ABSTRACT
We are reporting a case of pyrethroid poisoning with atypical presentation in a 21-month-old toddler who was transferred to us from a peripheral center. Signs and symptoms at presentation were predominantly of cardiopulmonary dysfunction contrary to more common presenting features of gastrointestinal and neurological impairment. The reason for this seems to be the aspiration pneumonitis as a consequence of vomiting induced by parents at home, rather than the toxin itself even though a rather rapid progression of lung injury does not rule out the possibility. He had developed decreased level of consciousness and increased work of breathing after ingestion, which had progressed to Acute Respiratory Distress Syndrome, septic shock, and multi organ failure. He even had a brief cardiac arrest with Return of Spontaneous Circulation after 5 min of cardiopulmonary resuscitation, immediately after arrival at our unit, which seemed more likely to be a consequence of inappropriate management during transfer of the child. In addition to antibiotics and vasopressors, he required high frequency oscillatory ventilation and prone positioning initially, and lung-protective conventional ventilation later. His cardiopulmonary status improved gradually and he was successfully extubated after 12 days. Other organ systems also showed complete recovery. Even though Magnetic Resonance Imaging of brain done a few days after cardiac arrest showed features suggestive of hypoxic-ischemic encephalopathy he showed complete neurological recovery. He was thriving well at three-month follow-up with no neurological deficits, good exercise tolerance, and normal renal and liver function. Atypical presentation of pyrethroid poisoning is associated with significant morbidities and there seems to no reliable parameters in children to identify the risk of the same. Considering that there is no specific antidote, prompt, and aggressive supportive therapy is necessary for a favorable outcome. This case highlights several important aspects in the care of the pediatric patient after ingestion of insecticides. First, attempt to induce emesis, especially outside of a healthcare facility is not only ineffective but also highly dangerous, and should not be done. Second, unstable patients require inter and intrahospital transfer by experienced and trained personnel; and lastly, management for these complex and atypical cases should be done as early as possible in a center which is equipped to provide high level of circulatory and ventilatory support while prioritizing neuro-protective measures, and neurologic recovery and rehabilitation.
ABSTRACT
BACKGROUND: Literature on the use of nicardipine, a dihydropyridine calcium channel antagonist, in children recovering from cardiac surgery is sparse and, to our knowledge, nonexistent in children with single ventricle anatomy. We aimed to report our experience with nicardipine in these patient populations. METHODS: We performed a retrospective review of children recovering from aortic coarctectomy or superior cavopulmonary anastomoses who received nicardipine for hypertension at our institution between 2007 and 2013. Hemodynamic variables prior to and after nicardipine initiation were compared using paired t tests. RESULTS: Seven children recovering from aortic coarctectomy (median age 8.6 months, range: 1.5 months-7.9 years) and four children recovering from superior cavopulmonary anastomosis (median age: seven months, range: five-nine months) were reviewed. For all patients, at six hours after initiation of nicardipine, mean systolic blood pressure was significantly decreased, 123 ± 19 versus 103 ± 14 mm Hg (P = .001), as were diastolic blood pressure, 68 ± 20 versus 53.5 ± 10 mm Hg (P = .041), and sodium nitroprusside dose, 4.3 ± 2.9 versus 1.3 ± 1.7 mcg/kg/min (P = .002). Further, within 24 hours, serum lactate decreased from 1.45 ± 0.82 to 0.81 ± 0.29 mg/dL (P = .016). Heart rate, blood urea nitrogen, and serum creatinine measurements were statistically unchanged. CONCLUSIONS: Nicardipine effectively decreased blood pressure without apparent adverse events in a small cohort of children with postoperative hypertension while recovering from aortic coarctectomy or superior cavopulmonary anastomosis. Further research comparing nicardipine to more conventional titratable antihypertensive agents in these patient populations is warranted.