Peds: Pyloric Stenosis
6-week-old infant for pyloromyotomy. Focus on electrolyte optimization and aspiration risk.
"A 6-week-old male presents with projectile, non-bilious vomiting. He appears lethargic and dehydrated. Labs show Na 132, K 3.1, Cl 88, and a metabolic alkalosis. The surgeon wants to proceed immediately with pyloromyotomy..."
Medical optimization before surgical intervention, electrolyte correction, and aspiration risk in newborns.
A classic test of 'not rushing to the OR' until the patient is medically optimized.
How a Board-Certified Consultant answers this scenario.
Pyloric stenosis is never a surgical emergency; it is a medical emergency. My first priority is correcting the patient's metabolic alkalosis and dehydration before any anesthetic is administered.
I will cancel the immediate surgical request and initiate aggressive fluid resuscitation with 20cc/kg boluses of normal saline until the patient is making urine and shows improved skin turgor. I will replace potassium (K+) and chloride (Cl-) to restore the metabolic balance. Only once the chloride is >100 mEq/L and the bicarbonate is <30 mEq/L will I proceed. For the induction, I will perform a 'modified' Rapid Sequence Induction (RSI) after emptying the stomach with an OG tube in multiple positions (left, right, supine), as these infants are at high risk for aspiration of curdled milk.