This case involves the delivery of triplets on April 29, 2010 at 26 weeks 6 days gestation.
The patient was diagnosed with a short cervix via sonogram on 3/30/10.She was in the hospital on 3/31/10 due to a herpes outbreak. She was prescribed terbutaline pump and home monitoring and discharged on 4/1/10. She had multiple visits to her OB after that date. She went into PTL on 4/29/10 and after an hour and a half a decision was made to C/S deliver due to increasing cervical dilatation.
Our OB and pediatric neurologist have opined that it was a departure not to have administered steroids for lung development and magnesium sulfate for neuro-protection until the morning of delivery.
Two of the children have severe injuries. Aiden has been diagnosed with cerebral palsy with developmental delays and Jonathan has been diagnosed with physical, cognitive and speech delays.
We are investigating whether there were any departures form from the standard of care with regard to these two babies. We have summarized some points that we feel may require further analysis:
Aiden Baby 1
INITIAL MANAGEMENT: This baby was born extreme premature 26 weeks and weighing 860grams with APGAR of 7 and 8 requiring PPV at birth and then was shifted to NICU on CPAP. Yet they didn’t do Cord gas, didn’t instill Surfactant inspite of the kid having Respiratory distress because of hyaline membrane disease.
INEFFECTIVE VENTILATION: This baby was extreme premature and yet the care givers preferred to ventilate the child on CPAP rather than on HFOV or conventional ventilation PRVC mode. As a result the ventilation was ineffective which resulted in multiple episodes of hypoxia, hypocarbia, acidosis, hypercarbia The baby had many episodes of desats and bradycardia yet they continued to Rx the baby on NCPAP with 21% Fio2 (482,494,541,544/902). All these episodes
lead to hypoxic brain damage and Bilateral PVLs which resulted in Global developmental delay and cerebral Palsy.
The baby was administered gives Aminophyline? I mean in this era of caffeine citrate as a Rx for Prevention and Rx of apnea why are the care givers preferring to give Aminophyline which has so many side effects including sudden cardiac arrest.
HYPERGLYCEMIA: This kid had many episodes of hyperglycemia; The Heel glucose levels were consistently rising yet they didn’t address the issue and it did actually resulted in fungal UTI/ septicaemia.
Jonathan baby 2
1) INITIAL MANGEMENT: This baby was born weighing 907 grams with 26 -27 weeks gestation and was asphyxiated at birth with APGAR of 1 and 7 at 1 and 5 minutes of life, didn’t have respiratory effort was hypotonic, limp and cyanosed and was resuscitated with oxygen, bag-mask ventilation and intubated too. Further they did cord gases, instilled surfactant in view of the child having respiratory distress due to hyaline membrane disease, the X-ray chest confirmed the diagnosis. However a repeat X-ray chest done next day does reveal a persistent ground glass appearance suggesting that the HMD hasn’t cleared fully which means a repeat Surfactant dose was indicated but unfortunately wasn’t administered. Do most of these extreme premature babies do need 2 or 3 doses of surfactant in first 24 hours of life? Thus preventing prolonged oxygenation and need for prolonged ventilation and CPAP and avoiding repeated desats, hypoxia and hypercarbia which occurred in this child.
2) VENTILATION STRATEGIES: Initially during resuscitation the baby was intubated and ventilated and then was continued on IMV mode with Fi02 of 100 %, further baby was weaned to 58% and later weaned to NCPAP at 40% Fi02, then weaned to fi02 28% and thence to 0.21 and then was successfully weaned off O2 to RA and baby remained off oxygen and discharged with out requiring oxygen support at home. This appears to be a correct plan to accept sats of 90-95 and Pco2 of 40 to 45 and Pa02 of 55 to 60. There were few episodes of desats and bradycardia mostly due to apnoea of prematurity but the baby responded to stimulation but would not starting caffeine citrate have helped? Finally the baby had severe episodes of desats, apnoea, bradycardia and cyanosis hence baby was started on Aminophyline and they did start caffeine later on.
3) APNEOA OF PREMATURITY: Baby had multiple episodes of desats , apnoea , bradycardia which responded to stimulation initially but later on needed Aminophyline they even suspected Late onset sepsis and hence sent blood culture and upgraded antibiotics to Vancomycin and Amikacin and cultures were negative.
Files:
No questions yet!
Do you believe there might have been medical error?
Antenatal betamethasone is given to mature lung function. Without additional information it appears the obstetrician appropriately began antenatal steroids. Infants born at this gestational age are at higher risk of neonatal complications and multiples exacerbate this. The use of nasal CPAP is quite reasonable in a preterm infant with spontaneous ventilation. There is no harm in beginning with nasal CPAP and subsequently intubating if fails CPAP. Rescue surfactant would then be given if criteria are met. Would not describe Apgars of 1 and 7 in a premature infant as being asphyxiation. Looks like a good response to resuscitation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As described above. Need more details about neonatal course not provided here.
What makes you a good expert for this case?
I am a board certified neonatologist with over 38 years of clinical experience. I have been medical director of 2 Level III NICUs and was a regional trainer of NRP.
How often do you encounter cases similar to this one in your practice?
Not infrequently. We cared for about 75 infants below 1500 grams at birth and all gestational ages as low as 23 weeks.
Do you believe there might have been medical error?
Baby Aiden 1. The standard of care is to give antenatal steroids in cases of imminent preterm delivery if the baby is considered to be viable. The research data show that even 12 hours of exposure to steroids will mature the babys lungs to some degree. 2. It is not the standard of care to manage a <1000 gm baby with CPAP. Typically such a baby would have been intubated and given surfactant right away. 3. It is true that we do not use aminohylline in premature babies. 4. Hypergylcemia can act as an osmotic agent and draw in flid into cerebral capillaries and lead to rupture and intracranial bleeds. This should have been corrected right away. Baby Jonathan 1. In cases of severe RDS more than one dose of surfactant is often needed. The initial dose is most effective of given within 2 h of birth and the next dose within 24 h of birth. Careful monitoring of the response to therapy is needed to decide when to change the mode of ventilation etc. 2. Apnea of prematurity should have been anticipated and often caffeine is started prophylactically. It is unsafe to decide to send a baby home if apneas are occurring
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Aiden 1. Lack of antenatal steroids definitely did not give the possibility of some degree of maturation of the lungs 2. The hours of ineffective ventilation would have definitely worsened the lung injury and alos caused brain damage from the episodes of hypoxia. 3. Hyperglycemia very likely contributed to IVH Jonathan 1. A repeat dose of surfactant would most likely reduced the days on a ventilator 2. Untreated apnea of prematurity with repeated desaturations would have likely affected his brain
What makes you a good expert for this case?
I am a tenured Professor of Pediatrics and Neonatology at the University of Illinois at Chicago. Previously I worked at the University of California San Francisco and then at UCLA for 24 years. I am a physician scientist and have over 190 publications. As a Board Certified Pediatrician and Neonatologist who has had over 40 years of clinical experience in major University Hospitals I have encountered a myriad of complicated cases in neonatology. I was also the Head of the Department of Pediatrics and the Physician in Chief of our Children’s Hospital, and in that capacity I oversaw standards of care in all areas especially in the Division of Neonatology. I have served as expert witness in many cases, both for the plaintiff and the defendant, as well as testified in court. My biosketch and CV are available upon request.
How often do you encounter cases similar to this one in your practice?
WE do not have such cases in our in-born babies as I have always worked in an academic center however they do occur often in our outborn cases
Do you believe there might have been medical error?
1. Surfactant was not given and the mother did not receive antenatal steroids.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
1. Not giving surfactant. 2. Continuing with the non-invasive mode of ventilation with hypoxia, hypercarbia, and acidosis.
What makes you a good expert for this case?
I have practiced at a level III academic center for 10-plus years and trained fellows and residents. I review cases regularly.
How often do you encounter cases similar to this one in your practice?
I practice in a busy academic center and encounter similar cases regularly.
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