Pulmonary embolism is a rare, but serious, potential perioperative complication and crisis. We present a case of a 12-year-old female undergoing distal femoral and proximal tibial osteotomies with internal fixations who experienced acute onset hypercapnia, tachycardia, and prolonged minimal responsiveness following deflation of the tourniquet and cessation of inhaled sevoflurane. CT-chest demonstrated bilateral partially occlusive filling defects of the pulmonary vasculature. We concluded that the patient experienced a pulmonary embolism resulting in V/Q mismatch, retained sevoflurane, and ultimately delayed emergence.

1Medical University of South Carolina, Charleston, SC 2MUSC Health of Medical University of South Carolina, SC 3Medical University of South Carolina

Introduction: Bacterial tracheitis is an infection of the trachea typically preceded by a viral infection. It is a life-threatening infection in children, often occurring in immunocompromised and tracheostomy-dependent patients, though incidence has declined with childhood immunizations. Description: We report an 8-month-old fully vaccinated female who presented with a week of fever, cough, and diarrhea. She had been diagnosed with croup the previous week but had worsened despite steroid treatment. Shortly after admission she was intubated with a 3.5mm cuffed endotracheal tube for respiratory failure. Glottic purulence, ulceration and edema were seen, so steroids, vancomycin and ceftriaxone were started. Tracheobronchoscopy findings were consistent with bacterial tracheitis, and tracheal aspirate grew methicillin-sensitive Staphylococcus aureus (MSSA). She uneventfully weaned on the ventilator and was extubated on hospital day (HD) 5. On HD 9 her fevers recurred with feeding intolerance and hypoxia requiring increased respiratory support. She was re-intubated on HD 10 with a 3.5mm cuffed tube. However, there was a profound air leak that persisted despite replacing with a 4.0mm cuffed tube. With the tube extrinsically held in place to minimize leak, repeat airway evaluation showed a necrotic subglottis and proximal trachea with completely exposed posterior cricoid plate cartilage and tracheomegaly. There was no evidence of tracheal disruption. Due to the persistent air leak, oxygenation and ventilation continued to fail and she was cannulated to veno-venous ECMO. She unfortunately suffered two cardiac arrests during cannulation and converted to veno-arterial-venous ECMO. Over the next few weeks, she developed multisystem organ failure and life sustaining treatment was withdrawn on HD 36. Discussion: Outside the neonatal period, necrotizing tracheitis is an extremely rare condition. Our case describes the severity of this disease and the need for early recognition and treatment. Repeat airway evaluations may have improved the outcome and should be considered in all future cases of bacterial tracheitis especially if not following a typical treatment course though larger studies are needed to further determine this.

Introduction: Physician well-being has become increasingly important for health systems across the country due to the strong ties between quality, safety, and overall patient outcomes. Burnout has increased steadily and has been exacerbated by the COVID-19 pandemic. This study seeks to successfully identify factors that both enhance and detract from well-being in a cohort of pediatric faculty and advanced practice providers (APPs). Methods: This study utilized a multimethod approach including surveys and a total of 8 semi-structured, virtual focus groups of pediatricians and advanced practice providers (orchestrated through Microsoft Teams) to understand perspectives on burnout and well-being. Each group session was scheduled 2-3 months in advance to allow for maximum participation. Results: A total of 83 physicians and APPs participated in the focus groups. The majority of respondents were female, white, aged 31-50 years, and married with children living at home. When asked about current level of burnout, the most frequent response was 8 out of 10 (10 as highest, mean 5.5, std 2.5). Factors associated with higher burnout: outpatient providers (compared to inpatient) (p = 0.0361), female gender (p = 0.0127), and those without a mentor (p = 0.0021). Multiple factors were identified that improved and detracted from well-being. Well-being was positively impacted by the shift to telework practices and increased autonomy in scheduling and focus on self-care. Well-being was reduced by a perceived disconnect from leadership, lack of control, and societal influences and expectations. Conclusion: This study provides insight into modifiable factors that affect well-being at an academic institution that can support interventions and systemic modifications to promote physician well-being.

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 217 doi: 10.1097/01.ccm.0000808144.03216.63

Toxic ingestions are an increasing concern among pediatric patients in the United States. Less common, but troubling, are those patients with persistent toxicity symptoms despite stabilization, resuscitative, and decontamination efforts. We report a case of refractory serotonin toxicity in an adolescent for whom endoscopic removal of medication remnants led to the resolution of his clinical course. A 14-year-old male patient with anxiety and depression, treated with escitalopram and clonidine, presented to an outside hospital (OSH) emergency department (ED) with tonic-clonic seizure activity and altered mental status. Non-contrast head computed tomography (CT), complete blood count, and basic metabolic panel were unrevealing. Repeated seizure activity that occurred in the OSH ED prompted transfer to a tertiary pediatric care facility for ongoing management. Based on the constellation of symptoms (tachycardia, muscle rigidity, and lower extremity clonus) and his medication history, there was concern for serotonin toxicity. His clinical course worsened, despite treatment with midazolam and cyproheptadine, requiring intubation for respiratory failure. Because of his refractory symptoms and concern for ongoing medication side effects, on hospital day 4, he underwent an esophagogastroduodenoscopy (EGD), which revealed 20 partially digested pills firmly adhered to the gastric mucosa. The pill fragments were removed and whole bowel irrigation was started, and the patient improved rapidly, allowing for extubation within 24 hours. An EGD is not routinely used for the management of toxic ingestions. In addition to this case, evidence from prior case reports supports the judicious use of EGD as a diagnostic and therapeutic decontamination modality for severe toxicities.

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 353 doi: 10.1097/01.ccm.0000809196.66689.c5

1Medical University of South Carolina, Charleston, SC 2MUSC Health of Medical University of South Carolina

Background There is a paucity of literature around sedation and anesthesia in patients with severe anorexia nervosa. Chronically malnourished patients are known to have myopathy, neuropathy, and altered neurotransmitter signaling. Ketamine is a non-competitive N-methyl-d-aspartate (NMDA) receptor antagonist that is an established general anesthetic and short-acting dissociative analgesic agent. It generally has a reassuring adverse event profile and rarely has been reported to result in apnea. We aim to raise awareness of this untoward adverse event in patients with severe anorexia nervosa among sedation providers and those referring patients for hospitalization or sedation. Case presentation We describe an episode of apnea, a rare adverse event of ketamine, which was given for procedural sedation to a severely malnourished 13-year-old female with anorexia nervosa, generalized anxiety disorder, and high-functioning autism spectrum disorder. She had no history of apnea nor of ketamine sedation. She was given a standard dose of ketamine and had no other central nervous system depressants within 24 h. Within 1 min after slow medication administration, she had a 9-min period of apnea without laryngospasm. She was supported with bag-valve-mask ventilation throughout this period and did not require intubation. She returned to baseline shortly after procedural sedation. Conclusions This case describes apnea after ketamine sedation in a patient with severe anorexia nervosa. It supports the importance of a thorough pre-procedure review of a patient's underlying medical problems and the consideration of how sedatives may interact with these conditions. We aim to alert those who care for this complex population of the possible altered neurotransmitters, myopathy, and adverse response to sedation, anesthetics, and analgesics.

1Medical University of South Carolina, Charleston, SC 2MUSC Health of Medical University of South Carolina, Charleston, SC 3Charleston, SC

Critical Care Medicine: January 2020 - Volume 48 - Issue 1 - p 478 doi: 10.1097/01.ccm.0000642928.10551.cb

Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.