A 4-year-old girl presented to an outside hospital for an elective tooth extraction secondary to dental caries. At the time of anesthesia induction on the day of surgical extraction, the patient was noted to have a blood pressure of 180/70 mm Hg and a pulse of 120/min. Notably, a blood pressure of 88/60 mm Hg and a heart rate of 60/min had been documented during the patient’s physical examination performed 9 days before surgery by her primary care physician. Similarly, a blood pressure of 82/50 mm Hg and a pulse of 66/min were documented on the anesthesia preoperative note on the day of surgery.
Induction of anesthesia began with administration of inhaled sevoflurane. Fifteen minutes after induction, the blood pressure was noted to have decreased to 160/65 mm Hg.
The blood pressure continued to decrease throughout the procedure with a measurement of 130/50mm Hg 30 minutes after induction. The procedure continued for 4 hours with measurements in the range of 120 to 130/50 to 60 mm Hg. After the procedure, the patient was extubated and taken to the recovery room where the blood pressure was noted to be 201/125 mm Hg and the heart rate was 120/min. The patient was observed to be somnolent but was able to open her eyes to voice. Hydralazine 5 mg intravenously (IV) was given for a blood pressure of 195/110 mm Hg after 30 minutes of persistent hypertension. Next, labetalol 5 mg IV was given after 5minutes for a blood pressure of 182/118 mm Hg.
The house pediatrician evaluated the child and recommended that a urinalysis and basic metabolic profile be obtained and that the patient be transferred to the tertiary care hospital. In the interim, midazolam 0.5 mg IV was given to obtain a catheterized urine specimen; yet the blood pressure persisted at 160/85 mm Hg. Thereafter, IV hydralazine was given twice more and IV labetalol once more with blood pressure remaining at approximately 160/80 mm Hg. Transfer to the tertiary pediatric center was uneventful.
On arrival in the emergency department (ED), the parents confirmed that the patient was a previously healthy girl without any significant medical history. Family history was also unremarkable. The patient had no known drug allergies. On physical examination, vital signs included a temperature of 36.9??C, heart rate of 131/min, blood pressure of 150/76 mm Hg, respiratory rate of 20/min, and an oxygen saturation of 99% on room air. The patient weighed 21 kg. In general, she was a well-developed 4-year-old girl who was sleepy but arousable to voice. Oral examination revealed moist mucus membranes and 4 front teeth missing with no bleeding from the surgical site. Her neck was supple. The lungs were clear to auscultation bilaterally. The heart had a regular rate and rhythm with no murmurs, rubs, or gallops. Her abdomen was soft, nontender, and nondistended with normal active bowel sounds. There was no hepatosplenomegaly. Extremities were warm and well-perfused with brisk cap refill and no peripheral edema nor rash.
Laboratory studies performed at the outside hospital included a urinalysis with a specific gravity of 1.015 and pH of 6.0. Serum electrolytes demonstrated the following: sodium 138 mEq/L, potassium 4.0 mEq/L, chloride 106 mEq/L, bicarbonate 22 mEq/L, blood urea nitrogen (BUN) 13 mg/dL, creatinine 0.5 mg/dL, glucose 138 mg/dL, and calcium 8.4 mg/dL. Given the prolonged hypertension and somnolence, a computed tomography (CT) scan of the head without contrast was obtained, which was negative for pathology. Further diagnostic interventions at the tertiary center revealed the diagnosis.
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Jeffrey R. Dingman MDlow asterisk and Pavan P. Zaveri MD
Division of Emergency Medicine, Children’s National Medical Center, Washington, DC
University of Maryland Medical Center, Baltimore, MD