Sarah Isbey, MD Children’s National Medical Center

Case: 2 yo child with signs and symptoms consistent with Kawasaki disease however is a difficult intravenous access. This patient clearly needs fluid resuscitation as the case is not so straightforward for distributive vs. cardiogenic shock.

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Discussion:

As Dr. Agrawal stated, “kawa-shocky” disease is becoming a more and more well recognized phenomenon associated with KD. A group as UCSD Rady Childrens in 2009 published in Pediatrics regarding this entity which had not been previously described in the literature prior to 2003. Patients with Kawasaki disease shock syndrome more often had impaired left ventricular systolic function (ejection fraction of <54%: 4 of 13 patients [31%] vs 2 of 86 patients [4%]), mitral regurgitation (5 of 13 patients [39%] vs 2 of 83 patients [2%]), coronary artery abnormalities (8 of 13 patients [62%] vs 20 of 86 patients [23%]), and intravenous immunoglobulin resistance (6 of 13 patients [46%] vs 32 of 174 patients [18%]). Impairment of ventricular relaxation and compliance persisted among patients with Kawasaki disease shock syndrome after the resolution of other hemodynamic disturbances.

Compared with hemodynamically normal KD, KDSS is associated with increased inflammation, platelet consumption, IVIG resistance, coronary artery abnormalities, mitral
regurgitation, and myocardial dysfunction.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848476/pdf/nihms-178280.pdf

How to place an IO in an awake patient:

Once the catheter is in position one should be aware that infusion pain will occur in the conscious patient. For this reason, it is recommended that awake patients receive 2% lidocaine without preservatives or epinephrine via the EZ-IO catheter prior to any flush, bolus, or infusion.

• If prescribed by a provider, the 2% lidocaine without preservatives or epinephrine (cardiac lidocaine) must be infused slowly (over one minute) to prevent it from being sent directly into the central circulation. Medications intended to remain in the medullary space, such as a local anesthetic, must be administered very slowly until the desired anesthetic effect is achieved.

• Prime extension set with lidocaine in these situations.

• The dosing of lidocaine must follow local protocols. Health care providers have reported achieving effective pain management with as little as 20 mg and some patients that need as much as 100 mg.

• Titrate lidocaine to effect and repeat as needed to a max dose of 3 mg/kg in 24 hours.

• Lidocaine dosing for pediatric patients is 0.5 mg/kg.

Denouement:

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