Paediatric anaesthesia15 / 17
Midgut volvulus in an infant with repaired heart disease7-week-old boy, born at 34 weeks, 3.8 kg
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Know this first
- Bilious vomiting in an infant means volvulus until proven otherwise.
- Once obstruction is diagnosed it is a surgical emergency; infants deteriorate fast.
- Children keep their blood pressure until shock is advanced; hypotension is late.
- Fluid boluses of 10–20 mL/kg; adrenaline or noradrenaline if fluid-refractory.
- Hyperkalaemia: calcium, insulin with glucose, bicarbonate.
The patient
7-week-old boy, born at 34 weeks, 3.8 kg, with 6 hours of bilious vomiting and a distended, tender abdomen.
VSD closed at 4 weeks; recent echo shows good function and no residual shunt.
Mottled and cool, capillary refill 5 s; lactate 6 mmol/L; K 5.4 mmol/L. Ultrasound: midgut volvulus.
Vitals: HR 190, BP 62/30, SpO2 94% on air, RR 60, temperature 36.0 °C.
The examiner asks
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Consider
What are your considerations?
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- A 7-week-old ex-34-weeker with a closed VSD and volvulus, in shock, for emergency laparotomy. Patient
- As an ex-prem infant he risks apnoea, cold and low glucose; his output depends on rate.
- Bilious vomiting means volvulus: his whole midgut hangs on one twisted pedicle. Disease
- His low pressure means late, decompensated shock.
- His closed VSD with good function matters less than his shock.
- No waiting for full workup: resuscitation runs alongside surgery. Stem trigger
Prepare
How do you prepare him?
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- Two IV or IO lines; fluid in 10–20 mL/kg aliquots, reassessed each time. Stem trigger
- Blood crossmatched; glucose, gas, calcium and potassium checked. Disease
- Nasogastric tube aspirated before induction. Airway
- Arterial line as soon as feasible; warming from the start. Disease
- Adrenaline and calcium drawn up before induction. Crisis
Plan
How do you anaesthetise him?
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- Rapid sequence induction: ketamine, reduced from the usual 1–2 mg/kg and titrated, holds his pressure. Airway
- Rocuronium 1–1.2 mg/kg for intubation.
- Atropine 0.02 mg/kg ready, as hypoxia or laryngoscopy can slow him.
- Opioid-based maintenance; volatiles are poorly tolerated while he's shocked. Disease
- Ventilated to PICU afterwards. After surgery
Crisis
After detorsion, BP falls to 45/20, pH 7.05, lactate 9. What do you do?
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- Reperfusion of his gut: acid and potassium wash back into his circulation. (Crisis)
- Tell the surgeon; gas, potassium, calcium and glucose now.
- Further fluid 10–20 mL/kg; blood if he's bleeding.
- Still hypotensive after fluid: adrenaline or noradrenaline infusion.
- Bicarbonate 1 mEq/kg IV, given slowly, only with good ventilation.
Crisis
Minutes later, T waves peak, then a broad-complex rhythm; K 7.8 mmol/L; pulse weak. What do you do?
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- Hyperkalaemia with a failing circulation: PALS team ready, compressions if pulse lost. (Crisis)
- Calcium chloride 10%, 20 mg/kg IV, slowly.
- Insulin 0.1 units/kg IV with 10% glucose 5 mL/kg.
- Bicarbonate 1 mEq/kg IV, ventilating well.
- Pulseless: CPR; if VF, shock 2 J/kg first; adrenaline 0.01 mg/kg after the second shock; asystole or PEA: immediately.
- Surgeon resects the dead bowel to remove the source.
Fatal mistakes
- Delaying theatre for full workup.
- Induction without emptying his stomach.
- Untreated hyperkalaemia at reperfusion.
Checked against: Miller 10e · Barash 9e · AHA and AAP guidelines: pediatric advanced life support (2025) · AHA guidelines: special circumstances of resuscitation (2025)
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