Hot Seat #193: 6 yo female with SOB

Posted on: August 9, 2022, by :

Masouma Mohamed, PGY4, INOVA Children’s Hospital Fellowship


A 6-year-old female presents with difficulty breathing accompanied by her grandfather. For the past 3 days, she was not feeling well and was noted to be breathing quickly. No fever, vomiting, or diarrhea. She was seen by her PMD this week and started on Augmentin and cyproheptadine for appetite stimulation. Today, her work of breathing has been worsening, which prompted the family to bring her to the ED. Her grandfather knows that she had heart surgery when she was little, but he does not remember what it was


HR 137, BP 150/73, RR 50, SPO2 60%, Temp 101.2

Constitutional: Significant respiratory distress. Notable pallor.

ENT: mucus membranes moist. Oropharynx within normal, severe pallor of lips.

Neck: normal range of motion, non-tender, no meningismus

Respiratory: poor air entry, diffuse wheezing and coarse breath sounds. Tachypneic to 50s with intercostal retractions, supraclavicular retractions, and nasal flaring. Midline sternotomy scar is well-healed.  + chest wall deformities.

Cardiovascular: Regular rate and rhythm. No murmur/rubs/gallops, PMI is bounding.

Abdomen: Soft and non-tender. No masses or hepatosplenomegaly. G-tube site C/D/I

Extremities: No edema or cyanosis.

Neurological: No focal motor deficits by observation. Speech normal. Slightly asymmetric smile.

Skin: Warm and dry. No rash.

Psychiatric: Appropriate affect/concentration. Interaction with adults is appropriate for age.

Pt was started initially on 100% oxygen via non re-breather. She received nebulized albuterol and was subsequently transitioned to HFNC.

You are able to pull up her chart and obtained more information:
-Medical hx: VACTERL, intermittent asthma

-Surgical hx: TEF & TOF s/p repair, G-tube placement

You obtain point-of-care labs, which show:
VBG: 7.21/25.3/9.9/16/oxygen sat 75%
H/H: unreadable/15%

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2 thoughts on “Hot Seat #193: 6 yo female with SOB

  1. This is such an interesting case! I’m curious as to why she was so anemic in the setting of this subacute presentation (tachypnea and discomfort evolving the past few days). I definitely agree with slow transfusion of a small aliquot of pRBCs in this setting, and I’m also curious as to the mechanism of how this may have precipitated SVT (or whether the two issues were unrelated). A quick search showed that hypothermia from transfusion of a large volume of cold blood products (which does not seem to be the case here) can lead to arrhythmias, but the most common are a-fib and v-fib. This leads me to suspect that this patient’s arrhythmia is not iatrogenic, but perhaps related to whatever acute insult is going on, overlaid on her repaired congenital cardiac defect. Have others seen a complication like this from blood product transfusion?

  2. Top on differential: congestive heart failure, pneumonia, asthma, respiratory viral illness…
    Based on the information provided several questions come to mind:
    TOF generally when repaired (the arch and VSD) generally does well- so why would she develop heart failure?
    That is profound hypoxia for pneumonia, asthma or even severe anemia…. so is it all about the heart?
    Her tachypnea seems appropriately compensatory for her metabolic acidosis… why does she have that?…. we don’t have her chemistry to know if anion gap or not…
    On the EKG provided, could I convince myself there is a small p wave… maybe… but given her history, she’s certainly high risk for arrhythmias.
    Why is she so anemic?! Parvovirus?
    How to put it all together, need some more information… Her VACTERYL seems like a red herring. What does her CXR show? What does her CMP and CBC show, is she hemolyzing (bili?) Is she improved with asthma management?
    So basically I have more questions than answers…

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