Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 49821

AbstractCase ReportDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2023 | Month : March | Volume : 17 | Issue : 3 | Page : UD06 - UD08 Full Version

Challenges in the Anaesthetic Management of Congenital Disorder Infantile Hypertrophic Pyloric Stenosis

Published: March 1, 2023 | DOI:
Monika Sharma, Aruna Chandak, Vijay Chandak

1. Postgraduate Resident, Department of Anaesthesia, Datta Meghe Institute of Medical Science, Wardha, Maharashtra, India. 2. Professor, Department of Anaesthesia, Datta Meghe Institute of Medical Science, Wardha, Maharashtra, India. 3. Professor, Department of Anaesthesia, Datta Meghe Institute of Medical Science, Wardha, Maharashtra, India.

Correspondence Address :
Monika Sharma,
Shalinta PG Girls Hostel, Sawangi, Wardha, Maharashtra, India.


Pyloric stenosis is characterised by a thicker, lengthened, and larger pylorus as well as hypertrophy of the circular and, to a lesser extent, the longitudinal smooth muscles.The classical presenting features are non-bilious, projectile vomiting, visible peristalsis and hypochloremichypokalaemic metabolic alkalosis. Definitive treatment is often performed by a relatively quick surgical procedure shortly after diagnosis. Surgery for pyloromyotomy is usually performed when fluid, acid/base, and electrolyte imbalances have been properly and completely corrected, which in turn results in speedy recovery of patient. The complications linked to these diseases call for caution when administering anaesthesia for even ostensibly straightforward surgical procedures. The case report is about a 1-month old male neonate who presented with features of pyloric stenosis.Weighing the increase risk of complications and mortality, the neonate was managed using rapid sequence induction approach in combination with caudal block for an adequate analgesia.


Electrolytes, Neonates, Postoperative risk, Pyloromyotomy surgery

Case Report

A 1-month-old, 2.5 kg baby boy, presented with mild dehydration and non-bilious projectile vomiting after breast feedings for the previous ten days. He had been experiencing small amounts of non-bilious, non-bloody emesis after feedings since previous week. He was alert, afebrile, didn’t seem tired to his parents, had a regular amount of feedings during the week, and had wet diapers on a consistent basis. He had the following vital signs: Heart Rate (HR) 142 bpm, Blood Pressure (BP) 86/44 mmHg, Respiratory Rate (RR) 36 min, Temprature 36.8°C, and SpO2 100%. Upon physical examination, he showed signs of activity and had normal mucous membranes, capillary refill time, and a fontanelle. The respiratory and cardiovascular systems performed normally. There were no obvious abdominal masses felt on palpation.

Investigations revealed that, the patient had 11.6 g/dL Haemoglobin (HB), 3.6 lakh platelets, 0.6 mg/dL serum creatinine, 10.8 mg/dL blood urea nitrogen, and electrolytes of 128 mmol/L Na+, 2.9 mmol/L K+, and 74 mmol/L Cl. Tests to measure thyroid function were within acceptable ranges. He had a pH of 7.6, a pCO2 of 38.4 mm Hg, and an HCO3 of 38.6 mmol/L in his arterial blood. A 48-hour period of medical care consisted of correcting electrolyte imbalance and dehydration with 5% dextrose in 0.45% saline and potassium chloride. He had pre-operative blood sugar of 100 mg%, Na+ 133 mmol/L, K+ 4.2 mmol/L, and Cl 91 mmol/L, and an abdominal ultrasound indicated abnormalities that were perhaps related to pyloric stenosis. Pyloromyotomy surgery was therefore planned accordingly.

Operation theatre was equipped with Miller and Macintosh laryngoscope blades, endotracheal tubes, stylets, and Laryngeal Mask Airways (LMA) in anticipation of difficult airways. Monitors for the SpO2 and electrocardiogram were fitted. Ryle’s tube aspiration was performed. Keeping in mind about providing good analgesia, Prior to induction, after taking all necessary aseptic precautions, patient was given left lateral position, caudal block total 1mL volume (0.5 mg/kg) of 0.25% bupivacaine local anaesthetic was administered (Table/Fig 1). It was performed by inserting a needle through sacral hiatus (Table/Fig 2).

After preoxygenation for 5 minutes,the infant was premedicated with intravenous (IV) glycopyrrolate and IV midazolam for 5 minutes.

With the help of atracurium 0.5 mg/kg and propofol 2 mg/kg, general anaesthesia was achieved. With a modified rapid sequence induction approach with cricoid pressure and gentle,smooth laryngoscopy, the patient was intubated using a 3 mm endotracheal tube. Sevoflurane, oxygen, and air were used to maintain anaesthesia during the procedure. Fentanyl top-ups IV were used to give adequate analgesia intraoperatively (1mcg). A temperature probe and capnograph were fitted. In case replacement of fluids required, a second IV access was established. 1% dextrose in ringer lactate was given to him in 25 mL over the course of the 45-minute procedure. His temperature was kept between 35.5°C and 36.5°C, SpO2 was kept between 97-99%, and his heart rate was kept between 120 and 140 beats per minute (Table/Fig 3).

The neuromuscular blockade was reversed with glycopyrrolate 8 mcg/kg and neostigmine 0.05 mg/kg. He had a good cry after being extubated, and then he was moved to the Paediatric Intensive Care Unit (PICU) for post-operative monitoring and fluid replacement. His post-operative electrolytes revealed Na+ concentrations of 131 mmol/L, K+ concentrations of 5.0 mmol/L, and Cl concentrations of 98 mmol/L. Appropriate electrolyte correction was carried out while maintaining input output charting.

Postoperatively, there was no complaint of pain and vital signs were steady. On the second post-operative day, the patient began consuming oral feeds. On the fifth post-operative day, he was moved out of the PICU, and on the seventh day, he was discharged from the hospital without any complications.


Infantile Hypertrophic Pyloric Stenosis (IHPS) has an uncertain specific aetiology, but it is likely influenced by both genetic and environmental factors (1),(2). The condition has been linked to a number of environmental factors, including living in a rural region, using bottles while nursing, and exposure to macrolide antibiotics [3-6]. Patients with IHPS are often first-born males, and there may be a very slight association between preterm and IHPS (7). A infant with IHPS would typically present as a three to five week old with non-bilious projectile vomiting and a healthy appetite.(8) During a physical examination, a palpable pyloric “olive like” mass in the belly may be present along with symptoms of dehydration(9).Patients may experience substantial hypovolemia and concomitant electrolyte problems due to stomach acid loss (10).

The index patient presented with the typical non-bilious projectile vomiting, hypokalemic, and hypochloremic,metabolic alkalosis symptoms with mild dehydration, which was treated with potassium replacement and 5% dextrose in 0.45% saline. Following the initial 20ml/kg 0.9% saline bolus, maintenance fluid was initiated with the aim of ensuring appropriate hydration and preventing hypernatraemia and hypoglycemia. Barium investigations have been supplanted with ultrasound as the preferred diagnostic method for IHPS. Pyloric muscle thickness, length, and diameter are typical measurements. Patients with IHPS have values for these dimensions that are higher than usual. Since, pyloromyotomy is often not an emergency procedure, hypovolemia and electrolyte abnormalities should be treated with intravenous treatment prior to surgery. The risk of aspiration during the anaesthetic process may be reduced by maintaining an appropriate NPO interval while providing fluid treatment (11), a complete pre-operative evacuation of the stomach’s contents using a nasogastric or orogastric tube to further reduce the risk of aspiration. In this case, the infant was provided some continuous IV fluids but did not need aggressive volume replacement. If necessary, intraoperative boluses of an isotonic fluid (10 mL/kg of hartmann’s solution or saline 0.9%) can be administered to adjust the circulation volume. In the operating room, glucose-containing maintenance solutions may be continued, but they must not be used to replace bolus fluid. If intraoperative glucose-containing maintenance fluids are stopped, the blood glucose level should be monitored frequently to guarantee normoglycemia throughout the perioperative phase (12). Similarly,Puri B et al., hadtreated the initial hypovolaemia with a bolus of Ringer lactate as part of the resuscitation strategy, and the shortfall was then corrected with calculated quantities of normal saline. Then, to supply maintenance fluids, 5% dextrose with a fifth strength of normal saline was employed. They had shown the preferred method is balanced general anaesthesia combined with aspiration preventionprophylaxis (13).

Sevoflurane or desflurane is used to sustain anaesthesia in a mixture of oxygen and air as seen in study by Scrimgeour GE et al., since nitrous oxide causes bowel gas to expand, it is typically avoided.

When compared to desflurane, isoflurane causes more bouts of postoperative apnea in infants undergoing pyloromyotomy and prolongs recovery durations (14).

In order to prevent cooling, it is important to keep an eye on the patient’s temperature and keep the patient in a warm atmosphere. Because infants undergoing pyloromyotomy are more likely to aspirate gastric contents, a secured airway with endotracheal intubation is necessary (15). Awake intubation, fast sequence intubation, and modified rapid sequence intubation were the three procedures that Cook-Sather SD et al. Compared (16). Awake intubation is no longer utilised since it failed to stop oxygen desaturation or bradycardia. Modified rapid sequence was used that included pre-oxygenation, IV induction, and a non-depolarizing muscle relaxant because these babies are often low weight and cannot survive total apnea even for 60 seconds during rapid sequence intubation. Prior to endotracheal intubation, gentle positive pressure ventilation and cricoid pressure were applied. Sevoflurane, oxygen, and air were employed for maintenance.

Infant must be fully awake, have strong protective reflexes mechanisms, and a regular breathing pattern before extubation. Regardless of the medication used, apnea monitoring and pulse oximetry are recommended for the first 24 hours following surgery due to the increased risk of post-operative apnea. Parenteral fluids are given to maintain adequate hydration until oral intake is sufficient (17). Although intravenous opioids like fentanyl 1 mcg/kg can be used intraoperatively to generate adequate analgesia, opioids should be avoided due to the increased risk of respiratory depression. In index patient, analgesia was maintained utilising low dose fentanyl in conjunction with caudal anaesthesia. It was discovered that caudal analgesia was just as effective as injecting bupivacaine locally into a wound for treating postoperative pain in children undergoing surgical correction of congenital pyloric stenosis (18). Caudal anaesthesia with 0.25% bupivacaine has also been used among children undergoing surgical correction of congenital pyloric stenosis in various studies.

Loetwiriyakul W et al., had used 1.2 mL/Kg of 0.25% bupivacaine plus 50 g/Kg of morphine to the caudal region, and concluded that this combination is adequate for intra-operative analgesia and surgical relaxation when given to children,undergoing intra-abdominal surgeries, after induction of general anaesthesia (19). The use of caudal block in this case led to a lower fentanyl dose requirement and reduction in additional demand for other analgesics both intraoperatively and postoperatively. The patient’s vital signs were stable throughout the perioperative period, and there was no postoperative pain. Patients should remain under cardiorespiratory surveillance throughout the night because of the infants’ relatively recent post-conceptional ages. There are particular cases of postoperative apneic episodes in IHPS patients following surgery who were previously fullterm (20),(21). The exact origin of the predisposition is unknown, although it’s conceivable that respiratory depression could result from metabolic alkalosis, which raises the pH of the Cerebrospinal Fluid (CSF).


Pyloric stenosis is not a medical emergency, although, it can become one if an early surgical correction is performed without sufficient resuscitation.Thus, the report presents recent evidence-based medical research on the perioperative care of infants with pyloric stenosis with focus on preoperative metabolic abnormality assessment and correction, intraoperative care, including airway management maintenance anaesthetic techniques, and postoperative pain management strategies. During an infant’s recovery from general anaesthesia, it is important to keep an eye out for any signs of respiratory depression and episodes of apnea brought on by metabolic alkalosis, general anaesthesia, and reduced body temperature. It also reflected that use of rapid sequence intravenous induction and maintenance with an inhalational agent among these infants is common and safe mode without any significant complications.


To T, Wajja A, Wales PW, Langer JC. Population demographic indicators associated with incidence of pyloric stenosis. Arch PediatrAdolesc Med. 2005;159(6):520-25. PubMed PMID: 15939849. [crossref] [PubMed]
Pedersen RN, Garne E, Loane M, Korsholm L, Husby S. EUROCAT Working Group. Infantile hypertrophic pyloric stenosis: A comparative study of incidence and other epidemiological characteristics in seven European regions. J MaternFetal Neonatal Med. 2008; 21(9):599-04. Doi: 10.1080/14767050802214824. PMID: 18828050. [crossref] [PubMed]
Eberly MD, Eide MB, Thompson JL, Nylund CM. Azithromycin in early infancy and pyloric stenosis. Pediatrics. 2015;135(3):483-88. Doi: 10.1542/peds.2014- 2026. PubMed PMID: 25687145. [crossref] [PubMed]
Lund M, Pasternak B, Davidsen RB, Feenstra B, Krogh C, Diaz LJ, et al. Use of macrolides in mother and child and risk of infantile hypertrophic pyloric stenosis: nationwide cohort study. BMJ. 2014;348:g1908. Doi: 10.1136/bmj.g1908. PubMed PMID: 24618148; PubMed Central PMCID: PMC3949411. [crossref] [PubMed]
McAteer JP, Ledbetter DJ, Goldin AB. Role of bottle feeding in the etiology of hypertrophic pyloric stenosis. JAMA Pediatr. 2013;167(12):1143-49. Doi:10.1001/jamapediatrics.2013.2857. PubMed PMID:24146084. [crossref] [PubMed]
Stark CM, Rogers PL, Eberly MD, Nylund CM. Association of prematurity with the development of infantile hypertrophic pyloric stenosis. Pediatr Res. 2015;78(2):218-22. Doi: 10.1038/pr.2015.92. Epub 2015 May 7. PubMed PMID:25950452. [crossref] [PubMed]
Schwartz D, Connelly NR, Manikantan P, Nichols JH. Hyperkalemia and pyloric stenosis. AnesthAnalg. 2003;97(2):355-57. table of contents. PubMed PMID:12873916. [crossref] [PubMed]
Kundal VK, Gajdhar M, Shukla AK, Kundal R. Infantile hypertrophic pyloric stenosis in twins Case Reports. 2013;2013:bcr2013008779. [crossref] [PubMed]
Kumar TR, Srikanth C. Infantile hypertrophic pyloric stenosis in an extremely preterm male twin; A case report and review. J Indian Assoc Pediatr Surg. 2014;19(3):184-85. Doi: 10.4103/0971-9261.136484. PMID: 25197202; PMCID: PMC4155641. [crossref] [PubMed]
Huang IF, Tiao MM, Chiou CC, Shih HH, Hu HH, Ruiz JP, et al. Infantile hypertrophic pyloric stenosis before 3 weeks of age in infants and preterm babies. Pediatr Int. 2011;53(1):18-23. Doi: 10.1111/j.1442-200X.2010.03185.x. PMID: 20557472. [crossref] [PubMed]
Jobson M, Hall NJ. Contemporary management of pyloric stenosis. Inseminars in pediatric surgery 2016;25(4):219-24). WB Saunders. [crossref] [PubMed]
Miozzari HH, Tönz M, von Vigier RO, Bianchetti MG. Fluid resuscitation in infantile hypertrophic pyloric stenosis. Acta Paediatr. 2001;90(5):511-14. [crossref] [PubMed]
Puri B, Sreevastava DK, Kalra AS. Idiopathic Hypertrophie Pyloric Stenosis: Our Experience. Medical journal, Armed Forces India. 2006;62(3):216-19. https:// [crossref] [PubMed]
Scrimgeour GE, Leather NWF, Perry RS, Pappachan JV, Baldock AJ. Gas induction for pyloromyotomy. Ped Anesth. 2015;25:677-80. [crossref] [PubMed]
Engelhardt T. Rapid sequence induction has no use in pediatricanesthesia. PediatricAnesthesia. 2015;25(1):5-8. [crossref] [PubMed]
Cook-Sather SD, Tulloch HV, Cnaan A. A comparison of awake versus paralysed tracheal intubation for infants with pyloric stenosis. Anesth Analg. 1998;86:945-51. [crossref]
Andropoulos DB, Heard MB, Johnson KL, Clarke JT, Rowe RW. Postanestheticapnea in full-term infants after pyloromyotomy. Anesthesiology. 1994;80:216-19. [crossref] [PubMed]
Moyao-García D, Garza-Leyva M, Velázquez-Armenta EY, Nava-Ocampo AA. Caudal block with 4 mg x kg-1 (1.6 ml x kg-1) of bupivacaine 0.25% in children undergoing surgical correction of congenital pyloric stenosis. PaediatrAnaesth. 2002;12(5):404-10. Doi: 10.1046/j.1460-9592.2002.00855.x. PMID: 12060325. [crossref] [PubMed]
Loetwiriyakul W, Asampinwat T, Rujirojindakul P, Vasinanukorn M, Chularojmontri T, Rueangchira-urai R, et al. Caudal block with 3 mg/Kg Bupivacaine for intraabdominal surgery in pediatric patients: a randomized study. Asian Biomedicine. 2017;5(1):93-99. 7415.0501.011 [crossref]
Pappano D. Alkalosis-induced respiratory depression from infantile hypertrophic pyloric stenosis. PediatrEmerg Care. 2011;27(2):124. Doi:10.1097/ PEC.0b013e318209af50. PubMed PMID: 21293220 [crossref] [PubMed]
Liu K. Challenges in the Perioperative Management of Infantile Hypertrophic Pyloric Stenosis. Proceedings of UCLA Healthcare. 2016;20.

DOI and Others

DOI: 10.7860/JCDR/2023/60910.17574

Date of Submission: Oct 18, 2022
Date of Peer Review: Dec 06, 2022
Date of Acceptance: Dec 17, 2022
Date of Publishing: Mar 01, 2023

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Oct 19, 2022
• Manual Googling: Nov 29, 2022
• iThenticate Software: Dec 15, 2022 (11%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)