Pyloric Stenosis Pre-Op Guideline

Guideline · Aug 2019 · 1 min read

In brief

Clinical guideline for preoperative preparation of infants with pyloric stenosis, covering fluid resuscitation, electrolyte correction, and optimization before pyloromyotomy.

Written by the GCMD Library team from the guideline.

Clinical Presentation and Diagnosis

Infants present with progressive non-bilious emesis and a palpable epigastric olive on physical examination. Diagnostic confirmation includes laboratory findings of hypochloremic, hypokalemic metabolic alkalosis and ultrasound demonstrating pyloric muscle width >3mm and length >14mm.

Initial Management and Admission

Patients require admission to surgery service with immediate fluid resuscitation if clinically dehydrated using normal saline boluses. Maintenance intravenous fluids should be initiated at 1.5x maintenance rate using D5 ½ NS with potassium chloride supplementation (10 meq) once urine output is established.

Preoperative Optimization Criteria

Surgical intervention is delayed until metabolic derangements are corrected, specifically targeting bicarbonate <30 mEq/L, chloride >100 mEq/L, and normalized potassium levels. Prophylactic antibiotic (Ancef) is administered on call to the operating room once electrolyte goals are achieved.

Statements in this guideline

Pyloric stenosis presents with progressive non-bilious emesis and palpation of an olive in the epigastrium.
Established
Pyloric stenosis causes hypochloremic, hypokalemic metabolic alkalosis.
Established
Ultrasound diagnosis of pyloric stenosis requires muscle width greater than 3 mm and length greater than 14 mm.
Established
Patients with pyloric stenosis should be admitted to the surgery service.
RecommendationPlan
If clinically dehydrated, bolus normal saline.
RecommendationPlan
Maintenance intravenous fluids should be given at 1.5 times maintenance with D5 half normal saline.
RecommendationPlan
Add 10 mEq potassium chloride to intravenous fluids once urine output is established.
RecommendationPlan
Proceed to the operating room when bicarbonate is less than 30, chloride is greater than 100, and potassium is normal.
RecommendationPlan
Administer Ancef on call to the operating room.
RecommendationPlan

Full text

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

Open in a new tab ↗