Hot Seat #178: To do or not to do…?Posted on: October 17, 2021, by : Brian Lee
HPI: AS is a 12yoF ex-25 weeker, with history of hypoxic ischemic encephalopathy, currently with trach and g-tube dependence presenting with fevers and increased tracheal secretions. At baseline she is on trach collar during the day and BiPAP at night. She was last well 3 days ago when she developed nasal congestion and daily fevers (Tm-101). Symptoms have progressed and she is now having increased tracheal secretions, so her mother brings her to the emergency department. Her mother states that her oxygen levels have been lower than baseline but has not required supplemental o2. Otherwise, she has been tolerating feeds, without vomiting or diarrhea. No recent travel and no sick contacts.
PMHx: HIE, Trach & g-tube dependence, admitted to picu 6 months prior for presumed aspiration pneumonia; fully vaccinated (including COVID)
PSHx: As above
Review of Systems: +Fevers, +congestion, +tracheal secretions (clear, thick), +cough. No increased work of breathing, no vomiting, no diarrhea, tolerating feeds well.
Exam: T- 36.8 HR- 110, RR-19, BP: 118/86, SaO2- 97% on trach collar (FiO2=21%)
General: no distress, lying in bed
HEENT: copious clear nasal secretions, clear thick tracheal secretions
Pulmonary: Coarse throughout but no focal findings; good aeration. No retractions
Cardiovascular: No murmurs, warm extremities, cap refill < 2sec
Abdomen: soft, g-tube c/d/i
Neurological: baseline for patient, no focal deficits
On exam, she continues to appear comfortable. Saturations on room air range from 89%- 95% but improve after mom suctions her. CXR shows persistence of both chronic left sided retrocardiac opacity and chronic right pleural thickening, but no new focal consolidation, pleural effusion, or pneumothorax.
Reviewing prior trach cultures, she grew pan-sensitive S. pneumo 6 months ago when she was admitted for aspiration pneumonia, and achromobacter sensitive to only meropenem 18 months ago. Multiple cultures in between show only ‘mixed respiratory flora’.
AS’s pulse ox is now persistently 92-93% but does improve to 95% with suctioning. In speaking with the family, they really want to go home. They state that they have oxygen at home if needed and feel comfortable suctioning patient. If she gets worse, they will bring her back to the ED.
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