Hot Seat #185: An IVF Conundrum

Posted on: February 18, 2022, by :

By Harrison Hayward, MD, Children’s National Medical Center


You receive a call from an outside hospital to transfer an 8yo M with NBNB vomiting x2 days with soft stools and abdominal pain who received two boluses and failed a PO trial. No fever, respiratory symptoms, rash, sick contacts, or travel. They require transfer for inpatient pediatric admission. Attempt at direct admission was unsuccessful, so the patient will be coming through the ER. After the two boluses and initiation of D5NS MIVF, the patient’s VS prior to transport are: HR 108, BP 110/60, T 97.3, RR 23, 100% on RA. He is sleepy, but arousable and overall comfortable-appearing. Capillary refill is brisk and the exam is otherwise unremarkable. Their ETA is 15 minutes. Transport asks to continue the MIVF and for other recommendations.

You recommend the transport team continue with MIVF and to administer NSB if needed, which was not given. On arrival, the patient is placed in a room. Transport reports that the patient became sleepier en route. He is accompanied by his mother. The family is primarily non-English-speaking (Haitian Creole).  You examine the patient while interpreter services are pending:

VS T 37.5C, HR 134, BP 90/54, RR 42, 100% on RA

Gen Sleepy. Wakes up to voice & painful stimuli but goes back to sleep. Small for age. Vomit on shirt

MSK hyperflexed at the hips (nearly folded in half), reduced muscle bulk throughout. Hypertonic, extended LE’s

HEENT Normocephalic, atraumatic

CV Tachycardic, regular rhythm, no gallops/murmurs, extremities warm, cap refill 3-4 seconds. No sternotomy scar

Pulm Tachypneic, non-labored, CTAB, aerating well

Abd s/nt/nd. G-tube in place c/d/i

Neuro per above. Pupils 3mm and equally reactive. Unable to assess CN on arrival due to patient’s mental status and language barrier

NSB is started and a second PIV is obtained. You get a VBG that shows pH 7.19, BG 722, BE -18, HCO3 7, Na 137, K 2.7, pCO2 18, lact 2.1. Repeat labs are sent. Your resident goes through the documentation from the OSH, which reveals initial workup notable for WBC 31.6, 70% PMNs; CMP with BG 36, HCO3 8, AG 28; UA obtained by bag specimen with +ketones/glucose. He had received D50 boluses x2, NSB x1, and IV ondansetron. You are still waiting for interpreter services at this time.

NSB is finished and HTS given empirically. CT head obtained that shows abnormal white matter hypodensities most prominent in the bilateral parietal lobes and parts of the frontal lobes, as well as partial sulcal effacement of bilateral parietal lobes consistent with chronic gliosis. Radiology calls you to tell you that these findings are atypical for cerebral edema seen in DKA and are likely not acute. The Martii interpreter is acquired and mom reveals that the pt has muscular dystrophy.

Walter Palmer
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3 thoughts on “Hot Seat #185: An IVF Conundrum

  1. I think we are missing some history. Muscular dystrophy doesn’t cause CNS gliosis and hypertonicity.
    Also, a stat HgbA1C level should help differentiate reactive hyperglycemia s/p dextrose bolus vs. new-onset DKA.

  2. Also not clear to me. It sounds to me like a child with chronic underlying conditions, including DD and CP. I would wonder about underlying vulnerability to hypothalamic/pituitary dysfunction and would repeat the labs and obtain a cortisol. I wouldn’t pursue treatment for increased ICP at this point. Given the change in mental status, it makes sense to obtain neuroimaging.

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