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
Alergies: NKDA
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
Case Continued:
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’.
Case Continued:
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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The phrasing about sending home after discussion – if family still “refuses” admission. They are declining a choice that you are presenting as an option – that’s not a refusal. It’s always been a word that bugs me – implies a confrontational relationship, rather than a collaborative one. It’s a subtle CYA, defensive medicine thing, and I try to not use the word.
Just ranting.
Great point! I’ll admit that I made the language more polarizing to stimulate discussion (mission accomplished??) Ultimately, my hope was to further explore how individuals navigated situations where the family requests/declines services where you feel the opposite and in what scenarios (barring an imminently life threatening emergency) would you proceed with something the patient/family disagrees with. Thanks for the comment!
I’d offer family a period of ED obs and pulm toilet (albuterol, Atrovent which pulmonary thinks may help with secretions in CLD, consider steroids if wheezing or strong hx of reactive component/asthma). I’d send viral testing and gram stain from trach, ideally sent early in ED course. If + virus and neg WBC with stable chronic changes, I’d defer antibiotics. If discharging with borderline sats before these results returned , I’d send home on Augmentin with instructions for phone f/u next day with Pulm or PCP to discuss how to proceed once results are back. With the family, I’d explore what support they have at home to do frequent suctioning and monitoring, but if they have prn oxygen and adequate support, I’d recommend either ED obs or admission but discharge if they feel strongly. I find that with kids with longstanding, fairly stable, chronic medical problems, parents very often (not always, but frequently) have a sense of what they can and can’t handle and of how sick their kid is. Document well your conversation and rationale if you discharge.
I definitely agree with engaging their primary healthcare provider or relevant specialist in the discharge process, and can say that these individuals were very helpful in this particular clinical scenario. Also agree with working with the family to determine how comfortable they are providing an increased level of care at home. I do find the part about observing in the ED to be particularly challenging in this environment of high volumes and limited bedspace. On the one hand, observation and time are one of the most important interventions we utilize in pediatrics, but on the other, realizing that there may be a child in the waiting room who may also need this bed is really tough. Any suggestions?