Managing Persistent Hypertension and Tachycardia Following Septic Shock, Limb Ischemia, and Amputation: The Role for β-Blockade

Abstract

A 6-year-old previously healthy Hispanic female presented to her primary care provider and later to the emergency department (ED) with 1 day of emesis and fever. She was conservatively managed for a suspected viral syndrome and discharged home. Two days later, her symptoms progressed with new-onset tachypnea, left lower extremity pain, and abdominal pain, prompting return to the ED. Her presentation was concerning for acute respiratory failure as well as significant left lower limb edema, pain, petechiae, and purpura on examination. Baseline laboratory results included white blood cells 18.8 cells/mm3, platelets 31 cells/mm3, lactate 10 mg/dL, and international normalized ratio 2.7. Arterial blood gas revealed severe acidosis with pH 7.17. Blood and wound cultures grew group A streptococcus. There was no radiographic evidence of osteomyelitis on plain films; however, magnetic resonance imaging showed worsening left lower extremity muscular edema and a subperiosteal abscess. The patient was emergently intubated, and administered fluid resuscitation, epinephrine norepinephrine, and vasopressin for severe group A streptococcus septic shock with secondary disseminated intravascular coagulopathy, limb ischemia, and multiorgan failure. Empiric cefepime and clindamycin were initiated. Given the degree of limb ischemia, extensive irrigation and debridement and a 4-compartment fasciotomy were performed. In the intensive care unit, the patient required management of multisystem complications from septic shock including continuous renal replacement therapy for anuric acute kidney injury, and heparin infusions for disseminated intravascular coagulopathy. She underwent below-the-knee amputation of the left lower extremity, through-the-ankle-amputation of the right lower extremity, and multiple days of soft tissue debridement in an attempt to obtain source control. The patient’s hemodynamic and overall clinical status subsequently improved with no further decompensation, warranting transfer to the general pediatrics unit. All antibiotics were discontinued during the fifth week of hospitalization. Her lower extremity amputation sites were managed with biweekly dressing changes and showed appropriate formation of granulation tissue with viable skin and muscle throughout. Autologous splitthickness skin grafts were transplanted to the bilateral lower extremities. Interestingly, the patient was noted to be persistently tachycardic and hypertensive throughout her acute management in the intensive care unit and while recovering in the general pediatrics unit (Figure 1). Her median systolic blood pressure (SBP) and diastolic blood pressure (DBP) was 112 mm Hg (interquartile range [IQR] = 108-117, 99th percentile for age and height) and 72 mm Hg (IQR = 67-83, 95th percentile), respectively, for the first 2 months of admission. Similarly, her median heart rate (HR) was 149 beats per minute (BPM; IQR = 138148), which was tachycardic for her age (reference range = 70-115 BPM for a 6-year-old female). A broad differential diagnosis was considered for persistent tachycardia and hypertension including cardiovascular, infectious, neurological, hematologic, and iatrogenic etiologies. Electrocardiogram showed normal sinus rhythm and echocardiogram revealed normal biventricular systolic function with no valvular vegetations suggestive of bacterial endocarditis or rheumatic heart disease. Furthermore, the absence of a fever, appropriate wound healing, and repeatedly negative 1006704 CPJXXX10.1177/00099228211006704Clinical PediatricsBrewster et al brief-report2021