GA3-70
Anesthetic Management of an Infant with New Onset Iatrogenic Phlegmasia Cerulea Dolens After IO Placement and Ongoing Sepsis Presenting for RLE Angiography
shah A, Demidovich Y
university of illinois, plainfield, IL, USA
Phlegmasia Cerulea Dolens is rarely seen in the pediatric population but it is a medical emergency. It is defined as a near total or total occlusion of venous outflow. This can result in elevated compartment pressures, arterial insufficiency, circulatory shock and limb ischemia. It is precursor to frank gangrene and the patient is at risk for pulmonary embolism. Risk factors for the development of PCD include lines, cancer and sepsis.2 We present the case of a 16-month old female who presented in septic shock with difficulty in obtaining peripheral and central access. Presentation was preceded by 2-week history of URI. Patient was born full term via vaginal delivery with prolonged NICU stay for FTT and was diagnosed with microcephaly, developmental delay and infantile spasms.
After multiple failed attempts to obtain femoral lines bilaterally, an IO was placed in the R tibiaFluid boluses and antibiotics were administered until , the RLE noted to be cold and mottled. IO was discontinued and replaced by L Subclavian line. CT showed extensive DVT with minimal flow in anterior and posterior tibial artery. Heparin drip was initiated at that time with no significant improvement in perfusion. Vascular service was consulted and they recommended emergent tPA therapy in place of fasciotomy.
On presentation, the patient was hypotensive, tachycardic and febrile with increased clear oronasal secretions and wet cough. Induction was complicated by sudden cardiac output depression, manifested by acute desaturation, drop in ET CO2 as well as decrease in cerebral and somatic NIRS immediately after intubation. A round of epinephrine and chest compressions for 20-30 seconds was given with full ROSC. The patient received 1 u platelets for acute thrombocytopenia . The patient was returned to PICU intubated due to worsening clinical status as well as anticipation of further surgical intervention.
This case highlights how failed recognition of a rare adverse effect led to a negative outcome with the patient currently undergoing assessment for RLE amputation. Since phlegmasia cerulea dolens occurs in less than 1% of patients with a DVT, it is important to understand the clinical presentation, risk factors and management of this disease. Up to 60% of the patients can develop gangrene and up to 50% can require a limb amputation. 1
1 Tran, J. Phlegmasia Cerulea Dolens in the Pediatric Population: A Life-threatening Condition, The Journal of Emergency Medicine, Oct 2015, Pgs 111-114.
2 Ikegami, T. Phlegmasia Cerulea Dolens, QJM: An International Journal of Medicine, Apr 2016, Pgs 281-282.
Top
