Stroke?

[littlefishy]

Hi All!

I have lurked the boards for a long time now but never posted. This week though I had a patient who is weighing heavily on my mind and wanted to get some other peoples input.

I work in a PICU and have about 3 years experience now.

I was taking care of a patient this past week in septic shock on ecmo (post ECPR). Pts background: multisystem organ failure with hx of seizures (none seen since meds reached therapeutic level). Obvious injury on head CT (we have portables) but can't quite tell if stroke or just general encepalopathy (which pt definitely has based on EEG & imaging). Pt is on NO sedation as we are trying to determine extent of neurologic injury. Pt has no cough/gag, pupils vary from 1mm to 4mm, sometimes brisk, sometimes sluggish. The last few days pt has had increased response to pain (slight withdrawal of fingers/toes to pinching).

Anyways I was changing lines and per my usual routine I hung his pressors & carrier ahead of time and ran them for a few minutes. Doses were not high, pt is a toddler, on about full ecmo support and we were tolerating lower maps (50's) in effort to take off fluid. When I changed the lines I expected a little fluctuation but his pressures just SHOT up, high 150's/100's. Ecmo pump started freaking out for a few seconds I immediately paused both the dopa & epi and pressures slowly came back down. Whole episode probably lasted less than 2 minutes of course when it's happening it feels like 30. I turned his pressors back on, at lower doses initially but titrated back to baseline and he never "slumped" his pressures returned completely to baseline. After this I took a quick peek at his eyes and his pupils were large, about 5's I would say. There was another, well experienced, nurse in the room with me through this who event and she immediately grabbed the flashlight and checked them, they responded equally though sluggish. She thought he was fine. I relaxed. About 15 minutes after this as I was sitting down to chart I noticed that his HR was about 10 bpm lower than he had been all day (had been consistently about 134-138 all shift, was now low 120's). I know that's not technically "bradycardic" but I have just been stressing out that I this may have caused further, significant injury, stroke or beginnings of herniation.

Any thoughts? This was at the end of my shift so I couldn't assess how the next few hours went. I am so worried and haven't been back to work in a few days, not until the end of the week.

[NotReady4PrimeTime, RN]

Something very similar happened with a patient of on our unit not long ago - not my patient, I was in charge that day. We were never able to explain it, there were no long-term sequelae and it never happened again. I would say that if your patient displayed any significant changes in neuro status in the interim this kiddie will have had a CT head by now. It's unlikely that anything you did or didn't do made it happen.

[littlefishy]

thanks Jan. I am hoping that the situation didn't change anything in his outcome. He was going to be scheduled for another CT soon anyways to see if his swelling and possible injuries were stable, improving or worsening anyways. Unfortunately the hope was for the (previous) CT to give us some evidence of a really bad or a not so bad injury, which it does neither therefore makes it hard to make decisions based on what the neurological outcome is going to be, but the heart, lungs and kidneys don't seem to be making any improvements and it's going on ecmo day 13/crrt day 6...

[NotReady4PrimeTime, RN]

Hmm. ECMO day 13, CRRT day 6... we have kids on for a LOT longer than that. We recently had one go for more than 8 weeks on both. Not to say they all have good outcomes, but we do long runs for certain reasons (post-pertussis, adeno/RSV, bridge to transplant and such). We've had kids on CRRT for months at a time. Having said that, in my experience the longer a kid goes with no appreciable change in condition the less likely they'll survive. The main question is at what point does aggressive treatment stop? How do we know when reversibility has left the building? Some illnesses have a reasonably identifiable course; for example pertussis typically takes 8 weeks for recovery. If a kid is on ECMO for pertussis and is approaching the 8th week with no improvement, it's not likely there will be improvement. Likewise with adeno/RSV... that should show signs of reversal within 6 weeks. As for renal failure... our nephrologists repeatedly tell us that there's no hard-and-fast time frame for reversibility. I don't think CRRT should be the mainstay of therapy for someone whose renal failure may resolve, mainly due to the costs associated with equipment, supplies, drugs, blood products, human resources and so on. But I seem to be in the minority here.

I wouldn't totally count this kiddo out yet. He might need a bit more time, or he may never recover but it's probably too soon to make that call.

[littlefishy]

thanks for that input! I heard from a friend who cared for him this week that the episode doesn't seem to have had lasting effects. He's continuing to make small hand/feet movements, take occasional spontaneous breaths & open his eyes. No one has really discussed how long we would continue this support, there was a family meeting this week but I haven't been there so no idea what was presented. Docs were encouraged though by the movements. I had never seen a kiddo (non immunocompromised or w/o other significant medical history) so sick from adenovirus but good to know that it can take upwards of 6 weeks to clear the system.