1/2/19, 17 y/o female with significant global developmental disorder and no speech, presented to pediatrician with c/o constipation, no appetite, fatigue and low grade fever. Relevant vitals: temp-99.8, O2 sat 90%.
Dx included UTI and Macrobid 100mg BIDX5days. Urinalysis on 1/3 confirmed bacteria.
F/U 1/7/19. Essentially norma PE. Pulse 127, temp 98.2, O2sat 95%
F/U 1/11/19 Essentially normal PE. Pulse 120, temp 98, O2sat 96%
F/U 1/16/19 Other than patient pale, PE essentially normal. Temp 97.6, O2sat 96%
lungs clear. Relevant labs: WBC 13.8, Hg 8.3, Hct 26.4, Seg 78%, absolute neut count 10.8,
alb/glob ratio 0.4
Imp: Iron deficiency anemia
1/23/19 labs drawn. (no OV). WBC 12.6, Hg 7.2, Hct 22.9, Bands 18%, absolute neut count 9.6, Ferritin 966, IGG 1780
On 1/26/19, patient admitted to hospital with fulminant septic shock 2' to necrotizing pneumonia req mechanical ventilation. VVECMO started and pt transferred. Finally discharged stable on 3/24/19.
Should pediatricians have intervened sooner and if so, would it have prevented pseudomonas sepsis.
Files:
Q: Was there a cough at any point?
A: —
Q: What was the PE on the first day with O2 sat at 90%?
A: —
Do you believe there might have been medical error?
The patients oxygen saturation at initial presentation was 90% which meets the criteria for hypoxia. There is no mention of the patient having a cough but for a nonverbal ill patient with hypoxia a CXR would have been indicated. There is no documentation of a urine culture having been performed - just a urinalysis - so there’s no way to know what organism was being treated and if that organism was sensitive to the chosen antibiotic. The patient was noted to be tachycardic on 1/7 and 1/11 yet no investigation was made. Labs on 1/23 show a bandemia and elevated inflammatory markers yet nothing was done.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There were multiple subtle red flags that all was not well after treating the UTI yet no further attempt at elucidating the cause was made. No explanation for the initial hypoxia, no explanation for the tachycardia or anemia, no explanation for the bandemia and elevated ferritin. Perhaps had further studies been done the patient could have been diagnosed prior to developing septic shock. It’s possible that had a CXR been ordered the pneumonia could have been diagnosed before it progressed. Assuming the organism came from the urine, had a urine culture been performed it would have been obvious that the macrobid would not effectively treat pseudomonas.
What makes you a good expert for this case?
I have been treating similar patients my entire 17 year career. I have a fair number of developmentally delayed non verbal teenage patients and they can be challenging to treat effectively.
How often do you encounter cases similar to this one in your practice?
Occasionally I see patients with necrotizing pneumonia. I do not generally see patients where an ineffectiveness treated UTI progresses to sepsis and pneumonia.
Do you believe there might have been medical error?
O2 sat was low at initial presentation, but in this apparently debilitated child this might have been her baseline. For example, a child like this might have a history of chronic aspiration and bronchiectasis. Bronchiectasis would explain the presence of pseudomonas in the airway. While an exacerbation of bronchiectasis would lead to an x-ray that could be interpreted as showing pneumonia, it would be unusual for this to lead to sepsis. None of the additional information provided suggests clues that the child might have been developing pneumonia or sepsis. Further, if the physician were a general pediatrician, expectations regarding diagnosis and management of a child like this are lower than for a pediatric subspecialist, but even for the latter, I see nothing in the description of the case suggesting medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If evidence (not provided) suggests medical error, then it is possible that the prolonged hospitalization and need for ECMO might have been avoided. However, as the child is described as having been discharged "stable", the injury would just be limited to what was incurred during the hospitalization.
What makes you a good expert for this case?
Pediatric pulmonologist with >30 years of experience in an academic setting.
How often do you encounter cases similar to this one in your practice?
I frequently care for children with neurologic/developmental disorders who have chronic and acute respiratory infections and prolonged hospitalizations.. However, the progression to pseudomonas sepsis and ECMO is unusual
Do you believe there might have been medical error?
It appears standard of care was not met in the care of this patient however I have some questions and comments. These will be brought up for each visit. 1/2 How was Uti diagnosed. how was urine collected in this severely handicapped patient. If it was not a cath specimen it would not be clean. Was a culture sent and what did it show. Also O2 says 90 percent is troublesome. Was an X-ray considered 1/7, 1/11. Why were these followup visits done 1/16 Is paleness new or chronic. Pt significantly anemic, is it new or chronic. How was iron deficiency anemia diagnosed. There are many other causes of anemia in a chronically ill patient and were these considered 1/23Why were labs drawn with no office visit? Child still anemic. 18% bands suggest serious bacterial infection. What was platelet count?. Did child show any other signs of impending sepsis and pneumonia such as tachycardia, fever, low body temp, tachypnea, ,poor perfusion, etc that would suggest that admission would be indicated?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If early signs of sepsis or pneumonia were present this patient could have been admitted earlier and the severe outcome could have been prevented
What makes you a good expert for this case?
I am a board certified pediatrics with over 20years experience caring for children with special needs, multiple handicaps and who are technology dependent. I have taken care of these children in an office setting, the emergency department and the hospital setting.
How often do you encounter cases similar to this one in your practice?
When I was in private practice I would see children like this weekly and now that I work in the emergency department I see them monthly
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