ABSTRACT
A 15-year-old female with no significant past medical history presented to the emergency department with 1 day of substernal and pleuritic chest pain, chills, cough, and hematuria. She also had swelling of the face and ankles that resolved by presentation. She was found to have elevated troponin and brain natriuretic peptide during initial workup. Electrocardiogram was normal, but there were significant pleural effusions on chest x-ray. She was strep positive and had blood pressure up to 150/90, prompting admission for cardiac monitoring and cardiology consultation. Blood pressure decreased down to 125/72 without intervention. She was afebrile with unlabored breathing and normal saturations. She was clear to auscultation bilaterally, with no abdominal distension or hepatosplenomegaly, and edema was not evident on exam. There was mild erythema to the bilateral tonsillar pillars. Initial considerations included viral myocarditis, pericarditis, and atypical nephritic syndrome. Workup revealed elevated antistreptolysin antibodies, low C3 complement, negative antineutrophil cytoplasmic antibodies, and negative flu testing. Renal sonography was unremarkable. Cardiology recommended echocardiography, which confirmed pleural effusions but revealed no cardiac abnormalities. Urinalysis revealed hematuria and mild proteinuria. Diagnosis was found to be post-streptococcal glomerulonephritis complicated by fluid overload and left ventricular strain secondary to hypertensive emergency. Post-streptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. The mechanism of disease is a proliferation and inflammation of the renal glomeruli secondary to immunologic injury, with deposition of immune complexes, neutrophils, macrophages, and C3 after complement activation. This leads to hematuria, proteinuria, and fluid overload. Edema is present in 65%-90% of patients, progressing to pulmonary involvement in severe cases. Cardiac dysfunction secondary to fluid overload is a potentially fatal outcome in the acute setting. Physicians should consider post-streptococcal glomerulonephritis for patients presenting with hypertension, cardiac/pulmonary pathology, or symptoms of acute heart failure in the context of strep infection.
ABSTRACT
OBJECTIVE: Propofol is frequently used for outpatient sedation for pediatric patients, some of whom require multiple rounds of sedation for separate procedures within a short period. Anecdotal experience suggests that frequent use of propofol results in escalating doses; however, clinical evidence is unconvincing. This study was designed to evaluate if tolerance develops with frequent administration of propofol for children requiring multiple successive sedations. METHODS: A retrospective chart review of patients requiring multiple doses of propofol for separate procedures from 2011 through 2019 was conducted. Cumulative propofol dose and induction dose were analyzed using a mixed model for patients requiring sedation for serial procedures. RESULTS: Data from 24 different patients who required 3 or more sedations during the study period were analyzed. The number of sedations ranged from 3 to 28. The mean total propofol dose rate was 0.19 ± 0.14 mg/kg/min, and the mean induction dose was 3.2 ± 0.97 mg/kg. The total doses and induction doses were not statistically significantly different at different sedations (p = 0.089 and 0.180, respectively). There was a statistically significant decrease in the total dose as the time interval between 2 sedations increased (p < 0.001). CONCLUSIONS: Repeated administrations of propofol at time intervals used in outpatient sedation do not lead to the development of tolerance. A small decrease per day interval may be significant when propofol is used more frequently (multiple times per day or as a continuous drip) in an ICU setting.
