6/11/21 at 10:30pm, 3 y/o female admitted to a children's hospital following MVA. Monitored in hospital and due to increasing pain, decision made to go to OR on 6/13/21 at 8:27am. (34 hours post admission). Intraoperatively, found large amount of fluid and fibrinous exudate. Also noted turbid fluid and succus material. 2 areas of mesenteric tear and perforation found and repaired in mid small bowel area. Surgery end 11:13am. Antibiotics ordered Ceftriaxone 1100mg IVPB and then q24H and Metronidazole 550mg IVPB and then q24H. At 12:46pm HR 169; RR 33; BP 77/52. 4:00pm, HR 175;RR 54; BP 105/62. 6:00pm, HR 150's-170's; SBP 100's/60's; RR 40-50. 8:00pm, HR 182; RR60. 12:35am on 6/14/21, CXR lung volumes low with diffuse hazy opacities bilaterally that are new. 7:00am fever at 101.5. 8:00am temp 104. 8:30am began to desaturate. 9:27am DX was compensated shock. 12:25pm CODE BLUE. (Resp. arrest secondary to sepsis). 1:03pm ECMO surgery. 4:18pm Vancomycin added to cefepine and metronidazole. ID consult on 6/16/21 documented septic shock from peritoneal source due to small bowel perforation. Added Micofungin IV 5mg/kg. Child was never stabilized and continued to deteriorate and coded multiple times on 7/1/22. Pronounced at 12:59pm.
I am NOT looking for standard of care expert as ID is not implicated at fault. Antibiotic and decisions to intervene handled by surgical team. In need of causation opinions on following:
1. Was antibiotic coverage appropriate given Hx of small bowel perforation. (Ceftriaxone and metronidazole).
2. Should Vancomycin been ordered.
3. Given post-op clinical course, should physicians have intervened sooner rather than waiting almost 24 hours
4. Had treatment been instituted sooner, would child have survived
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Do you believe there might have been medical error?
It is always challenging to make a judgement with minimal information. However, I believe the choice of antibiotics may not have been appropriate. Of course more detailed information is the only way to make a final opinion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The minimal information provided suggests it might be
What makes you a good expert for this case?
I have been in practice for more than 32 years. I am knowledgeable about pediatric infectious diseases. I am clinically active, have done research (NIH funded) participated in developing national, state and local guidelines, I have held leadership roles in professional medical organizations. I am Professor and Chief. I am hospital epidemiologist. I trading pediatric infectious diseases fellows, residents and medical students. I served on pediatric infectious diseases sub-board. I don’t solicit Medicolegal cases. Only take ones who approach me. I will give my best opinion without regard to if I am working with plaintiff or defendant. I think of myself advocating for children.
How often do you encounter cases similar to this one in your practice?
In my inpatient practice at a quaternary children’s hospital I encounter such cases often.
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