Article

Surfactant for the management of pediatric hydrocarbon ingestion

American Journal of Emergency Medicine 36 (2018) 2260-2262

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American Journal of Emergency Medicine

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Brief Report

Surfactant for the management of pediatric hydrocarbon ingestion

Christopher Sommer, PharmD a, Adam B. Johnson, MD d, G. Sam Wang, MD, b, Kevin Poel, PharmD, c,?

a Department of Pharmacy, Children’s Mercy Hospitals and Clinics, Kansas City, MO, United States of America

b Department of Emergency Medicine, University of Colorado Denver, Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, CO, United States of America

c Department of Pharmacy, Children’s Hospital Colorado, Aurora, CO, United States of America

d Wake Forest University School of Medicine, Winston Salem, NC, United States of America

a r t i c l e i n f o

Article history:

Received 24 August 2018

Accepted 14 September 2018

Introduction

Hydrocarbons are a common source of ingestion in children and en- compass a wide array of compounds that include essential oils, lighter fluids, and household cleaners [1]. Toxicity after ingestion depends on the chemical properties of each compound including viscosity, volatility, surface tension and lipophilicity [2].

In 2016, over 27,000 known cases of single-substance hydrocarbon exposures were reported to the National Poison Data System (NPDS); 8821 of these were children <=5 years old [3]. Patients can present with a range of symptoms from none to rapid pulmonary toxicity or cardiac arrhythmias. Treatment modalities include: high-frequency ventilation, bronchodilators, corticosteroids, surfactant, and extracorporeal mem- brane oxygenation [1,4-6].

We describe a case series of seven hydrocarbon ingestions and asso- ciated aspirations, along with management at a pediatric tertiary care hospital, focusing on the potential efficacy for the off-label use of surfac- tant for severe pneumonitis in two of the cases.

Cases

A retrospective review from August 2013 to May 2016 of all patients

>=31 days old and <=10 years old evaluated by the medical toxicology ser- vice for hydrocarbon ingestions was performed (Table 1). Patients were identified from toxicology service billing census for hydrocarbon inges- tion or aspiration. A total of 7 patients were identified, and the following 2 cases received surfactant therapy due to significant pulmonary toxicity.

* Corresponding author at: Department of Pharmacy, Children’s Hospital Colorado, 13123 E. 16th Ave, Aurora, CO 80045, United States of America.

E-mail address: [email protected] (K. Poel).

Case 1

A previously healthy 17-month-old female presented to the emer- gency department (ED) from a referring health care facility approxi- mately 9 h after ingestion of approximately 1 Oz of citronella- containing candle fluid (brand unknown). Immediately after ingestion, the patient developed cough, emesis, and agitation. At the referring fa- cility, patient developed intercostal retractions, stridor, and hypoxia. Her vital signs (VS) consisted of: heart rate (HR) of 178 beats per minute (bpm), respiratory rate (RR) of 32 breaths per minute, oxygen (O2) sat- uration of 93% on room air, and afebrile temperature. A Blood pressure was not reported. Initial labs (serum) were significant for a potas- sium of 2.8 mEq/L, bicarbonate of 17 mEq/L, and a lactate of 2.41 mg/dL. She was given dexamethasone 6 mg IV, placed on continuous albuterol via nebulization, 1 L O2 by way of nasal cannula, and started on mainte- nance IV fluids. A Chest x-ray was performed and demonstrated a right lobe infiltrate concerning for pneumonitis. Upon arrival to our fa- cility her VS were: HR of 154 bpm, RR of 46 breaths per minute, afebrile, and an O2 saturation of 86% on room air, so she was placed back on 1 L nasal cannula. Four hours after presentation her respiratory status con- tinued to worsen and she was escalated to 8 L heated high-flow nasal cannula (HHFNC). Approximately 1 h later, she was escalated to BiPAP and eventually intubated 14 h after ingestion. Her initial ventilator set- tings (Servo I-vent) were 100% FiO2, SIMV/VC/pressure support, a rate of 28, tidal volume of 60 mL (5.8 mL/kg), pressure support above PEEP of 8, and PEEP/CPAP of 9. An arterial blood gas 2 h after intubation showed a pH of 7.23, PCO2 of 55 mm Hg, PO2 of 87 mm Hg, HCO3 of 22 mEq/L, a Base deficit of 5.4 mEq/L, and an O2 saturation of 92%. One hour later, due to an oxygenation index (OI) persistently N10, 1260 mg (3.5 mL/kg) of surfactant (calfactant, Infasurf(R), ONY, Inc., Am- herst, NY) was administered (18 h after ingestion) via endotracheal tube in four separate aliquots as described by Wilson and colleagues [7]. Her Ventilator settings continued with a rate of 28, but the following were changed: tidal volume of 62 mL (6 mL/kg), pressure support above PEEP of 10, and PEEP/CPAP of 10. A repeat ABG 1 h later remained un- changed and norepinephrine, epinephrine, dopamine, and stress dose steroids were started for decreasing blood pressures and concern for progression to ARDS requiring extracorporeal support. Ventilator set- tings were increased to PEEP/CPAP of 12 with a maximal OI of 18. Amoxicillin/clavulanate was started for concern for aspiration pneumo- nia and the patient was also paralyzed to decrease metabolic demand.

https://doi.org/10.1016/j.ajem.2018.09.016

0735-6757/(C) 2018

C. Sommer et al. / American Journal of Emergency Medicine 36 (2018) 22602262 2261

Table 1

Summary of Hospital courses.

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Patient 7

Age

14 months

18 months

17 months

21

33 months

21 months

19 months

months

Agent aspirated

Tiki torch

Paint

Citronella torch

Paraffin

Paint thinner

Grill lighter

Tiki torch

fluid

thinner

fluid

oil

(xylene-containing)

fluid

fluid

Required intubation?

No

No

Yes

No

Yes

No

Yes

Duration of invasive mechanical

N/A

N/A

6 days

N/A

18 h

N/A

60 h

ventilation Received surfactant?

No

No

Yes

No

No

No

Yes

Duration of hospitalization

20 h

8 days

11 days

23 h

2.5 days

2 days

10 days

Presentation and hospital course summarized for the seven patients included in this case series.

She remained on mechanical ventilation for six days. The OI trended downwards several hours after surfactant administration. She was extubated to 1 L HHFNC and slowly weaned down on pressor support over the first four days. She was then weaned to 1 L nasal cannula, and ultimately discharged on room air on hospital day 11.

Case 2

A previously healthy 19-month-old female presented to the ED ap- proximately 10 min after she was found outside with a can of “Tiki Torch fluid” (As reported by father of child, brand unknown, ingestion amount unknown) by her father. The patient was initially noted to be unbalanced and sleepy with a flushed face. She developed worsening cough and emesis when given water to drink. Over the next few mi- nutes, she became more lethargic and had worsening respiratory dis- tress. Upon ED arrival, she had poor air movement and dyspnea, with a prolonged expiratory phase. Positive pressure was delivered via bag mask. A venous blood gas (VBG) upon arrival showed a pH of 7.08, pCO2 of 65 mm Hg, HCO3 of 20 mEq/L, and base deficit of 10 mEq/L. She was lethargic with a BP of 85/69 mm Hg, HR of 144 bpm, RR of 18 breaths per minute, and O2 saturation of 89%. Her VS improved with ad- ministration of 20 mL/kg of normal saline. She was intubated after ad- ministration of etomidate and rocuronium. A post-intubation CXR revealed bilateral perihilar opacities and a left lower lobe infiltrate. 1260 mg (3 mL/kg) of surfactant (calfactant, Infasurf(R), ONY, Inc., Am- herst, NY) was administered 60 min after ED presentation via endotra- cheal tube in four separate aliquots as described by Wilson and colleagues [7]. Her initial ventilator settings upon transfer to the PICU were synchronized intermittent ventilation/volume control pressure support (Servo-I) with an FiO2 of 40%, rate of 26, tidal volume of 70 mL (6 mL/kg), and a PEEP of 8. The patient experienced acute wors- ening overnight within 24 h of ingestion due to bronchospasm, and a re- spiratory viral panel suggested concomitant rhino/enterovirus pneumonitis. She was started on continuous albuterol (7.5 mg/h for 15 h) and a course of methylprednisolone 1 mg/kg intravenously (IV) every 6 h weaned to prednisolone 1 mg/kg orally (PO) daily for 14 days total. Her ventilator settings were weaned as tolerated and she was extubated to CPAP approximately 60 h after ingestion. She was de-escalated to room air 24 h after transition to CPAP and discharged home 10 days after initial ingestion.

Discussion

Our case series suggests most pediatric hydrocarbon ingestions do not require invasive airway intervention, and management of hydrocar- bon aspiration depends largely on the initial presentation and risk of acute respiratory decline [1,8]. G.R. Bond et al. describe a proposed tri- age decision rule to determine if a patient between 3 and b5 years old presenting within 2 h of a hydrocarbon ingestion will require interven- tion of any kind or not. Their decision rule states that if wheezing, tachypnea or altered mental status is not present, the patient can be ob- served at home as complications are very unlikely. The work done by

this group was intended for Developing countries, but can apply to the developed world too [10].

Care for patients, post hydrocarbon ingestion and aspiration with progression to respiratory failure requiring mechanical ventilation con- sists largely of supportive care [9]. However, administration of exoge- nous surfactant has been reported to be a safe option with positive patient outcomes as an adjunct therapy for hydrocarbon lung injury in children, though the timing of administration is highly variable [5,6]. Wilson and colleagues report the only randomized controlled trial of surfactant use in pediatric acute lung injury (not specific to hydrocarbon aspiration) [7]. Respiratory parameters for inclusion consisted of being within 48 h of initiation of mechanical ventilation, parenchymal lung disease confirmed by radiography (pneumonia, ARDS, sepsis, Near drowning, Acute chest syndrome) and having an OI N7. Patients received one 80 mL/m2 dose of surfactant (calfactant, Infasurf(R), ONY, Inc., Am- herst, NY) and a second dose 12 h later if OI remained above 7. Fifty five percent of treatment group patients demonstrated an OI decrease of 25% or more after the first dose of surfactant (compared to 33% in the placebo group). Overall, in-hospital mortality was 28% across all pa- tients (19% in the treatment group vs. 36% in the placebo group; p = 0.03). Common adverse effects in the treatment group were hypoten- sion (9% vs. 1%) and transient hypoxia during administration (12% vs. 3%) [7]. Mastropietro and colleagues describe the administration of surfactant (calfactant, Infasurf(R), ONY, Inc., Amherst, NY) to a 19- month-old approximately 10 h after lamp oil ingestion when OI and peak inspiratory pressures failed to improve on escalating venti- lator support [5]. It is important to note that 1 mg/kg of methylpred- nisolone was given prior to surfactant administration and surfactant was delivered in two separate aliquots. The patient’s OI and peak in- spiratory pressure decreased initially, however, the oxygenation index was noted to worsen again approximately six hours after the first dose of surfactant. A second dose of surfactant was given and the patient was successfully extubated approximately 64 h after in- gestion [5]. Richards and colleagues similarly reported the rapid ad- ministration of surfactant (calfactant, Infasurf(R), ONY, Inc., Amherst, NY) to an 18-month-old within 1 h after ingestion of tea tree oil [6]. The patient was successfully extubated on hospital day 2 and discharged on day 3. No adverse effects were attributed to surfactant administration in the previous reports but were seen in the larger trial by Wilson and colleagues [5-7].

Two of the three patients requiring intubation in this series were administered surfactant. The patient that did not receive surfactant had greatly improved blood gases shortly after intubation and was rapidly weaned to extubatable settings within 24 h. The concern for delayed pulmonary effects was low as the patient presented with altered mental status, suggesting that her need for intubation was secondary to CNS-related adverse effects rather than pneumoni- tis. There was a difference in time to extubation and hospital stay with patient five versus patients three and seven. The lack of aspira- tion may have contributed to her rapid time to extubation compared to the other two intubated patients who received surfactant for worsening lung disease.

Declaration of interest/financial disclo”>2262 C. Sommer et al. / American Journal of Emergency Medicine 36 (2018) 22602262

Conclusions

The management of hydrocarbon aspiration varies greatly, primarily due to the heterogeneity of the hydrocarbon class of compounds and wide spectrum of clinical presentation. The complications of pneumoni- tis can evolve over a week or more and may lead to a prolonged hospital stay and even death. For patients with Rapid progression of ARDS, al- though human experience is limited, surfactant could be considered as an appropriate option prior to pursuing more invasive treatment options.

Declaration of interest/financial disclosures

None for all authors.

Author contributions

KP, ABJ, GSW and CS conceived of the case series and assisted in obtaining IRB approval and dataset. CS performed data collection and drafted the manuscript. All authors contributed to revision and final ap- proval. KP takes responsibility for the manuscript in full.

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