Pediatric Anesthesiology
Case Discussion

Case Stem:

An 8 year old boy presents to the ED with abdominal pain for 2 days. He is diagnosed with acute appendicitis requiring immediate appendectomy. The child's Mom said that he has congenital heart disease and had corrective surgery soon after birth and again at two years of age. She recalls that the second procedure was called a "Fontan." After the second surgery the patient has been doing relatively well but he cannot exercise as much as the other children in his class. He has not eaten or drank anything for 12 hours; his blood pressure is 95/60 mmHg, heart rate is 120 bpm, respiratory rate is 28 bpm, he has a peripheral intravenous line is receiving maintenance fluid.

Study Questions:

After a fluid bolus and a rapid sequence induction-intubaton, the child is hypotensive with BP 60/40 mmHg and heart rate 140 bpm.
  • What is differential diagnosis?
  • Which additional monitors can be used?
You turn down the inhaled agent concentration and place a central line and an arterial line. Low arterial BP is confirmed and the CVP is 7 mmHg.
  • What CVP constitutes adequate preload for Fontan patients?
Following CVP guided fluid administration, you notice that the patient remains hypotensive and the oxygen saturation has decreased to 91% with FIO2 = 1.
  • What is your differential diagnosis? Would a Valsalva maneuver help? What problems specific for Fontan physiology can cause this hypotension and hypoxia?
  • What can be done to resolve the problem?
The surgeon meanwhile reports to you that he has excised the appendix, however, he sees signs of peritonitis and is going to leave drainage tubes in the abdominal cavity. You get results from a previously sent ABG: 7.26/32/60/-6/90%, lactic acid 3.3. The surgeon is planning to place the child in the PICU and asks you if the child should remain intubated.
  • What are the warning signs you see on ABG?
  • What are the pros and cons of keeping the child on mechanical ventilation?
Procedure finishes and the child starts to breathe spontaneously.
  • Do you still plan to keep the child on mechanical ventilation in the PICU? If you decide to keep the child intubated, will you reparalyze him? What parameters would affect your decision?
  • What postop pain management would you plan? Will it affect the PICU course? What the pros and cons of different methods?


Greg Gordon MD