What is the management plan for a 14-year-old patient with cerebral palsy (CP) and epilepsy, on Tazocin (piperacillin/tazobactam) and anti-epileptic drugs, with a recent episode of bleeding from the tracheostomy site, a sacral ulcer, and no current venous thromboembolism (VTE) prophylaxis?

Management of Tracheostomy Bleeding and VTE Prophylaxis in a 14-Year-Old with CP and Epilepsy

For this 14-year-old patient with cerebral palsy, epilepsy, and tracheostomy bleeding, VTE prophylaxis should be initiated as the benefits outweigh the risks, while the tracheostomy bleeding requires careful assessment and management. 1

Subjective

• 14-year-old female with cerebral palsy and epilepsy
• Mother reports blood coming out of tracheostomy during suctioning (approximately one tablespoon)
• Mother was attempting to place the tube at the time
• No fever, pain, dysphagia, or discharge reported
• Recently discharged from ICU due to epilepsy
• Currently on day 2 of Tazocin (piperacillin/tazobactam) and anti-epileptic medications
• Not currently on VTE prophylaxis

Objective

• Patient appears well, not in distress
• Not pale
• Vitally stable with oxygen saturation 99% on 4L
• Sacral ulcer present without discharge
• Laboratory values:
  • Hemoglobin 12.9 g/dL (unremarkable)
  • Other labs unremarkable
  • Blood culture, urine culture, and sputum culture pending

Assessment

1. Tracheostomy Bleeding

• Minor bleeding likely related to trauma during tube placement/suctioning 1
• Bleeding appears self-limited (one tablespoon) without ongoing active bleeding 1
• Hemoglobin is stable at 12.9 g/dL, indicating no significant blood loss 1
• Bleeding from tracheostomy sites can range from minor to life-threatening, with causes including:
  • Traumatic suctioning 2
  • Local granulation tissue 2
  • Local infection 2
  • Rarely, tracheo-arterial fistulae (which would present with more significant bleeding) 1

2. Infection Risk

• Currently on Tazocin (piperacillin/tazobactam) day 2
• Sacral ulcer present without signs of infection
• Awaiting culture results to guide antimicrobial therapy 3
• Piperacillin/tazobactam is appropriate empiric coverage while awaiting culture results 3

3. VTE Risk Assessment

• Multiple risk factors for VTE present:
  • Reduced mobility due to cerebral palsy 1
  • Recent ICU admission 1
  • Presence of tracheostomy 1
  • Presence of sacral ulcer (indicating limited mobility) 1
• Currently not on VTE prophylaxis 1

Plan

1. Tracheostomy Management

• Assess tracheostomy tube placement and patency 1
• Implement gentle suctioning technique to minimize trauma 1
• Ensure proper tracheostomy care:
  • Use appropriate suction catheter size (half the internal diameter of the tracheostomy tube) 1
  • Maintain sterile technique during suctioning 1
  • Ensure proper securement of the tracheostomy tube to prevent displacement 1
• Monitor for signs of continued bleeding 1
• Have emergency tracheostomy equipment at bedside including:
  • Functional suctioning system
  • Oxygen source
  • Manual resuscitation bag
  • Complete tracheostomy kit 1

2. Infection Management

• Continue Tazocin (piperacillin/tazobactam) pending culture results 3
• Monitor for adverse effects of piperacillin/tazobactam including:
  • Bleeding manifestations (particularly with renal impairment) 3
  • Seizures (particularly important in this patient with epilepsy) 3
  • Electrolyte abnormalities 3
• Assess sacral ulcer daily and implement pressure relief measures 1

3. VTE Prophylaxis

• Initiate VTE prophylaxis with LMWH as the patient has multiple risk factors for VTE and no active significant bleeding 1
• Low-molecular-weight heparin (LMWH) is preferred in pediatric patients with VTE risk factors 1
• The small amount of tracheostomy bleeding that has occurred is not a contraindication to prophylactic anticoagulation, as it appears to be minor and self-limited 1, 4
• Monitor for signs of bleeding with daily hemoglobin checks 1
• If platelet count drops below 50 × 10^9/L, consider dose adjustment of LMWH 1

4. Neurological Management

• Continue anti-epileptic medications as prescribed 3
• Monitor for seizure activity, particularly as piperacillin/tazobactam may lower seizure threshold 3

5. Follow-up

• Daily assessment of tracheostomy site 1
• Review culture results when available and adjust antibiotics accordingly 3
• Monitor hemoglobin levels daily to ensure no significant bleeding 1
• Reassess need for VTE prophylaxis daily based on mobility status and bleeding risk 1