Multiple drugs

Abstract

Multiple drugs Lack of efficacy: 2 case reportsIn a case series of 5 patients, 2 female infants aged 40 days and 45 days were described, who exhibited lack of efficacy following treatment with epinephrine, norepinephrine, milrinone, nitric oxide or vasopressin for malignant pertussis [not all dosages and routes stated].A 45-day-old girl (Case 3 from the article) exhibited lack of efficacy following treatment with epinephrine, norepinephrine and milrinone for malignant pertussis. The girl presented with cough and shortness of breath. She was admitted to pediatric ICU for apnoea due to acute bronchiolitis. Her clinical condition remained unaltered with mild respiratory distress and hypoxia requiring O2 supplementation. Pertussis was suspected. She started receiving azithromycin. Echocardiography showed moderate tricuspid valve regurgitation. She was transferred to pediatric ICU of another hospital with diagnosis of malignant pertussis with hyperleukocytosis for further management. Upon transfer, she was hypoxic and haemodynamically unstable. She was administered epinephrine, norepinephrine and milrinone along with high-frequency oscillatory ventilation. Despite treatment with epinephrine, norepinephrine and milrinone, her condition progressively worsened to multi-organ failure with acute kidney injury, encephalopathy and coagulopathy. Her respiratory-panel PCR confirmed Bordetella pertussis and rhinovirus infection. She was started on broad-spectrum antibiotics with vancomycin and ceftriaxone along with azithromycin. Subsequently, she underwent leukapheresis and the WBC count dropped. After 10h, there was rebound hyperleukocytosis. Fatal cardiac arrest occurred after initiation of the second leukapheresis session. Cardiopulmonary resuscitation was performed without return of spontaneous circulation.A 40-day-old girl (Case 4 from the article) exhibited lack of efficacy following treatment with epinephrine, norepinephrine, milrinone, vasopressin and nitric oxide for malignant pertussis. The girl presented with cough, cyanosis and signs of mild respiratory distress. She was admitted to the pediatric ICU. Ampicillin and cefotaxime were administered. She was intubated due to repeated episodes of apnoea and bradycardia. Presence of Bordetella pertussis was confirmed on respiratory-panel PCR. She was diagnosed with malignant pertussis with hyperleukocytosis. Azithromycin was added to her antibiotic regimen. Echocardiography revealed tricuspid regurgitation with supra-systemic pulmonary hypertension. She was administered epinephrine, norepinephrine, milrinone and vasopressin along with high-frequency oscillatory ventilation (HFOV) with inhaled nitric oxide 20 ppm. Despite treatment with epinephrine, norepinephrine, milrinone, vasopressin and nitric oxide, her condition progressively worsened to multi-organ failure with acute kidney injury, acute encephalopathy, acute liver injury and disseminated intravascular coagulation. Subsequently, she underwent leukapheresis and the WBC count dropped. Her respiratory status gradually...