Pediatric SurgeryA. Tubbs

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19mo M brought to the ED 12/22 by EMS after cardiopulmonary arrest EMS called by father for “difficulty breathing” but was completely normal

per father prior to this episode PMH: Born at 29 weeks, fraternal twin, NICU for 6-8 weeks, s/p ex lap

after umbilical vein line infiltration Found apneic and cyanotic by EMS, lost pulses en route, CPR initiated ED exam: Unresponsive without pulse, no signs of trauma, cyanotic and

cool with mottled extremities, right pupil sluggish, abdomen soft and mildly distended

Regained pulses after 5 min CPR in the ED, intubated, 3 saline boluses CXR:

The cardiomediastinal silhouette is within normal limits. There is no visible pneumothorax or large pleural effusion. Gaseous distention of the stomach and multiple loops of small bowel seen within the visualized portion of the abdomen. No displaced rib fractures are noted.

CT Abd/pelv: Multiple dilated, fluid-filled loops of bowel with mucosal enhancement

consistent with shock bowel secondary to hypoperfusion. CT Head:

No acute process.

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HD1-3 high dose pressors Peds surg consulted HD 2 for shock bowel-

large soft distended abdomen NGT decompression, medically stablized, HD 6

developed mild periumbilical erythema otherwise labs, vitals WNL, CT scan unchanged

HD 7-10 erythema improved, continued to have normal labs, vitals on minimal vent support

HD11 night team called to evaluate worsening erythema over the entire lower abdomen

3rd CT scan unchanged HD 12 WBC elevated from 13.0 to 20 Exploratory laparotomy

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Analysis of Complication• Was the complication potentially

avoidable?– Yes

• Would avoiding the complication change the outcome for the patient?– Yes

• What factors contributed the complication?– Inconsistent clinical history– Lack of clinical findings – Delay in exploration

Diffuse small-bowel ischemia in hypotensive adults after blunt trauma (shock bowel): CT findings and clinical significance.1

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SE Mirvis et al. AJR Am J Roentgenol. 1994 Dec;163(6):1375-9. CT scans showed diffuse thickening of the small-bowel wall

in all patients, ranging from 7 mm to 15 mm (mean, 11 mm); fluid-filled, dilated small bowel in nine patients; subjectively increased contrast enhancement of the small-bowel wall in six patients; and a flattened inferior vena cava (< 9 mm anteroposterior diameter at renal veins) in 10 patients.

The colon appeared normal in all cases. Celiotomy in eight patients revealed normal-appearing small

bowel by inspection in two and localized bowel injuries, with the remaining bowel appearing normal in six.

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Hypovolemic shock in children: abdominal CT manifestations. GA Taylor et al. Radiology. 1987 Aug;164(2):479-81. The authors describe a "hypoperfusion complex,"

seen on abdominal CT, which consists of marked, diffuse dilatation of the intestine with fluid; abnormally intense contrast enhancement of the bowel wall, mesentery, kidneys, and/or pancreas; decreased caliber of the abdominal aorta and inferior vena cava; and moderate to large peritoneal fluid collections. This complex was present in three patients less than 2 years of age and was associated with severe injury and a poor outcome.

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Multidisciplinary evaluation of the distended abdomen in critically ill infants and children: the role of bedside sonography.Azarow K et al. Pediatr Surg Int. 1998 Jul;13(5-6):355-9. Abdominal distention and metabolic acidosis are common in critically

ill infants and children, and can be manifestations of an intra-abdominal catastrophe.

8 infants and children presented with the above situation. 7 were immediately post-cardiopulmonary resuscitation and none had antecedent histories of abdominal pain or bilious vomiting. Abdominal radiographs could not rule out intra-abdominal pathology such as ischemic bowel. Review of all laboratory and radiological data showed US to be a discerning modality for acute bowel pathology.

A characteristic pattern of echogenic ascites, thickened bowel wall, dilated, fluid-filled bowel lumen, and lack of peristalsis was seen in those children with gangrenous bowel. Sonographic examination accurately predicted the status of the bowel in all patients.

4 patients survived: two had segmental ileal necrosis, one had localized gangrene of the jejunum (twice), and one had necrotic bowel from a closed-loop obstruction.

Bedside US can be extremely valuable as an adjunct in assessing the abdomen and diagnosing gangrenous bowel in critically ill infants and children.

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Take Home Points “Shock bowel” is a radiographic finding Volvulized bowel may not manifest with

systemic acidosis Abdominal wall erythema and distention Use of US in evaluating bowel