Surgical Referral

You decide to refer Charlie to the surgical team. They are busy with a myotomy for pyloric stenosis in another little baby, and tell you that it is interesting because it was a girl that they were operating on. They expect to be a couple of hours at least. They ask you to make Charlie “nil by mouth” and that they will come down shortly. If in the meantime she deteriorates, they ask you to obtain investigations as appropriate for the clinical need.

You review Charlie and find that she is still looking fairly well. You explain to the parents that she will be seen by the surgeons, but not just yet. She will need some intravenous fluid in the meantime so she does not be come dehydrated.

You write up some 0.9% NaCl. You also ask the nurses to monitor her regularly, check her urine output and to let you know if there are any changes. You go to review a child with a fever and a rash, and then a 12 week old infant with difficulty in breathing.

After 45 minutes the nurses ask you to see Charlie again immediately. She has gone pale, is disinterested in her surroundings and has just vomited greenish fluid. She is being held by her parents.

The nurse obtains a new set of observations:

HR 170/min; BP 110/55mmHg: RR 45/min; SaO₂ 97% air; T 37.2 C

You decide to give her a 20 ml/kg fluid bolus, but first you examine her to see if there are any new findings. When you do so, you see that the chest is clear, the abdomen is more distended. Bowel sounds are present, but the abdomen seems quite tender. The chest is clear, capillary refill 4 seconds.

You request an erect chest radiograph and an arterial blood gas, which you have to do yourself. Fortunately Charlie does not really object much.

pH                   7.39
pCO₂                    3.9         KPa     
pO₂                 8.3       KPa
BE                   -7.3      mmol/L
Lactate            2.1       mmol/L

Click on the link below to access the x-ray image

http://resources.elu.london/cases/tame/charlie/jr_ricketschest_xray.jpeg

About half way through the fluid bolus, Charlie begins to look a lot better, more alert and pink. Her observations are repeated and her HR is now 150/min, respiratory rate 40/min and CRT 2-3 seconds.

What would you like to do next?