pyloric

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joncmarkley

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quick poll

We have great peds surgeons...18 minutes skin to skin (pyloromyotomy)

wake ups usually take as long as the surgery!

been debating not using any narcotic (not much post op pain)

or

No NDMR..I do like using roc w induction because it takes laryngospasm out of the differential if we are struggling with the ventilation if the resident missed the airway during the rsi

if you don't mind, I would appreciate your input😳
 
For pylormyotomy... usually a teeny kid. Like 3-4 weeks up to a coupla months.

Pre-O2 'em. Then, stick a soft suction down their throats while they are still awake. Suck the crap out of them. Usually you get a ton of barium and undigested formula. Suck all the way on the way out. Then, stick it back in and do it a second time. Moving them around or holding them upside down (etc.) is a waste of time.

Next, mask 'em until they're deep. Usually many already have an IV because they're dehydrated. If so, you can give 'em a little ketamine or propofol. Point is, get 'em deep and pre-O2 the hell outta them. Then, take a look with no muscle relaxation. If you see the cords, gently intubate. If not, a little Roc 0.6mg/kg and re-mask them. If they're really tiny (like under 4 kg), give them 0.1 mg of atropine.

I put the tube in and run them deep on sevo (like 1.5-2.0 MAC). Have done more than a few of these, and usually do not give NMB. When they're sticking the bovie pad on their back, stick 40mg/kg of tylenol up their butt. Give 'em 20mg/kg bolus of IVF. Kid hasn't been eating right since before they got to the hospital. Usually D5-1/4 NS wills suffice, but LR is okay too.

Once they're done, suck 'em out again. Wake-ups are usually pretty fast if you don't use narcotic. And, if you give them the tylenol up front, this has a pretty sedating/good pain control effect and the baby doesn't wake-up crying.

This techique has served me pretty well for this procedure. No disasters or bad outcomes yet.

-copro
 
SUX. Like a peds attending once told me, if they have pyloric stenosis and some sort of neuromuscular issue they lost the genetic lottery. Its a full stomach situation. The NG may not clear everything and the benefits outweigh the risks for succinylcholine in this case.
 
i'm pretty much with copro.
good pre-ox.
suction stomach 2-3 times while still awake (good pre-ox in between too).
mask down with sevo --> insert IV if none --> thiopental 6mg/kg (here you can +/- small dose of roc 1.2 mg/kg) --> ETT.
tylenol given as well.
haven't seen the need for fentanyl yet.
 
No IV? put it in awake. they do it in the ER all the time on kids. suction stomach. rapid sequence with succ. No narcs. they wake up quick and easy. Now granted this is with N=6, but it seems to work. I dont understand the reluctance to use succ. to me this is one of the indications. NG does not equal empty stomach.
 
I think you know that the kid's "sedated" by the analgesic effect of the tylenol.

Why the question when you know the answer?
 
analgesia and sedation are different endpoints. Just because a drug causes one doesnt mean it'll cause the other. The kid isnt sedated from the tylenol. He's sedated from the inhaled agent and isnt thrashing around in pain because of the tylenol/local which was plank's point.
 
huktonfonix said:
No IV? put it in awake. they do it in the ER all the time on kids. suction stomach. rapid sequence with succ. No narcs. they wake up quick and easy. Now granted this is with N=6, but it seems to work. I dont understand the reluctance to use succ. to me this is one of the indications. NG does not equal empty stomach.
Click to expand...

To me "no IV" means they haven't been given any IV fluid and have a contraction alkalosis and probably hypokalemia that haven't been corrected yet. At our place, these kids get tuned for a day or so before coming to the OR (mostly they just get rehydrated with IVF). Does it matter? I have no idea.
 
"analgesia and sedation are different endpoints. Just because a drug causes one doesnt mean it'll cause the other. The kid isnt sedated from the tylenol. He's sedated from the inhaled agent and isnt thrashing around in pain because of the tylenol/local which was plank's point."

I wasn't arguing with plank, hence the quotes around "sedated."

Just thought it was picking on the guy a bit and thought I'd point it out. No big deal.
 
Haven't done one in >16 years, but we always did awake intubations on these babies. Is that no longer done anywhere?
 
I don't have any problems doing these cases any of these ways. But a couple points need to be made. My peds attendings always told me that sux was safe in the newborns and neonates. The complications from muscular disorders do not occur until later in life, 1st year, 2nd year not sure, but not in these cases. I'd use sux without a worry. I'm not a fan of masking the kid down but I've done it without any problems. I use rocronium b/c my surgeons are not doing these cases in less than 20 minutes and I find roc easy to reverse in youngsters. It keeps the surgical field relaxed as well.

Tylenol is not sedating as far as I know. It makes sedation easier by decreasing pain therefore requiring less sedation/anesthesia.

These pts always have an IV. If they don't, it's b/c it came out on the way to the OR. I follow the Na on these kids b/4 coming to the OR. Most of them are not all that bad when they come to the hospital so they are ready for surgery the next day.
 
Why the Na Noy? Sodium is useful, but I usually follow the Cl more closely.
 
Planktonmd said:
I didn't know that Acetaminophen had a "sedating" effect, could you enlighten us on the mechanism?
🙂
Click to expand...

I don't know the mechanism, but would imagine that it is similar to the way that sucrose exerts its effects.

To assume that a neonate's physiology and response to medications is always similar to an adult's or even a child's is simplistic at best. For certain, I do know that when I take 1,000mg of acetaminophen, it has a "sedating" effect on me. I'm ineluctably forced to take a nap once it starts to kick in.

But, studied? Yes (and that was at a 12mg/kg dose... not the 40mg/kg we usually give perioperatively):

http://pediatrics.aappublications.org/cgi/content/abstract/55/6/818

The effective dose is far higher in normal perioperative practice, and certainly far more than an average-sized adult on a milligram per kilogram basis is given. So, you tell me: is the observation wrong and mean there is no effect?

-copro
 
coprolalia said:
I don't know the mechanism, but would imagine that it is similar to the way that sucrose exerts its effects.

To assume that a neonate's physiology and response to medications is always similar to an adult's or even a child's is simplistic at best. For certain, I do know that when I take 1,000mg of acetaminophen, it has a "sedating" effect on me. I'm ineluctably forced to take a nap once it starts to kick in.

But, studied? Yes (and that was at a 12mg/kg dose... not the 40mg/kg we usually give perioperatively):

http://pediatrics.aappublications.org/cgi/content/abstract/55/6/818

The effective dose is far higher in normal perioperative practice, and certainly far more than an average-sized adult on a milligram per kilogram basis is given. So, you tell me: is the observation wrong and mean there is no effect?

-copro
Click to expand...
Ah, so you are actually serious, You do think that you have observed a direct sedative effect of Acetaminophen on babies (not secondary to analgesia), and you are basing that conclusion on your personal experience with Tylenol making you sleepy.
Did anyone else other than you ever observed a sedative effect of acetaminophen in any age group?
I Personally think that rectal Acetaminophen in children is pure Voodoo and doesn't do anything (not even analgesia), it's actually a placebo effect on the person who administers it, in other words because you know you gave it you start imagining that it's doing something.
It's just a personal opinion based on my personal experience similar to your personal experience of getting sleepy after Tylenol. 😉
 
ok, as a peds fellow I like this best, do them a lot............this case is medical emergency not surgical. Once all labs are checked (k, cl, na) , always IV in place. Pre ox kid, place shoulder roll (usually use 250 saline bag, or rolled blue towel) to optimize position.......after awake og suction (usually times 2). Check iv function by giving .1 mg of atropine, also helps avoid brady. If good precede with propofol and sux. Then intubate, rectal tylenol with bovie, then usually .1 /kg nimbex perfect..........rocuronium can be used, but if you look up studies it is very unreliable time wise in the very young, probably liver development.......can last really long time in babies. No narcotic at all. Local by surgeon, extubate...done.

just one way, but works well where i am. Some just use roc low dose (.5-.6 /kg, usually fine.......high dose not as reliable to wake up. Surgeons are fast too, about 15-20 minutes total barring complication.
 
Planktonmd said:
I Personally think that rectal Acetaminophen in children is pure Voodoo and doesn't do anything (not even analgesia), it's actually a placebo effect on the person who administers it, in other words because you know you gave it you start imagining that it's doing something.
It's just a personal opinion based on my personal experience similar to your personal experience of getting sleepy after Tylenol. 😉
Click to expand...

Well, that's just dumb.

-copro
 
coprolalia said:
Well, that's just dumb.

-copro
Click to expand...

Really?
The subject of postoperative acetaminophen in children is at best controversial and there is more evidence against it than for it:

http://bja.oxfordjournals.org/cgi/content/full/ael371v1

and
http://www.theannals.com/cgi/content/abstract/38/11/1935

and
http://www.anesthesia-analgesia.org/cgi/content/full/92/4/907

I know that you with your 2 years of experience as a resident feel that you already mastered all the aspects of anesthesiology and that there is nothing more you could possibly learn, but describing other people's opinions as "dumb", especially if these people have at least 10 times more experience and knowledge than you, is simply dumb!
 
Planktonmd said:
The subject of postoperative acetaminophen in children is at best controversial and there is more evidence against it than for it.
Click to expand...

No there's not. That's just an outright fabrication on your part.

Here is the landmark study from 11 years ago, and what current pediatric anesthesiologists routinely practice:

http://www.anesthesiology.org/pt/re/anes/abstract.00000542-199708000-00010.htm;jsessionid=LvdMy6Nqz06nq9WrVDc8Ks2vLfVyRggFyqnnwCHhQWLdBhmX7DNL!1855075860!181195628!8091!-1

First study you post is examining it as an adjunct, and not as a solo therapy (i.e., hard to draw any meaningful conclusion about it as a solo agent). Second study you post is a meta-analysis by a pharmacist (who, as I have posted about before, apparently love to make clinical practice recommendations without any actual direct patient care experience) where it is admitted that the analyzed studies are too "limited, variable, and non-standardized" to draw a meaningful conclusion. And, the last study you post, again, looks at it in kids already receiving an opioid. Kudos! You cherry-picked three studies, one from a pharmacist and two others in kids already receiving opioids.

Furthermore, I don't care if you're Barash, Miller, Stoelting, Apfelbaum, or the Lord God Jesus himself. When you refer to something as "voodoo" - something that is widely practiced, studied, and understood - just because you don't personally believe in it, I'm going to call such an opinion "dumb" every time. That is not the way to have a meaningful discussion about the merits of a particular therapy. Dose matters. Absorption matters. Timing of administration matters. Likewise, your argumentum ad verecundiam tactic is duly noted.

Here's some more data to chew on...

http://www.anesthesia-analgesia.org/cgi/content/abstract/80/2/226

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1483338

http://www.ncbi.nlm.nih.gov/pubmed/9204788

http://www.anesthesiology.org/pt/re/anes/abstract.00000542-199908000-00019.htm;jsessionid=LvmHpr3gz2z72npm4QRgzg30CyYy1th4p3fy7T9zLJPZL172nQLl!1420013937!181195629!8091!-1

http://www.sciencedirect.com/scienc...serid=10&md5=3c274a05f2eb88028c2bf0b54f22c767

http://www.anesthesia-analgesia.org/cgi/content/abstract/102/5/1365

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://archpedi.ama-assn.org/cgi/content/full/158/6/521

http://www.anesthesia-analgesia.org/cgi/content/full/93/6/1626-a

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

-copro
 
coprolalia said:
No there's not. That's just an outright fabrication on your part.

Here is the landmark study from 11 years ago, and what current pediatric anesthesiologists routinely practice:

http://www.anesthesiology.org/pt/re/anes/abstract.00000542-199708000-00010.htm;jsessionid=LvdMy6Nqz06nq9WrVDc8Ks2vLfVyRggFyqnnwCHhQWLdBhmX7DNL!1855075860!181195628!8091!-1

First study you post is examining it as an adjunct, and not as a solo therapy (i.e., hard to draw any meaningful conclusion about it as a solo agent). Second study you post is a meta-analysis by a pharmacist (who, as I have posted about before, apparently love to make clinical practice recommendations without any actual direct patient care experience) where it is admitted that the analyzed studies are too "limited, variable, and non-standardized" to draw a meaningful conclusion. And, the last study you post, again, looks at it in kids already receiving an opioid. Kudos! You cherry-picked three studies, one from a pharmacist and two others in kids already receiving opioids.

Furthermore, I don't care if you're Barash, Miller, Stoelting, Apfelbaum, or the Lord God Jesus himself. When you refer to something as "voodoo" - something that is widely practiced, studied, and understood - just because you don't personally believe in it, I'm going to call such an opinion "dumb" every time. That is not the way to have a meaningful discussion about the merits of a particular therapy. Dose matters. Absorption matters. Timing of administration matters. Likewise, your argumentum ad verecundiam tactic is duly noted.

Here's some more data to chew on...

http://www.anesthesia-analgesia.org/cgi/content/abstract/80/2/226

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1483338

http://www.ncbi.nlm.nih.gov/pubmed/9204788

http://www.anesthesiology.org/pt/re/anes/abstract.00000542-199908000-00019.htm;jsessionid=LvmHpr3gz2z72npm4QRgzg30CyYy1th4p3fy7T9zLJPZL172nQLl!1420013937!181195629!8091!-1

http://www.sciencedirect.com/scienc...serid=10&md5=3c274a05f2eb88028c2bf0b54f22c767

http://www.anesthesia-analgesia.org/cgi/content/abstract/102/5/1365

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://archpedi.ama-assn.org/cgi/content/full/158/6/521

http://www.anesthesia-analgesia.org/cgi/content/full/93/6/1626-a

http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

-copro
Click to expand...
You know what your problem is?
You don't have any idea how little you know.
The Google search you provided above does not contradict what I already attempted to make you comprehend (unsuccessfully).
There are people out there who believe that Acetaminophen has some benefit in the the perioperative setting in children but there are others who disagree and I happen to be one of those.
Most of these studies and articles you provided are irrelevant and / or extremely weak, and had you attempted to spend some time reading them instead of trying to come up with more dumb arguments you might have learned something and realized that I was actually trying to teach you something beneficial.
It's not wrong to have some opinions when you have 2 years of experience but you need to realize the limitations of your knowledge and experience, because if you don't know your limits you will never learn.
 
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Planktonmd said:
... had you attempted to spend some time reading them instead of trying to come up with more dumb arguments you might have learned something and realized that I was actually trying to teach you something beneficial.
Click to expand...

:laugh: Is this 2win?

MAN you're arrogant!

-copro
 
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