The Management of a Pediatric Patient Under General Anesthesia with Undiagnosed Primary Hypothyroidism: A Case Study

Hypothyroidism is a common endocrine disorder known to produce major metabolic and physiologic disturbances in an individual under general anesthesia. This case deals with the perioperative management of a pediatric patient with undiagnosed primary hypothyroidism, and illustrates the successful use of high dose epinephrine during an acute decompensation of a pediatric patient with significantly depressed thyroid function. During an elective tracheocutaneous fistula closure, the patient suffered an acute hypotensive event with hypoxemia, shortly following intubation. He initially received a 100mL lactated ringer (LR) bolus and 2 micrograms (mcg) of intravenous epinephrine, but his condition continued to deteriorate. Multiple additional LR boluses, a high dose corticosteroid, and exponential doses of epinephrine (totaling 150 mcg) were then given, which successfully elevated and sustained the patient’s blood pressure. The patient’s condition was initially attributed to a pulmonary hypertensive crisis and a viral pneumonia secondary to rhinovirus. However, the healthcare team later discovered the decompensation was connected to an undiagnosed primary hypothyroidism, and with proper management and use of hydrocortisone and synthetic thyroid hormone, the young boy made a full recovery. To our knowledge this is the first published report of a pediatric patient surviving general anesthesia with a TSH greater than 500 U/mL, and brings to note the importance of primary hypothyroidism being a possible etiology in an acute decompensation of the pediatric patient after the exclusion of alternate causes.