Case: pediatric airway foreign body

[Wolverines83]

I never said we checked bp or spo2 on any other limb, I just told you where the monitors are located. All limbs were dusky including the limbs with monitors on them.

Well ok. Some honest feedback: try giving more complete information next time. These details matter.

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[GassYous]

Well ok. Some honest feedback: try giving more complete information next time. These details matter.

OP writes a novel for the first post and you're complaining? Why don't you try posting some cases?

 

[WholeLottaGame7]

LOL ok we're getting into the weeds, thanks for humoring me :-D

So the timing of the sudden cardiovascular collapse was very much timed with the administration of roc, therefore anaphylaxis was the highest at the top of the differential. Having just administered racemic epi for the surgery and decadron an hour ago, I was thinking we were masking lung manifestations.

Other things I considered:
- Pneumothorax - airway pressures fine, normal lung sounds
- Iatrogenic - ?pressor in the tubing that got bolused or drug swap? Checked meds, nothing suspicious
- Air embolism from air in IV tubing? Fluid bag and line were full, meds all delivered on the closest port
- Down in the weeds: ?Paraneoplastic syndrome from tumor release of bad humors? We did residency at a place with a carcinoid specialist surgeon... VERY unlikely

Due to the high suspicion of anaphylaxis, I considered epi but was nervous to give it since HR was already sky high, extremities were dusky, and the pulmonary situation was essentially stable. I thought the best thing to do would be a fluid bolus, so we pushed 20 mL/kg LR.

While that was happening I attempted an A line. Flashed 3 times but couldn't thread a wire each time. We are at that point hunting just for a phlebotomy, primarily to get a tryptase level. The kid was impossible to get access but eventually flashed a saphenous and dripped in a cc of blood into a test tube without threading the catheter.

For those that don't know, tryptase must be collected within 45 mins and immediately put on ice. It gets sent to Mayo (at least if you are in the Pacific Northwest) and results a few days after collection. A normal tryptase does not rule of anaphylaxis.

The fluid bolus worked. Within 30 mins NIBP came back, HR came down as fluid rolled in.

Sent the kid to the scanner: "mass" was consistent with inflammatory tissue. The scary thing to me was: the inflamed obstructing mass was extending around encasing the right PA. If the surgeon took maybe 2 more bites it would have been into the PA.

Culture +moraxella and antibiotic switched to cefdinir. Bronchoscopy performed 2 days later and airway much more patent than before, kid was discharged on antibiotics and rocuronium added to allergy list.

I've heard rocuronium anaphylaxis can manifest as just cardiovascular collapse without pulmonary signs. Wished I thought of giving sugammadex at the time but, you know, heat of the moment...

After more thinking, I was considering musculature relaxation with roc could have collapsed the right PA, causing decreased venous return and thus carcinogenic shock, but wouldn't have been able to predict that in the moment.

I'm pretty convinced it was rocuronium anaphylaxis!

I mean...I guess? Anaphylaxis with no cutaneous or pulmonary symptoms, only cardiovascular collapse? Not saying it can't happen obviously, and other posters have apparently seen it. But you're also saying the BP was so low that you couldn't get a reading, while at the same time the EtCO2 was reading 50 and there was pulsatility in the pulse ox waveform? Also unusual.

I wasn't there, so don't know the exact sequence or how things played out, but I'm not 100% convinced this was anaphylaxis. Maybe a little acute SIRS/sepsis-y period from poking around an inflammatory mass? Anyway, keep us updated when the tryptase gets back.

I think if the lessons people take from this thread are "always have anaphylaxis on the differential," and "don't take away spontaneous ventilation if you don't have to," this will have been a successful thread.

Side note: I haven't used a wire on a baby a-line in a couple years, probably. Success rate is so much higher just threading the catheter straight off into the vessel under ultrasound guidance. I suspect most of the failures are either the angiocath is not all the way in the lumen, or the wire itself induces some vasospasm.

 

[Wolverines83]

OP writes a novel for the first post and you're complaining? Why don't you try posting some cases?

Easy there. Was pointing out that the details of where we're seeing pulsatility, cyanosis, whatever is important when talking about a child. Wasn't talking about a global lack of details.

Sheesh.

I agree with wholelottagame, don't take away spontaneous ventilation if you don't have to and anaphylaxis always on the diff.

Sidenote: OP you mentioned that you wished you thought about giving suggamadex as a treatment for anaphylaxis. Just looked that up. Super interesting. Never thought of it.

 

[ethilo]

I agree with what is said. I'm fairly convinced it was anaphylaxis because it was so clearly a direct cause and effect: patient stable, push roc, cardiovascular collapse. But yeah without the other stuff (angioedema, rash, pull stuff) it leaves me wondering.

Tryptase was normal. Would have been nice if it was glaringly positive.

Probably could have sent the kid to the scanner with the OPA, facemask, and sedation, but all of that stuff happened after dropping off first in PICU. PICU team requested I intubate so they could send to scanner.

 

[daneeka]

Nice case. Sounds scary AF.

CVS collapse as the presenting (and only) feature of anaphylaxis has definitely been described. Was specifically highlighted in the NAP6 report: https://www.nationalauditprojects.org.uk/downloads/NAP6 Chapter 10 - Clinical features.pdf

The rash might only manifest once you've got enough blood pressure to perfuse the skin.

Re: tryptase - there's no rush to get it within 45 minutes. You want the first sample at the peak (around 1 - 2 hours after exposure - take it too early and it won't have peaked), then another sample at 4 hours and preferably a normal baseline at 24 hours after the exposure.

 

[Wolverines83]

I agree with what is said. I'm fairly convinced it was anaphylaxis because it was so clearly a direct cause and effect: patient stable, push roc, cardiovascular collapse. But yeah without the other stuff (angioedema, rash, pull stuff) it leaves me wondering.

Tryptase was normal. Would have been nice if it was glaringly positive.

Probably could have sent the kid to the scanner with the OPA, facemask, and sedation, but all of that stuff happened after dropping off first in PICU. PICU team requested I intubate so they could send to scanner.

So this is another interesting part of this case. Am I interpreting this correctly that the kid was intubated at the request of the PICU? I think I'm fuzzy on the timeline. Regardless, it's always worth a discussion with the PICU (or surgeon, ICU, whatever) about why they want a tube and to give them your concerns. I'm not monday-morning-quarterbacking your decision because I obviously wasn't there but if in your professional opinion the kid doesn't need the tube...don't tube him. Scanner isn't an indication for a tube.

Edit: To be clear, I'm speaking more in general than in your specific case. When I said I wasn't monday-morning-quarterbacking what I meant was I'm not telling you that you did anything wrong tubing the kid. Just that in general, discuss this stuff with the other teams.

 

[Hork Bajir]

@ethilo nice case, thanks for sharing- always appreciate a good clinical thread. Keep em coming

 

[daneeka]

@ethilo I'd have intubated this kid too.

I think that:
- Keeping a 9 month old sedated in the corridor without an airway is no fun
- There's weird stuff going on in the chest
- The CT will probably need breath holds to get good pictures

I don't commonly use muscle relaxants just to get the ETT for babies, but I'd definitely be bringing some along for the trip if I hadn't used it from the get go.

Maybe I'd see how the kid goes with some gentle positive pressure after getting the ETT in before using muscle relaxant, given the unexplained mediastinal pathology?

Otherwise I don't think I'd do anything differently.

 

[woopedazz]

I'm not paeds specialised, but if a 9 month old needs a CT and the FB has been cleared --> I tube them with relaxant. Would have done similar. Would have given adrenaline/fluid more aggressively.


I've dabbled in anaesthetic allergy testing (adults). The described presentation would be unusual for a true NMBD anaphylaxis (in an adult), but not unheard of.

Questions:
What was the baseline tryptase (>24 hours post event) and what was the peak tryptase? I.e. was there a dynamic tryptase rise? (I don't care about the static peak except to exclude other conditions)
Have they been referred for allergy testing?
Did they get Specific IgE testing at the allergy clinic?

If this patient was referred to me and a thorough workup was inconclusive I'd be confident to clear them of an allergy to Rocuronium. Perhaps something else might have happened post-intubation that led to the presentation? E.g. air embolism/hyperinflation/other?

 

[daneeka]

I'm not paeds specialised, but if a 9 month old needs a CT and the FB has been cleared --> I tube them with relaxant. Would have done similar. Would have given adrenaline/fluid more aggressively.

Totally fair and a legitimate option to paralyse for the laryngoscopy. However, if you've got the cardiovascular stability to get the baby very deep (on gas or IV anaesthetic of choice), it is a whole lot nicer for them to breathe (and not desaturate!) while you take your time getting the tube. I worry a lot less about laryngospasm if I've got a working drip.

Perhaps something else might have happened post-intubation that led to the presentation? E.g. air embolism/hyperinflation/other?

Yeah, if it wasn't anaphylaxis I wonder if there was a little breach into a vessel from the enthusiastic biopsy-ing that allowed a bit of air to enter the circulation with PPV.

 

[ethilo]

Hard to tell from the pic but PA is passing just anterior to R bronchus, it goes through the center of the inflammatory mass.

Intra op record... Can you tell when roc was administered? 😳

 

[ethilo]

I'm not paeds specialised, but if a 9 month old needs a CT and the FB has been cleared --> I tube them with relaxant. Would have done similar. Would have given adrenaline/fluid more aggressively.


I've dabbled in anaesthetic allergy testing (adults). The described presentation would be unusual for a true NMBD anaphylaxis (in an adult), but not unheard of.

Questions:
What was the baseline tryptase (>24 hours post event) and what was the peak tryptase? I.e. was there a dynamic tryptase rise? (I don't care about the static peak except to exclude other conditions)
Have they been referred for allergy testing?
Did they get Specific IgE testing at the allergy clinic?

If this patient was referred to me and a thorough workup was inconclusive I'd be confident to clear them of an allergy to Rocuronium. Perhaps something else might have happened post-intubation that led to the presentation? E.g. air embolism/hyperinflation/other?

Wish we could have helped you out with more labs to follow a tryptase trend but 1) the kid was a very difficult stick even for just getting phlebotomy and 2) they discharged already.

I didn't know you could even refer to allergy testing for that! I'd personally be pretty hesitant to do skin testing with rocuronium in a clinic on a 9 month old

As for the presentation, again, the tachycardia initiated before DL / intubation. Tube went in when he was probably already at a HR of 200 at that point, up from ~130s in a matter of seconds. During the laryngoscopy earlier the kid had been getting occasional "jet ventilation" breaths from me through the rigid bronch, no issues. Maybe PPV through the new ETT CONTRIBUTED to situation, but the timing was just not correct for it to be the causative agent for the event.

 

[ethilo]

I looked at the record again zoomed in to the "1 min" view and we had indeed lost SpO2 during the whole event, which would make sense. Sorry I'm not a board review scenario writer!

 

[Airway]

I have seen it before.

I've had it as well. Cardiovascular collapse (ensuing in cpr), no change in peak airway pressures, or wheezing. Maybe rash. +Tryptase and later allergy testing confirmed. Interestingly also + testing for sux and cisatra.

 

[Radetzky]

Did you take an ECG? Even 11 month olds struggle to produce a sinus rate in the 230s. Wouldn’t be surprised if this was some kind of SVT.

 

[IlDestriero]

Interesting case.
I would have been WAY more aggressive about treating the hypotension and tachycardia, including the procedural hypotension. The anesthesia record is giving me anxiety. For real.
Anyway, all’s well that ends well I suppose.

This is routine here. I would have done the case with prop bolus 1-2/kg, glyco, prop infusion 300, fent 1mcg/kg given in divided doses over several minutes to avoid apnea, ketamine 1/kg blouses. Spont vent no gas. Lido on cords and in trachea. Some of my partners like precedex/fent/ketamine, maybe even prop remi. Prop is better for rigid bronch, Dex is better for flex and eval for breathing mechanics (stridor eval).
At conclusion we would have just taken the kid to CT ourselves on prop, maybe @150-200. It’s a 5 min scan. They wouldn’t get breath holds if they asked. Boo hoo. They will be fine. Then to picu.
He can emerge up there with a natural airway.

Here’s my comments for consideration.
There is a pervasive avoidance of treating hypotension in peds. I see it here, there, reviewing unrelated cases on the side, it’s scary. Some of my own partners do it. MAP of 50, ok maybe. Map of 40? No way, unless it’s a neonate. Would you let an adult have a HR of 200+ and a map in the 30s? For ~30 min. Never.
His baseline BP was probably 90/60. I ask residents what their hemodynamic goals are for these little kids. They have no answer. Why? I don’t know. They’d have them for an adult.
Ok, off the soap box for an iced tea.

<Please treat pediatric hypotension!>
This PSA is funded by a grant from the Destriero Foundation.

 

[Airway]

@IlDestriero I don't take care of kids at all. I'd sooner let the janitor do this case before I volunteered.

That being said last I looked even the normal bps and heart rates for little kids was highly debated? And then what was/is acceptable under GA? Can the smart peds people comment on that?

 

[ethilo]

The anesthesia record is giving me anxiety. For real.

Yeah, me too 😆

 

[Arch Guillotti]

Good case.

My takeaways:

While this may be "bread and butter" for the "rokstars" on this forum for the rest of us it is a hair-raising adventure. I did maybe a couple of these in residency. One vaguely similar case in private practice that was stress-inducing for me and the ENT because we never do these and having the right equipment is a big deal.

I would think that a native airway is paramount. Unless a full stomach I would not intubate or paralyze this pt. If a full stomach then I don't know what the heck I would do.

I had a feeling it would be a swing and a miss. Always remember airway structures are in close proximity to major vascular structures and disaster is only a biopsy away.

While it is easy to criticize the decision to intubate the pt nobody wants to cart a small kid with a tenuous respiratory status who is under IV general anesthesia all over the hospital.

Anaphylaxis may manifest itself as cardiovascular collapse without some of the other signs.

Even though the heart rate is jacked up I would have probably given epi 1 mcg/kg (or less) incrementally to see what happens. I don't think it can hurt and it certainly might help.

 

[Wolverines83]

I looked at the record again zoomed in to the "1 min" view and we had indeed lost SpO2 during the whole event, which would make sense. Sorry I'm not a board review scenario writer!

Don’t apologize it’s a great case

 

[Wolverines83]

@IlDestriero I don't take care of kids at all. I'd sooner let the janitor do this case before I volunteered.

That being said last I looked even the normal bps and heart rates for little kids was highly debated? And then what was/is acceptable under GA? Can the smart peds people comment on that?

In general it’s hard to know what an appropriate BP is. You can go by the PALS algorithm if you like. If you’ve got adequate signs of perfusion and your bp isn’t terribly low I think you’re fine. As a general statement, if you go by the PALS algorithm, keeping any kid under 5 years with a systolic in the 70's should be fine.

BUT: I also see some people letting kids sit with BP that is way too low and they just shrug their shoulders. That drives me nuts. A 1 year old with a systolic of 58 or something. Come on people! I always think “how many brains cells did we just kill?” At least they have plenty to spare

And I agree with the sentiment about residents. They just make up a number and when I ask why they don’t have an answer. Their lack of blood pressure control leads to a lack of my blood pressure control!

 

[narcusprince]

Did you see any rashes or color changes indicative of a massive histamine release?

 

[IlDestriero]

This is BP data from a 2016 Anesthesiology article looking at >100k kids from 10 centers. BP during anesthesia.

Reference Values for Noninvasive Blood Pressure in Children during Anesthesia: A Multicentered Retrospective Observational Cohort Study

Although noninvasive blood pressure (NIBP) monitoring during anesthesia is a standard of care, reference ranges for blood pressure in anesthetized children are not available. We developed sex- and age-specific reference ranges for NIBP in children during ...

www.ncbi.nlm.nih.gov

Here’s some normal values from the AAP

Nobody agrees on adult vital norms and goals either, but this is good data to consider. The article is worth a read if you care for kids. What’s ok? Who knows. I don’t want to find out. I would put my low limit close to the 0 SD line, and I sure as hell don’t want to be more than 1 SD below, I’d be aggressively treating those numbers. YMMV.