UBP 2.6 (Long Form): Pulmonary - Cystic Fibrosis

Question 1

Intra-operative Management:

What monitors would you place for this case?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 1

In addition to the ASA standard monitors, I would place a 5-lead EKG to monitor for ischemia and signs of right-sided heart failure in this patient with long standing hypoxia.

Assuming there were no signs of pulmonary hypertension or right heart failure, I would not initially require invasive monitoring, since this case presents a fairly low risk for hemodynamic instability.

However, I would ensure adequate preoperative fluid replacement and be ready to employ invasive monitoring, if necessary.

Question 2

Intra-operative Management:

The patient refuses neuraxial anesthesia. How would you induce general anesthesia in this patient?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 2

While a rapid sequence induction would reduce the risk of aspiration in this patient with nausea and vomiting, and a potentially full stomach (emergent surgery and appendicitis), it would not reliably achieve the depth of anesthesia required to prevent bronchospasm and the stimulation of mucous secretions.

Therefore, I would:

1. optimize her pulmonary condition as much as time allowed (bronchodilators, chest physiotherapy, intravascular volume replacement, humidified nebulizers, etc.),
2. provide aspiration prophylaxis,
3. ensure adequate volume replacement,
4. place the appropriate monitors,
5. preoxygenate with 100% oxygen,
6. place the patient in slight reverse trendelenburg (to improve respiratory mechanics, facilitate rapid securing of the airway, and reduce the risk of passive regurgitation),
7. apply cricoid pressure, and
8. perform a slow controlled induction, with the goals of avoiding bronchospasm, hypoxia, hypercarbia, hemodynamic instability, and aspiration.

Question 3

Intra-operative Management:

The surgeon places a Varies needle, and begins insufflation of the abdomen. Suddenly, the patient becomes hypotensive with a blood pressure of 64/42 mmHg and heart rate of 58. What do you think might be the cause?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 3

Well-answered in UBP Online Mock Exam 13:27.

The timing of her hypotension and bradycardia suggests that – insufflation of the pneumoperitoneum resulted in a vasovagal response, possibly exacerbated by the decrease in cardiac preload that may occur with increased abdominal pressure in the setting of inadequate intravascular volume.

However, I would also consider other potential causes, such as –

• the cardio-depressant effects of anesthesia,
• cardiac arrhythmia,
• cor pulmonale,
• CO2 embolism (may occur with the direct insufflation of large amounts of CO2 into a blood vessel during pneumoperitoneum creation),
• tension pneumothorax (increased risk for spontaneous pneumothorax with cystic fibrosis; establishment of the pneumoperitoneum may result in capnothorax),
• sepsis (appendicitis), and
• anaphylaxis.

Question 4

Intra-operative Management:

The surgeon places a Varies needle, and begins insufflation of the abdomen. Suddenly, the patient becomes hypotensive with a blood pressure of 64/42 mmHg and heart rate of 58. What would you do?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 4

I would ask the surgeon to discontinue insufflation, hand ventilate with 100% oxygen, auscultate the chest, ensure adequate ventilation, check the EKG and pulse oximetry, start a fluid bolus, and administer vasopressors and/or inotropes as necessary.

If her condition persisted and I was unable to identify the cause, I would – check her electrolytes, obtain arterial blood gases, and consider invasive monitoring, transesophageal echocardiography, and/or a bedside ultrasound (the latter would be helpful in identifying or ruling out tension pneumothorax).

I would avoid the use of atropine, if possible, since it may lead to thickened respiratory secretions, further complicating this patient’s pulmonary status (while the use of atropine is controversial, there is no evidence of increased pulmonary complications associated with its administration).

Question 5

Intra-operative Management:

The patient stabilizes and the surgery continues. Over the next 10 minutes she becomes mildly hypoxic with a SpO2 of 89% and increased airway pressures.

What is your differential diagnosis?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 5

Considering the recent establishment of a pneumoperitoneum and, given this patient’s underlying cystic fibrosis, history of respiratory failure, and full stomach, I would be concerned that her hypoxia and increased airway pressures were due to:

1. partial obstruction of the endotracheal tube (may occur secondary to the thickened secretions associated with cystic fibrosis);
2. right mainstem intubation (cephalad displacement of the diaphragm and carina with inflation of the pneumoperitoneum can result in right mainstem intubation);
3. bronchiectasis (associated with cystic fibrosis);
4. bronchospasm (increased risk in patients with cystic fibrosis);
5. pulmonary edema (i.e. pulmonary hypertension, pulmonary infection, and/or heart failure);
6. pneumothorax secondary to alveolar rupture (increased risk due to bullae formation associated with cystic fibrosis, and the hyperventilation that is often necessary during laparoscopic surgery to maintain normal PaCO2);
7. aspiration (i.e. full stomach, pain, abdominal process, emergency surgery);
8. capnothorax (pneumoperitoneum formation may lead to movement of CO2 into the thorax through natural or iatrogenic communications between the peritoneal cavity and the pleural and pericardial sacs); and
9. atelectasis.

Question 6

Intra-operative Management:

The patient stabilizes and the surgery continues. Over the next 10 minutes she becomes mildly hypoxic with a SpO2 of 89% and increased airway pressures.

What would you do?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 6

I would immediately:

1. hand ventilate with 100% oxygen;
2. auscultate the chest;
3. examine the oropharynx for gastric material;
4. verify proper endotracheal tube placement;
5. check her blood pressure, EKG, and pulse oximeter;
6. suction the endotracheal tube;
7. ask the surgeon to observe the hemidiaphragm for abnormal motion (occurs with tension pneumothorax); and
8. check the PetCO2 (increases with capnothorax; decreases with tension pneumothorax and CO2 embolism, due to decreased cardiac output; and is usually unchanged with right mainstem intubation).
9. Depending on my findings and her response to these interventions, I would also consider – deepening my anesthetic (i.e. bronchospasm, increased mucous secretions due to sympathetic stimulation),
10. obtaining arterial blood gases,
11. ordering a chest radiograph,
12. releasing the pneumoperitoneum (i.e. CO2 embolism or capnothorax),
13. placing invasive monitors (i.e. arterial line, central line, pulmonary artery catheter, TEE);
14. administering bronchodilators, inotropes, and/or vasopressors; and,
15. in the case of significant pneumothorax, having the surgeon place a chest tube.

Question 7

Intra-operative Management:

Auscultation of the chest reveals diminished breath sounds over the left lung fields. The SpO2 is now 82%.

What would you do?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 7

Recognizing that hypoxia associated with diminished breath sounds on the left is consistent with a right mainstem intubation, capnothorax, or pneumothorax secondary to alveolar rupture, I would begin by checking the patient’s PetCO2.

If her PetCO2 was unchanged, suggesting endobronchial intubation, I would slowly withdraw the endotracheal tube while listening for the return of breath sounds over the left lung fields; being careful to avoid unintentional extubation.

If her PetCO2 was elevated, suggesting capnothorax, I would ask the surgeon to release the pneumoperitoneum, hyperventilate the patient, and, following the resolution of her hypercapnia, have the surgeon recreate the pneumoperitoneum using a lower insufflation pressure.

If, however, she exhibited a reduced PetCO2, which is consistent with a pneumothorax secondary to alveolar rupture, I would order a chest X-ray or bedside ultrasound, look for signs and symptoms consistent with pneumothorax (i.e. decreased cardiac output, increased PaCo2, hypotension, hypoxia, hyper-resonance to percussion over the left thorax, contralateral tracheal shift, distended neck veins, and abnormal motion of one hemidiaphragm as observed by the surgeon), and continue to carefully monitor her cardiopulmonary status.

If she began to exhibit signs of tension pneumothorax, such as worsening hypoxia in association with hypotension, I would perform needle thoracostomy by placing a 14 gauge needle in the second intercostal space at the midclavicular line, or ask the surgeon to place chest tube in the fourth or fifth intercostal space just anterior to the midaxillary line.

Question 8

Post-operative Management:

The surgeon is unable to complete the operation laparoscopically, and converts to an open procedure.

Would you place an epidural for postoperative pain management?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 8

Assuming adequate consent and normal coagulation, I would like to utilize a thoracic epidural for postoperative pain control, recognizing that this method of pain control results in improved pain scores, greater mobility, and decreased postoperative pulmonary complications in patient who have undergone abdominal surgery.

Moreover, a thoracic epidural would potentially benefit this patient with cystic fibrosis by:

1. reducing opioid requirements (thereby reducing the risk of opioid-induced respiratory depression) and
2. decreasing pulmonary splinting (pain-induced pulmonary splinting can lead to atelectasis, shunting, decreased clearance of pulmonary secretions, and pneumonia).

Therefore, if I were able to obtain adequate consent (the patient refused regional anesthesia, preoperatively) and rule out significant coagulopathy (Cystic fibrosis can lead to hepatic dysfunction and malabsorption of vitamin K, with subsequently reduced levels of clotting factors II, VII, IX, and X, placing this patient at increased risk of epidural hematoma formation),

I would use a dilute solution of local anesthetic to initiate a thoracic epidural.

My goal would be to provide adequate sensory analgesia while minimizing motor blockade, recognizing that high thoracic motor blockade could impair the patient’s ability to cough and clear secretions.

Question 9

Post-operative Management:

On emergence the child becomes delirious, starts thrashing around, and pulling at the endotracheal tube and IV.

What would you do?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 9

Since these symptoms are consistent with emergence delirium, I would:

1. call for help;
2. secure the child’s arms to keep her from pulling her endotracheal tube or IV line;
3. attempt to reassure her;
4. provide a quiet, stress-free environment; and
5. consider administering a sedating dose of fentanyl, ketamine, midazolam (effectiveness has been questioned), propofol, or dexmedetomidine, all of which have been used to decreased the duration and intensity of this condition.
6. However, recognizing that there are other potential causes of her agitation, such as –
   
   • pain (often confused with emergence delirium), hypoxia, severe hypercarbia, hypotension, hypoglycemia, and bladder distension, I would: – ensure adequate oxygenation, ventilation, and pain control;
7. correct any hypotension and/or hypoglycemia; and
8. rule out bladder distension (i.e. palpation, ultrasound, Foley catheter insertion).

Clinical Note:

• Emergence delirium is a dissociated state of consciousness in which children are inconsolable, irritable, uncompromising, and/or uncooperative, typically 1-5 years old child, thrashing, crying/screaming, disoriented, inconsolable, talking irrationally, and unable to recognize parents or surroundings.
• The delirium usually resolves spontaneously after 5-20 minutes.
• —–*
• MOCK Exam 22:46 – per Dr. George, it’s ok to set the stage with what you think is going on, but go into answering what you would do.*

Question 10

Post-operative Management:

Can emergence delirium be prevented?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 10

Emergence delirium is NOT well understood and cannot be reliably prevented.

However, some of the measures that have been suggested in prevention include:

1. reducing preoperative anxiety;
2. ensuring adequate post-operative pain control;
3. recovering the patient in a stress-free environment; and
4. administering preoperative midazolam (the evidence is conflicting as to the efficacy of midazolam, since some sources cite the administration of midazolam as a risk factor for emergence delirium), clonidine, fentanyl, physostigmine, ketorolac, and dexmedetomidine.

Question 11

Post-operative Management:

What are the risk factors for emergence delirium?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 11

The unclear etiology of emergence delirium and the difficulty in distinguishing it from post-operative pain, make reliably identifying risk factors challenging.

However, it appears to be associated with:

1. preoperative anxiety,
2. young age (highest incidence between 1-5 years),
3. post-operative pain,
4. the use of less-soluble volatile agents (i.e. sevoflurane and desflurane),
5. the patient’s underlying temperament,
6. the type of surgery (i.e. abdominal surgery and breast surgery), and
7. prolonged surgical duration.

Question 12

Post-operative Management:

Twenty minutes after receiving Metoclopramide for PONV in the PACU, the nurse calls you and says the patient is shaking violently.

Would you order Demerol for postoperative rigors?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 12

If I believed her shaking represented shivering, a relatively common side effect of general anesthesia, I would ensure normothermia and consider administering meperidine.

However, with the recent administration of metoclopramide, I would consider the possibility that her shaking may represent an adverse reaction to this drug, resulting in extra pyramidal symptoms (EPS).

• Clinical Note:*
• Types of EPS:*

1. Dyskinesias – movement disorders that result in repetitive, involuntary, and purposeless body or facial movements (i.e. tongue thrusts, lip smacking, eye blinking, etc.),
2. Akathisia – extreme internal or external restlessness, leading to an inability to sit, a strong urge toward constant movement, and feelings of jitteriness or shakiness.
3. Dystonia – a muscle tension disorder involving very strong muscle contractions (especially the neck), often resulting in twisting of the body and pain.

Question 13

Post-operative Management:

You go and examine the patient and find she is obtunded with extrapyramidal jerking movements in her head and neck.

What do you think is going on?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 13

The extrapyramidal jerking movements in her head and neck are consistent with acute dystonia.

Extra pyramidal symptoms (EPS) are a known side effect of antiemetics such as – metoclopramide, and less frequently, ondansetron.

Neuroleptic-induced EPS are thought to result from blockade of nigrostriatal dopamine tracts, leading to a relative increase in cholinergic activity.

Tardive (“delayed” or “late appearing”) dyskinesia, on the other hand, is less well understood, but is thought to be a super sensitivity response to chronic dopamine blockade.

The risk of extrapyramidal effects is increased in people under 20 years of age, and with high-dose or prolonged therapy.

Question 14

Post-operative Management:

You go and examine the patient and find she is obtunded with extrapyramidal jerking movements in her head and neck.

How would you treat this patient?

• (A 14-year-old girl with a history of cystic fibrosis presents for urgent appendectomy. She reports a history of progressive abdominal pain associated with nausea and vomiting over the last 18 hours.*
• PMHx: Cystic Fibrosis with respiratory failure 6 months ago; Nasal polyps*
• Meds: Ciprofloxacin, Pancrelipase, Prednisone, Albuterol, Guaifenesin, and Beclomethasone MDI*
• Allergies: NKDA*
• PE: Vital Signs: HR = 110; BP = 98/38 mmHg; RR = 24; T = 39 ºC*
• Abdomen: Abdominal Guarding and rebound tenderness*
• Pulmonary: Diffuse expiratory wheezing and decreased breath sounds in bilateral lung bases.*
• Labs: WBC = 18; Hgb = 18 mg/dL; ESR = 47; C-Reactive Protein = 4.76 ng/dL*
• CXR: Hyperinflated lung fields; cystic bronchiectasis; hilar adenopathy)*

Answer 14

Assuming this patient were experiencing an acute dystonic reaction (a type of EPS) as an adverse effect of metoclopramide, I would:

1. provide supplemental oxygen,
2. assess her respiration and oxygenation,
3. treat with diphenhydramine or benztropine,
4. discontinue any antiemetic medication, and
5. help the family to understand the adverse drug event.