This week, I went on rounds with the pediatric ICU team. Thus far, I've only been exposed to perspectives by neurosurgeons, so it is interesting to hear things from the side of the pediatricians who handle the pre and post operative care.
There were some very difficult cases this week. The first involved a 3-year-old female patient with tumors in both her frontal and temporal lobes. She had been admitted because she was unresponsive likely due to bleeding in the tumor spaces and causing them to expand. She had previously been fitted with a ventriculoperitoneal shunt, and she also had vancomycin-resistant enterococci (VRE).
Enterococci are bacteria normally found in the gut. It is resistant to most antibiotics except for vancomycin. However, incorporation of a plasmid into several strains of enterococci have made them resistant to vancomycin as well. Furthermore, these enterococci are able to transfer vancomycin-resistance to unrelated strains of bacteria, such as MRSA, making them very dangerous.
Not everyone with VRE becomes symptomatic, but they are still carriers of the bacteria and are able to spread them. The bacteria produces proteases that digests the wall of the gut. In large enough numbers, the bacteria could produce sufficient proteases to compromise the integrity of the gut, allowing the bacteria to escape into the bloodstream. This can cause meningitis, pneumonia, and endocarditis.
Going back to the patient, her primary care doctor as well as her neurosurgeon had determined that there was nothing more they could do for her, and that any intervention would reduce the quality of life for the remaining days that she had. However, after a few days in the pediatric ICU, the patient regained consciousness, and was responsive. With this turn of events, the doctors and neurosurgeon had to reevaluate their recommendations, because while the general consensus was still that the patient would not recover, the predicted remaining lifespan of the patient had changed from a few days to a few months. The new question was whether further surgical intervention might improve the quality of her remaining life. After much discussion, it was determined that palliative care was the best option, as any intervention at this point would only lengthen the dying process.
A second difficult case involved a teenage male with Acute Lymphoblastic Leukemia (ALL). This disease occurs when abnormal lymphoblasts are unable to differentiate into lymphocytes, leading the bone marrow to overproduce lymphoblasts in a bid to compensate for the lower lymphocyte levels. The large increase in abnormal lymphoblasts crowds out the other blood components - red blood cells (responsible for oxygen distribution), other white blood cells (responsible for immune response), and platelets (responsible for clotting).
The first line of treatment is chemotherapy. If the abnormal lymphocytes invade the central nervous system, radiation therapy may be used to target these cells. If chemotherapy is unable to provide long-term remission, a bone marrow transplant may be necessary despite the significant risks associated with the procedure.
This patient had undergone a bone marrow transplant, but it was unsuccessful. Furthermore, he has severe respiratory problems. A tracheostomy was recommended even though his lungs were in terrible condition. Breathing is approximately 50% dependent on the system above the throat, while the other 50% is dependent on the system below the throat. As such, a tracheotomy will solve the top 50%, making the patient easier to manage. The tracheotomy will allow the patient to be off sedatives, since intubation is terribly uncomfortable. The tracheotomy will also give the patient added mobility, since the ventilator may only be required during treatment times. The ultimate goal of alleviating the respiratory problems as quickly as possible is to allow the medical team to focus on cancer treatment.
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