The Septic Teen with a Full Stomach
A 14-year-old, 55 kg, ASA IIE boy presents with a 2-day history of fever, vomiting, and right lower quadrant pain. Vital signs: HR 138, BP 82/44, RR 28, SpO2 96% on room air, T 39.1°C. He has vomited within the last 90 minutes and is drowsy but arousable. Labs: WBC 19.2, lactate 3.8 mmol/L, glucose 210 mg/dL. The surgical team wants to proceed emergently for suspected perforated appendicitis. The parents are at the bedside and ask why anesthesia cannot 'just put him to sleep quickly.'
1. How do you weigh aspiration risk against the urgency of source control, and what induction strategy do you choose?
Read the worked answer
This patient has multiple aspiration risk factors: recent emesis (90 min), bowel obstruction physiology, sepsis-induced ileus, and decreased consciousness. However, the source is a perforated viscus with lactate 3.8 - delay for gastric emptying is not acceptable.
Strategy: Rapid sequence induction with cricoid pressure is optional/debated; more important is minimizing time to a cuffed ETT. Use:
- Preoxygenation with CPAP/PEEP for 3 min (functional residual capacity is reduced by sepsis and supine position)
- Head-up 20–30° if hemodynamics tolerate
- Hemodynamic optimization BEFORE induction: 20 mL/kg balanced crystalloid bolus, consider push-dose phenylephrine or norepinephrine infusion to counter propofol/volatile vasodilation
- Induction: ketamine 1–1.5 mg/kg or etomidate 0.3 mg/kg (hemodynamically neutral); avoid propofol in this hypotensive state
- Succinylcholine 1.5–2 mg/kg (or rocuronium 1.2 mg/kg if hyperkalemia concern) - no contraindication here
- Cuffed ETT, verify with capnography, then NG/OG decompression
Reasoning: The exam tests that urgency does not eliminate aspiration risk; you mitigate rather than delay. Sedative doses must be reduced because sepsis increases brain sensitivity and reduces catecholamine reserve.
2. The parents ask about 'waking up during surgery.' How do you counsel them, and what monitoring do you use?
Read the worked answer
Awareness risk is elevated in: young age (though <14 is lower than adults), emergency surgery, hemodynamic instability requiring reduced anesthetic doses, and total intravenous anesthesia (TIVA). This patient fits at least two.
Counseling: Explain that depth of anesthesia is monitored continuously by clinical signs, end-tidal agent concentration, and - if TIVA - processed EEG. Do not overpromise; acknowledge the risk is small but real.
Monitoring:
- If volatile: maintain ≥0.7 MAC age-adjusted, monitor end-tidal agent; this alone reduces awareness risk substantially
- If TIVA (reasonable here for hemodynamic stability): use processed EEG (BIS or similar) targeting 40–60, recognizing that sepsis and hypothermia can alter readings
- Avoid paralysis without anesthesia; if using cisatracurium, train-of-four monitoring
- Document end-tidal agent or EEG values at intervals
Key point: The strongest protective factor is avoiding a paralysed-but-light patient. If you must reduce volatile for hypotension, add opioid and consider dexmedetomidine rather than dropping to sub-MAC.
3. Postoperatively he remains intubated and hypotensive despite 40 mL/kg crystalloid. What is your next step in fluid/vasoactive management and why?
Read the worked answer
After 40 mL/kg, further crystalloid risks edema and does not address the distributive (vasodilatory) component of septic shock. This is a classic 'fluid-refractory' septic shock picture.
Next steps:
- Start a norepinephrine infusion (first-line vasopressor in pediatric septic shock per Surviving Sepsis) - titrate to MAP ≥65 mmHg (age-appropriate, roughly 65 + [age × 1.5] for children, but for a 14-year-old, adult target applies)
- Consider epinephrine if myocardial dysfunction is present (echocardiography or ScvO2 <70%)
- Reassess fluid responsiveness with dynamic measures (passive leg raise, stroke volume variation) rather than static CVP
- Hydrocortisone if catecholamine-refractory and risk factors for adrenal insufficiency
- Source control (already done) and antibiotics
Reasoning: The exam tests recognition that ongoing hypotension after adequate volume resuscitation is vasoplegia, not hypovolemia. Continuing crystalloid causes tissue edema and worsens oxygenation. Norepinephrine is the correct escalation.