Allegation
Negligently over-ventilating a 29-week prematurely born twin male while treating respiratory distress resulted in severe neurologic injuries
Case Details
An obstetrician performed an emergent C-section on a 22 YOF (5'6”, 248 lb) patient after she went into preterm labor at 29 weeks. The patient’s history included smoking, three previous uncomplicated vaginal deliveries, and a recent UTI. She was given terbutaline prior to the C-section, but no steroids since delivery was imminent. The patient gave birth to twins. Twin A weighed 1,265 grams, with Apgar’s of 7 and 8, and Twin B weighed 1,364 grams and Apgar’s of 7 and 7.
The defendant neonatologist was consulted and present at the delivery. Both infants had moderate bruising on the face and extremities, and both were diagnosed with respiratory distress syndrome. Twin B had a weak cry and severe subcostal and intercostal retractions. The defendant neonatologist intubated Twin B and placed him on a ventilator in the NICU. The next day, the twins were transferred to another hospital under the care of the same neonatologist.
At the new hospital, the defendant neonatologist regularly visited the infants’ bedside to observe their condition, and to order treatments and adjustments to ventilator settings according to protocol. Twin B had four episodes of bradycardia and desaturation, but each time recovered on his own. His pCO2 ranged from 19mm Hg to 35 mm Hg. Documentation by physicians and nurses included respiratory response to mechanical ventilation, ABG results, CBC results, vital signs, oxygenation, chest x-rays, and infant’s appearance, color, and breathing efforts.
On the second day at this hospital, a chest x-ray revealed patchy bilateral ground-glass densities suggestive of hyaline membrane disease; the patient had a moderate amount of bright red blood suctioned. His lungs were slightly diminished and sounded “tight.” The defendant neonatologist’s impressions included respiratory failure, pneumothorax, gastrointestinal hemorrhage, hyperbilirubinemia, and central nervous system problems. He concluded the infant had intraventricular hemorrhage, so he extubated, reintubated him, and changed ventilator settings. After three days, Twin B was transferred to a university hospital for specialized care.
Twin B remained at the university hospital for almost three months under the care of a neurosurgeon and another neonatologist. During this time, he underwent a double volume exchange transfusion, aggressive phototherapy, and ventriculoperitoneal shunt placement. His respiratory status gradually improved as he was extubated, weaned to nasal cannula oxygen, and finally to room air by the end of his stay.
After his hospitalization, Twin B experienced seizures from brain atrophy, visual impairment, bilateral hearing loss, and developmental delays. He also required a PEG tube for nutrition.
The family sued the defendant neonatologist, alleging he negligently over-ventilated twin B while treating his respiratory distress, which resulted in neurologic injuries.
Expert Testimony
Plaintiff’s experts alleged the defendant neonatologist “over breathed” the ventilator making the patient hypocarbic, and that the prolonged nature of the patient’s hypocapnia increased the risk for development of intracranial hemorrhage and periventricular leukomalacia. The experts stated the defendant neonatologist was negligent for delaying an order of serum bilirubin until the patient was 42 hours of age, and for delaying phototherapy until 60 hours of age, which necessitated a double volume exchange transfusion for hyperbilirubinemia.
Defense experts argued that Twin B’s intraventricular hemorrhage is consistent with what studies have shown can happen in extreme preterm, very low birth weight babies. They supported the defendant neonatologist’s management of the patient, including intubating the patient shortly after birth, and monitoring the ventilator settings. Defense experts also claimed that scientific literature did not support the assertions of the plaintiff experts that hypocapnia causes intraventricular hemorrhage. Instead, the defense experts attributed the hemorrhage to a combination of prematurity, respiratory distress, unstable intracranial pressure, and very low birth weight.
Commentary
Even with advanced capabilities of mechanical ventilators, overventilation can occur. Monitoring capabilities of ventilators are only as effective as the team responsible for the monitoring, interpretation, and treatments necessary to maintain precise pressure levels in the lungs. The danger with mechanical ventilators is the speed in which small adjustments can lead to acute hypocapnia and the possibility of neurologic birth injuries. Close monitoring and adjustments of ventilators are imperative.
Resolution
A jury returned a verdict in favor of the defendant neonatologist.
Risk Reduction Strategies
Proper education, training, documented competencies, and recorded maintenance logs are essential documentation. Complete and accurate medical record documentation, including specific interventions and patient response, can show that patients received appropriate care, within the standard, as well as promote patient safety and quality of care.
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