Pulmonary Hypertensive Crisis in a Pediatric Patient : Case
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A 5-month-old boy, weighing 4 kg, presented for repair of cleft lip. He was born prematurely at 28 weeks gestation and was hospitalized in the neonatal ICU for three weeks. His medical history included bronchopulmonary dysplasia (BPD) treated with bronchodilators, mild pulmonary hypertension (PH), and patent foramen ovale. After inhalational induction of general anesthesia with sevoflurane, IV access was established, and the patient was successfully intubated on the first attempt. Shortly after intubation and 180-degree rotation of the OR table, oxygen saturation fell to 88%, end-tidal CO2 (ETCO2) decreased to 25 mm Hg, heart rate increased to 180 beats per minute, and peak airway pressure increased to 34 cm H2O. Mainstem bronchial intubation was ruled out by lung auscultation.

Albuterol inhalation aerosol was administered through the endotracheal tube, after which the inspired oxygen concentration increased to FiO2 of 1. Blood pressure decreased to 30/20 mm Hg and a 40-mL lactated Ringer’s bolus was given without significant hemodynamic response.
Given this patient’s history and clinical signs, a pulmonary hypertensive crisis was suspected. Most likely, right arterial pressure exceeded left arterial pressure, leading to exacerbation of the preexisting shunt. A single dose of epinephrine 2 mcg was administered intravenously, resulting in an increase in blood pressure to 50/30 mm Hg. Fentanyl 4 mcg was administered, and sevoflurane concentration increased to a minimum alveolar concentration of 1.5. Oxygen saturation increased to 100% and peak inspiratory pressure dropped to 20 cm H2O. After completion of the surgical procedure, the patient was extubated, admitted overnight for observation and discharged home on the third postoperative day.

Conclusion
-Pulmonary hypertensive crisis is a life-threatening condition that is caused by an acute increase in PVR.

-Patients with preexisting PH and right ventricular dysfunction are at increased risk for developing a pulmonary hypertensive crisis.

-The mainstay of pulmonary hypertensive crisis prevention is maintaining proper oxygenation and ventilation, and avoiding pain, acidosis and hypothermia.

-Early recognition and treatment of pulmonary hypertensive crisis are crucial.

-A multidisciplinary approach including a pediatric anesthesiologist, cardiologist and pulmonologist are highly recommended.

Source: https://www.anesthesiologynews.com/Clinical-Anesthesiology/Article/03-20/Pulmonary-Hypertensive-Crisis-in-a-Pediatric-Patient/57420
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