Preoperative Management of Pyloric Stenosis

History and physical exam consistent with pyloric stenosis•Progressive non-bilious emesis•Palpation of olive in epigastrium Labs: Hypochloremic, hypokalemic metabolic alkalosis Ultrasound: Muscle width > 3 mm, length >14 mm Plan: •Admit to Surgery•If clinically dehydrated, bolus NS (see adjacent schematic) •MIVF at 1.5 x maintenance with D5 ½ NS •Add 10 meqKClonce UOP established To OR when HCO3<30, Cl>100, and K normal (Ancef on call) Suggested Resuscitation: Source: Dalton BGA, et al. Optimizing fluid resuscitation in hypertrophic pyloric stenosis. J PediatrSurg2016;51(8):1279-1282. Updated 1/2019 v1.0 Post-Op from Pyloromyotomy NPO x 2 hours Initiate home feeds (breast milk or formula) ad lib** Discharge when tolerates 3 consecutive feeds without emesis Continue ad lib even if patient has 2-3 episodes of emesis If persistent emesis, can make patient NPO x 2 hours and then re-start feeds Updated 1/2019 v1.0Sources:•Markel TA, et al. A randomized trial to assess advancement of enteral feeds following surgery for hypertrophic pyloric stenosis.J PediatrSurg2017;52(4):534-539. •AdibeOO, et al. Protocol versus ad libitum feeds after laparoscopic pyloromyotomy: A prospective randomized trial. J PediatrSurg2014;49(1):129-132. •Graham KA, et al. A review of postoperative feeding regimens in infantile hypertrophic pyloric stenosis. J PediatrSurg2013;48:2175-2179. **Note: Ad lib feeding is associated with equivalent or shorter hospital stay (compared to protocolized feeding), although patients on ad lib feeds may have more emesis.