
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If the infant with compensatory respiratory acidosis is taken to theater immediately, they are at elevated risk of postoperative apnoea. It is best to ensure near normalisation of acid base status prior to operating.

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Mar 17, 2012
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Intravenous glucose will be required to prevent hypoglycemia in the fasting infant awaiting surgery.

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Dec 04, 2012
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This is a medical, but not surgical emergency.
There is time to adequately resuscitate infant's volume and electrolyte deficits prior to surgery over 24-72hrs.

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Consider administering atropine prior to insertion of the nasogastric tube to prevent bradycardia

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Aug 23, 2012
10mcg/kg IV
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Aspirate stomach contents via gastric tube (four quadrants) prior to induction. If not already placed, insert orogastric & aspirate prior to induction. refl.in/5v

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May 23, 2011
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Induction: Non-depolarising relaxant, gently ventilate with volatile, intubate when relaxed. refl.in/5v

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May 23, 2011
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Induction: Rapid sequence induction with or without cricoid pressure. (Cricoid pressure may interfere with intubation) #ref

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Jul 07, 2011
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In resource constrained settings high volume caudal anaesthesia without a general anaesthetic is an option.
Eg 1.5ml/kg 0.2% Levobupivicaine with adrenaline #IM (referred to as McKenzie/Brown technique in Vietnam)
Be cognicent of the risk of bradycardia and apnoea with a high block

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Local anaesthesia infiltration by the surgeon is usually sufficient.
Opioids are usually not required.
www.frca.co.uk/article.as...

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Aug 24, 2012
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Before proceeding aim for :
pH 7.3-7.5,
Na >132 mmol/L,
Cl > 88mmol/L,
K >3.2 mmol/L and
HCO3 < 30 mmol/L.

www.frca.co.uk/article.as...

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If aciduria is present, there is likely significant potassium K+ deficit

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May 18, 2011
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If signs of shock are present, resuscitate with 20ml/kg intravenous fluid, repeated twice if necessary, titrated to improvement of hemodynamic parameters.

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Oct 10, 2011
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At the end of the procedure, the patient must be wide awake and in a left lateral position for extubation. refl.in/5v

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