UBP 6.2 (Long Form): Trauma – Pediatric Patient Flashcards
Secondary Subject -- Pseudotumor Cerebri / Ventriculoperitoneal Shunt / Head Injury / Intracranial Hypertension / FAST exam (Focused Assessment with Sonography for Trauma) / Abdominal Compartment Syndrome / Transfusion Medicine – ABO compatibility and Rh(D) status / Hypocalcemia - Citrate Toxicity / Propofol Infusion Syndrome (PRIS) / Child Abuse / Slit Ventricle Syndrome
Intra-Operative Management:
What monitoring will you require?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg**)*
Given this patient’s recent head trauma and potential for major blood loss and hemodynamic instability, I would employ the following monitors in addition to routine monitoring:
- an esophageal temperature probe,
- to avoid hypothermia (pediatric patient, potential for significant blood and fluid administration);
- an arterial line,
- to facilitate –
- the maintenance of adequate cerebral perfusion (recent head trauma and elevated ICP) and
- allow frequent blood gas analysis ;
- to facilitate –
- a central venous pressure catheter,
- recognizing that CVP measurement may be falsely elevated in the presence of abdominal compartment syndrome
- (central venous pressure, pulmonary artery pressure, and pulmonary artery occlusion pressure may all be normal or elevated, despite intravascular depletion, due to the transmission of intra-abdominal pressures into the thoracic cavity);
- recognizing that CVP measurement may be falsely elevated in the presence of abdominal compartment syndrome
- a Foley catheter,
- to monitor urine output in this patient at risk for impaired renal function secondary to hypovolemia and/or increased abdominal pressures; and
- a peripheral nerve stimulator
- to help ensure adequate muscle relaxation (abdominal muscle tone may contribute to increased abdominal compartment pressures).
I would also ensure the presence of –
- large bore intravenous access and a rapid transfusion device, and
- consider utilizing transesophageal echocardiography to monitor cardiac function and aid in fluid management.
Intra-Operative Management:
Would you empty the stomach with a nasogastric tube prior to induction?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
Given the increased abdominal pressures and risk of aspiration (abdominal compartment syndrome, altered mental status, and recent trauma),
it may be desirable to decompress and empty the stomach prior to induction.
However, I would delay the insertion of a nasogastric tube until after induction and intubation if I believed that it would result in a sympathetic response that could lead to a significant increase in intracranial pressure, which may not be well tolerated given his recent head injury, pseudotumor cerebri, and low Glasgow Coma Scale score.
Moreover, if I was concerned about a possible basilar skull fracture (i.e. periorbital ecchymosis and hemotympanum),
I would – utilize an orogastric tube, rather than a nasogastric tube, as this would risk advancing the nasogastric tube into the brain.
Intra-Operative Management:
How would you induce and intubate this child for transport to the operating room for surgery?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
I would:
- ensure the availability of difficult airway equipment
- (C-collar, facial trauma, risk of aspiration);
- pre-oxygenate the patient
- (hypoxia and hypercarbia are not well tolerated in the setting of increased intracranial pressure);
- ensure the availability of additional blood products, vasopressors, and inotropes
- (hypovolemia in combination with abdominal compartment syndrome increases his risk for hemodynamic instability);
- place an arterial line, if I believed I could do so without eliciting a sympathetic response;
- ensure manual in-line stabilization
- (higher risk of cervical spine injury due to the inertial forces associated with a fall);
- avoid the application of cricoid pressure (Judgement call) due to the high risk of cervical spine injury
- (this decision involves weighing the risk of aspiration against the risk of iatrogenic injury to the cervical spine);
- induce the patient using etomidate
- (in attempt to maintain hemodynamic stability);
- administer rocuronium for muscle relaxation to
- reduce abdominal muscle tone
- (may contribute to increased abdominal compartment pressures) and
- prevent patient movement during laryngoscopy
- (could contribute to cervical spine injury);
- reduce abdominal muscle tone
- ensure an adequate plane of anesthesia to prevent a sympathetic response
- (not well tolerated in the setting of increased intracranial pressure); and
- perform laryngscopy for attempt to avoid aspiration, hemodynamic instability, increased intracranial pressure, hypoxia, and harmful distraction of the cervical spine.
Intra-Operative Management:
Are you concerned about hemodynamic instability during induction?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
Recognizing that central venous pressures are often fictitiously elevated in the presence of abdominal compartment syndrome,
I would judge that this patient is most likely functionally hypovolemic, despite elevated central venous pressures.
Considering this functional hypovolemia,
the decreased cardiac output associated with abdominal compartment syndrome (increased systemic vascular resistance, decreased preload, and ventricular compression), and
the risk that laparotomy will result in additional hemodynamic instability following the loss of tamponade within the abdominal compartment,
I would be very concerned about hemodynamic instability during induction.
Therefore, I would:
- ensure the availability of additional blood products, vasopressors, and inotropes,
- induce the patient using etomidate (for hemodynamic stability), and
- maintain adequate muscle relaxation.
My goal would be – to avoid hypotension, while at the same time, achieving an adequate depth of anesthesia to prevent a potentially harmful sympathetic response (i.e. elevated ICP).
Intra-Operative Management:
The surgeon makes incision and the patient’s blood pressure drops to 63/38 mmHg.
What do you think is going on?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
Given the timing of this event, his hypotension is most likely secondary to the release of cardiodepressant factors with the reperfusion of ischemic tissue.
Other potential causes or contributing factors would include –
- the loss of intravascular volume with the release of abdominal tamponade (i.e. blood and/or fluid),
- inadequate preoperative fluid replacement, and
- excessive anesthetic (induction and/or maintenance).
I would also consider other possible causes such as –
- tension pneumothorax (central line placement, trauma),
- critically increased ICP with subsequent autonomic instability,
- cardiac tamponade (trauma),
- anaphylaxis, and
- arrhythmia.
Intra-Operative Management:
You decide that transfusion is required.
For the sake of discussion, assume that the patient’s blood type is not yet known. The blood bank wishes to switch to Rh(D) positive pRBC’s to preserve inventory of Rh(D) negative pRBC’s.
Are you ok with this?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
Recognizing that this is a male patient and that it is sometimes necessary to preserve a limited supply of Rh(D) negative PRBCs (for Rh(D)-negative female patients and females whose blood type is unknown),
I would probably agree to the switch.
However, I would first want to ask about any history of previous exposure to Rh(D) positive PRBCs recognizing that a previous exposure could lead to a hemolytic reaction (delayed transfusion reaction).
If it was later determined that the patient was Rh(D) negative, I would also consider providing him with Rhogam within 72 hours, and let the mother know that, if possible, he should be checked for anti-D antibodies prior to allowing a subsequent Rh-positive transfusion.
Intra-Operative Management:
Do platelets have to be ABO compatible?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
The platelets in apheresis packs should be ABO compatible since they are suspended in plasma containing anti-A and anti-B isoagglutinins, placing any recipient of a non-ABO compatible transfusion at risk for hemolysis (especially in the case of a donor with high titer isoagglutinins).
The administration of non-ABO compatible whole blood-derived platelets, on the other hand, does not result in clinically significant hemolysis in adults, due to the limited amount of plasma involved
(small children should receive ABO compatible platelets regardless of whether they are whole blood-derived or collected via apheresis).
Rh(D) antigen matching is desirable when red blood cells are present (red blood cells may express Rh antigens), placing the patient at risk for Rh(D) alloimmunization (mostly a problem for Rh(D) negative females with child-bearing potential).
Therefore, matching for Rh(D) antigen is unnecessary for apheresis platelets, which contain almost no red blood cells.
However, Rh(D) matching is preferable when utilizing whole blood-derived platelets, which may contain enough red blood cells to provoke Rh alloimmunization.
Rh immune globulin (Rhogam) may be administered within 72 hours when unmatched, whole blood-derived, platelets are administered to a female patient with child-bearing potential.
- Clinical Note:*
- The administration of Rh immune globulin (Rhogam) may be considered when unmatched, whole blood-derived, platelets are administered to a male patient, but the consequences of Rh alloimmunization in a male (delayed transfusion reaction) are less significant than that of a child-bearing female (hemolytic disease of the newborn, hydrops fetalis, or stillbirth).
Intra-Operative Management:
If you were to administer fresh frozen plasma, what should be the donor typing?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
Since fresh frozen plasma (FFP) may contain anti-A and anti-B isoagglutinins, it should be ABO compatible with the recipient’s red blood cells to prevent hemolysis.
If the recipient’s blood type is unknown, it is safe to transfuse with FFP from a donor with AB blood type, since the plasma of this donor would not contain anti-A or anti-B isoagglutinins.
Furthermore, since FFP does not contain any red blood cells, Rh(D) matching is not necessary to prevent Rh alloimmunization.
Rh typing matters with cells (RBC).
ABO typing matters with FFP (plasma).
Intra-Operative Management:
You are transfusing PRBCs and FFP when you notice a prolonged QT interval.
What (do you think is going on) and what would you do?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
Assuming this prolonged QT interval was not present prior to the transfusion of citrate-containing blood products (especially FFP, which contains significantly more plasma), the most likely cause is citrate-induced hypocalcemia.
Therefore, I would look for other signs of hypocalcemia, such as –
- hypotension and
- myocardial depression (other signs and symptoms, such as –
- paresthesias,
- lethargy,
- seizures,
- irritability,
- laryngospasm,
- Trousseau’s sign, and
- Chvostek’s sign would not be apparent in an intubated and anesthetized patient receiving muscle relaxants)
and initiate treatment.
The rapid transfusion of FFP can overwhelm the liver’s capacity to metabolize citrate, especially when administered through a central line (reduced time for dilution of the FFP prior to entering the heart and coronary vessels – may be better to administer FFP through a peripheral line) in the setting of hypotension (which may result in decreased hepatic perfusion) and impaired liver function (possibly resulting from his abdominal compartment syndrome).
Clinical Notes:
- Trousseau Sign = Eliciting carpal spasm by inflating a blood pressure cuff on the upper arm to a pressure greater than systolic pressure for about 3 minutes. This sign is more sensitive than Chvostek’s sign for hypocalcemia.
- Chvostek’s Sign = Eliciting facial spasm by tapping the facial nerve at the angle of the jaw (i.e. masseter muscle).
- —*
- UBP Notes – Citrate toxicity is more likely in this case because of –*
- FFP use
- Abdominal compartment syndrome → affecting liver
Intra-Operative Management:
Assuming this were citrate-induced hypocalcemia, how would you treat him?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
In treating his hypocalcemia, I would:
- Discontinue the administration of FFP;
- continue to monitor his ECG for persistent and additional signs of cardiotoxicity
- (i.e. heart block and/or ventricular fibrillation);
- correct any
- hypomagnesemia
- (rapid blood transfusion may cause hypomagnesemia, and the treatment of hypocalcemia is ineffective in the setting of hypomagnesemia) or
- hyperkalemia
- (potentiates hypocalcemia-induced cardiac and neuromuscular irritability), and/or
- metabolic or respiratory alkalosis;
- hypomagnesemia
- administer 10-20 mg/kg of –
- calcium chloride
- (1 mL of 10% solution = 100 mg calcium chloride = 27 mg elemental calcium) or
- calcium gluconate
- (1 mL of 10% solution = 100 mg calcium gluconate = 9 mg elemental calcium)
- through a large peripheral or central vein
- (both drugs can cause significant local vasoconstriction with subsequent tissue necrosis); and
- calcium chloride
- correct any hypokalemia and/or acidosis after normalizing his calcium levels.
Clinical Notes:
- The correction of hypokalemia prior to the normalization of calcium levels should be avoided, since hypokalemia has a protective effect against hypocalcemic tetany.
- Correcting metabolic and/or respiratory acidosis should be delayed until calcium replacement has been initiated, since hyperventilation and/or bicarbonate administration can exacerbate the symptoms of hypocalcemia (may result in increased binding of calcium by albumin, resulting in further reductions of ionized calcium).
Intra-Operative Management:
Operative control of the bleeding is achieved, the abdomen is packed and covered, and the patient is transferred back to the ICU still intubated.
Would you start a propofol infusion for sedation?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
I would NOT use an intravenous infusion of propofol to maintain continuous sedation for this pediatric patient.
My concern is that there is increasing evidence that the continuous infusion of high dose propofol (4-5 mg/kg/hr – approx. = to 66-83 mcg/kg/min) for long periods of time (usually cited as 24-48 hours); some case reports suggest developing propofol infusion syndrome after only 5-6 hours) may lead to a syndrome associated with lethal metabolic acidosis, called propofol infusion syndrome (PRIS).
Intra-Operative Management:
What is propofol infusion syndrome (PRIS)?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
Propofol infusion syndrome primarily occurs in children and critically ill adult patients following the continuous infusion of high dose propofol over a prolonged period of time.
PRIS often presents with the acute onset of –
refractory bradycardia in association with metabolic acidosis, rhabdomyolysis, lipemia, hyperkalemia, hepatomegaly, fatty liver, renal failure, and cardiomyopathy.
The end result is cardiovascular collapse that is refractory to resuscitative efforts.
In addition to the prolonged infusion of high-dose propofol, the risk factors for develping this syndrome include:
- a defect in lipid metabolism (including some forms of mitochondrial disease);
- serious neurologic injury;
- sepsis;
- concomitant infusion of catecholamines and/or inotropes; and
- the administration of high-dose corticosteroids.
Treatment is primarily supportive, following the discontinuation of propofol infusion;
the mortality rate is around 80%
(there is some evidence that hemodialysis may improve survival).
Post-Operative Management:
Later, while checking on the child in the ICU, you note several small circular scars on his right hand and on the inside of his right forearm.
You are concerned that these represent burns from a cigarette.
What would you do?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
If I suspected that his scars were the result of child abuse, I would look for other findings consistent with child abuse, such as:
- bruises or burns in the shape of objects;
- soft tissue or genital bruises;
- unexplained mouth and/or dental injuries;
- signs of neglect (e.g. poor hygieneor height and weight less than the 5th percentile);
- multiple fractures of various ages (order a skeletal survey of the skull, ribs, and all long bones);
- retinal hemorrhages on fundoscopic exam;
- the character and extent of injury not well explained by the offered history; and
- a delay in seeking medical care.
Moreover, I would keep in mind that physically and mentally handicapped children are more likely to be abused, and consider the possibility that this child’s injuries may have occurred secondary to abuse rather than the reported fall (abdominal and head injuries are common findings).
Finally, I would write a detailed note in the chart reflective of my findings and report my concerns to the appropriate authorities.
Post-Operative Management:
His mother, who is present, says the burns were inflicted by an ex-boyfriend who is no longer around.
She is afraid that, if you say something, they will take the child away from her because she didn’t report the problem when it was happening.
She assures you that she loves her child and will never let anyone hurt him again.
What will you do?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
I would explain to her that I understand her concerns and that I am not questioning her love for her child, but that I am ethically and legally obligated to report suspected or known child abuse.
Post-Operative Management:
Several months later, the same child is scheduled for surgery for insertion of a new ventriculoperitoneal shunt.
He has an external ventricular drain, which was placed after his previous shunt became infected and had to be removed.
During transport to the OR, the ventricular drainage bag falls from the bed to the floor.
Does this concern you?
- (A 7-year-old male presents to the trauma suite after falling from a height of eight feet when playing on a jungle gym. He has been diagnosed with acute abdominal compartment syndrome secondary to abdominal bleeding, and the surgeon wants to proceed to the operating room for laparotomy. He currently has a cervical collar in place and appears to have suffered some facial trauma secondary to his fall. You are further informed that a ventriculoperitoneal shunt was placed several years ago to treat pseudotumor cerebri.*
- PMHx: Pseudotumor Cerebri*
- Anesth Hx: No complications*
- Meds: Acetazolamide*
- Allergies: NKDA*
- PE: Vital Signs: P = 128, BP = 96/54 mmHg, O2 sat = 97%, T = 35.6 °C*
- General: The patient is somnolent and has a cervical collar and a central line in place*
- Airway: Appears normal despite facial trauma, not yet intubated*
- Lungs: clear to auscultation*
- Cardiovascular: regular rhythm; tachycardia*
- Labs: Pending*
- CT scan: Pending*
- Central Venous Pressure: 15 mmHg)*
I would be very concerned, because significantly changing the height of an open drainage bag in relation to the child’s head places him at risk for sudden and dangerous changes in intracranial pressure.
In this case, the rapid loss of intracranial CSF as it drains into the suddenly lowered drainage bag places the child at risk for ventricular collapse and ruptured cortical veins.
For this reason, the anesthesiologist should consider clamping the ventriculostomy tubing during the transport of patients with external ventricular drains.
