There is one thing that every pediatric nurse and mother can agree on: If the kid gets quiet, there’s usually trouble to follow. That is exactly what happened to a mother of a 9-year-old chronically ill boy 2 days following surgery.
The call toned out in the early morning hours on a Sunday: “9-year-old male, post cardiac arrest, 20kg, ER to ER”. My partner Paul and I gathered our supplies and headed out to the aircraft. It was a 35-minute flight. While enroute, we obtained some additional information. One interesting piece of data was that this child had hip surgery at our institution 2 days prior to this current event. We both discussed the possible differentials for pediatric arrest given the information we had at hand:
*Fat embolism from the orthopedic surgery?
*Post-op sepsis?
*Congenital cause given the fact he’s 9 years old and only 20kg?
*Aspiration?
We arrived to find numerous emergency room (ER) staff at his bedside, and distraught parents crying in the corner. This small, emaciated boy with a history of seizures and cerebral palsy, was lying supine on the stretcher, not moving. He was gasping around the endotracheal tube (ETT) while being manually ventilated. Paul quickly assessed the patient and I got report from the bedside RN and the mother. Throughout the day he had been vomiting, moaning and thrashing about. His mother tried to get him in to his pediatrician without success. Telephone calls to the orthopedic surgery center got her a prescription for Zofran. The child continued to vomit all day, despite the Zofran. His mother continued that he was in bed most of the day, crying, uncomfortable and moaning. She thought he may have fallen asleep when she didn’t hear much from his room later that evening. Like many mothers, she had a “feeling”. She went to check on him, he was waxy looking and not responding. She called 911 and enroute to the hospital, he experienced a cardiac arrest.
Part of the report that we were given was that he had received at least 30 minutes of CPR with 7 doses of weight-appropriate rounds of epinephrine before ROSC. He was treated for a glucose of 4 mg/dl and given Rocephin for infection coverage. Norepinephrine was infusing at 0.8 mcg/kg/min and he had 2 peripheral IVs inserted that were patent and infusing. We immediately performed a physical assessment and placed him on our monitoring equipment with the following results:
B/P 71/40 (50)
HR 85 bpm
RR assisted at 28 bpm
Oxygen Saturation was undetectable
Pulses were only detected femorally. A low-perfusion oxygen saturation probe was placed on his ear without better results. His abdomen was firm to palpation. His surgically-implanted gastric button was vented with scant coffee-ground return.
The norepinephrine was titrated up to 1mcg/kg/min and an epinephrine drip started in an attempt to improve blood pressure. Additionally, sodium bicarbonate, calcium gluconate and a push dose pressor of epinephrine were given.
After initial attempts at stabilization, telephone contact was made with both the pediatric Emergency Department and the Pediatric Intensive Care Unit (PICU) for medical direction. A vasopressin drip was started and a 3% saline bolus given for possible cerebral edema. Central access was attempted by the referring physician without success. In addition, Paul, tried for arterial access without success. Numerous attempts were made to draw blood. Eventually, we were able to get an ultrasound guided external jugular peripheral IV and updated laboratory values were run with the following venous sample results (iStat CG 8® cartridge):
pH 7.17
PCO2 73 mmHg
PO2 41 mmHg
HCO–3 26.6 mmol/L
Glucose 83 mg/dl
Hgb 6.8 gm/dl
Ionized Calcium 0.66 mmol/L
Potassium 6.2 mEq/L
MOMENT OF TRUTH:
At this point, with direction from the PICU fellow, epinephrine and norepinephrine drips were both at 3 mcg/kg/min and vasopressin was at 0.03u/kg/min. The high potassium was treated and the low calcium was replaced. The patient’s blood pressure still remained 70’s-80’s systolic. I quietly discussed direction of care with the patient’s mother. She was extremely tearful and expressed that she knew things most likely wouldn’t go well, but still wanted to continue with the transport. This was reiterated to the PICU fellow and she was in agreement with transport. Packed Red Blood Cells (PRBC) were requested to the bedside for the transport to treat the low hemoglobin level. Paul and I briefly conversed about the futility of the transport and the ethical dilemma presented. Should we continue with the transport knowing the possibility of death without any family at his bedside? Was the move from the ED stretcher to the transport cot going to do him in? Or, if we do get him to the receiving facility’s PICU, would he live long enough for his parents to get to his bedside (a 90+ minute drive)? A silent nod between us was shared, validating the inner turmoil we were having with the transport. It also was an agreement that the need for transport to a specialty care center was what this family needed to help them find peace knowing they tried everything offered to save their little boy.
The patient was transferred to the transport cot without much change in his vital signs. We then made our way to the helicopter and loaded him. Enroute to the hospital, we administered 20cc/kg PRBCs, gave 2 doses of sodium bicarbonate and 2 doses of calcium chloride. A second set of labs were drawn using the I-stat machine and resulted in:
pH 7.20
PCO2 75.7 mmHg
PO2 39 mmHg
HCO–3 29.4 mmol/L
Glucose 101 mg/dl
Hgb 7.5 gm/dl
Ionized Calcium 0.89 mmol/L
Potassium 5.1 mEq/L
We safely landed and arrived in the PICU. We called his mother and gave her the news that her son had arrived safely. He continued to be unstable throughout the night, receiving an additional unit of PRBCs, 2 units of liquid plasma and central venous access. His vasopressors remained at the same rates except vasopressin was weaned after blood product administration to 0.01 u/kg/min. That morning, a decompressive exploratory laparotomy was done at the bedside revealing a necrotic gall bladder and ischemic, dilated bowel loops. The suspected cause was a post-operative ileus leading to bowel obstruction and possible perforation, peritonitis and septic shock. That evening, with his parents at his bedside, care was withdrawn and he quickly passed.
COULD THERE POSSIBLY BE A POSITIVE OUT OF THIS SCENARIO?
Walking into the emergency room of the outside hospital, it was evident that this boy was not going to live through this ordeal. Both my partner and I struggled with taking this boy away from his parents and having the worst possible thing happen…He would die enroute, without his loved ones. We both quite frankly discussed this possibility with his mother and father and they wanted us to proceed. We made our concerns known to the accepting PICU fellow who also told us to press on. We had exhausted our pharmaceutical capabilities and he was still very unstable for transport. Rational thinking would dictate that he was a “non-transport”, but emotions run high with children and having him expire in an adult facility would not give his parents the peace of mind that everything possible was done to save their child. Leaving the PICU that early morning, neither Paul nor I would have said that was a positive transport. We talked about it when we got back and were both distraught. I worked that next night to learn he had expired.
But wait…despite the incredibly high doses of vasopressors and his ever expanding abdomen causing compartment syndrome, he was able to donate both kidneys and heart valves through Gift of Life. This scenario never crossed our minds at any point during that transport. Post cardiac arrest patients are an integral source for donated organs and a chance for another to have a better quality of life. Over 1,900 children received transplants in 2019. In trying to find any semblance of good from this experience, this was one small piece. We go in to this job to make a difference and a positive impact on those we care for, not knowing that sometimes that positive impact could be on someone we may never meet. Sometimes, this might be the only thing providing some peace.
REFERENCES
Nakayama, S., Migliati, E., Amiry-Moghaddam, M., Ottersen, O. P., & Bhardwaj, A. (2016). Osmotherapy With Hypertonic Saline Attenuates Global Cerebral Edema Following Experimental Cardiac Arrest via Perivascular Pool of Aquaporin-4. Critical Care Medicine, 44(8), e702–e710. https://doi.org/10.1097/ccm.0000000000001671
Organ and Tissue Donation Program | Gift of Life Michigan. (n.d.). Gift of Life Michigan. https://www.giftoflifemichigan.org/
Elmer, J., Molyneaux, B. J., Shutterly, K., Stuart, S. A., Callaway, C. W., Darby, J. M., & Weisgerber, A. R. (2019). Organ donation after resuscitation from cardiac arrest. Resuscitation, 145, 63–69. https://doi.org/10.1016/j.resuscitation.2019.10.013
Organ Donation and Children | Organ Donor. (2020, March 27). https://www.organdonor.gov/about/donors/child-infant.html#:%7E:text=The%20organs%20that%20children%20tend,kidney%2C%20followed%20by%20a%20liver.