This interesting case that was reported in the Case Book of MPS in May 2015 should be read by all medical students, junior doctors and nurses in training.

It is reported that a baby was born by caesarean section at 27 weeks of gestation weighing 980 gms. Soon after delivery the baby was [b] intubated, ventilated and endotracheal surfactant was administered [/b]. During the 1st four hours the oxygen saturation was recorded as between 90-97%. The blood gas at 5 hours was recorded as pH 7.68. (normal 7.3-7.4), a PaCO2 of 1.91kPa (normal 4.5 to 6), a PaO2 of 35.84kPa (normal 5 to 8) and a biacarbonate level 24.6mmol/L (normal 18 to 24). This suggested that the baby was being over-ventilated. The baby was ventilated for 3 days and placed on continuous positive airway pressure (CPAP) and then placed on 0.5L nasal canula oxygen due to recurrent apnoeic spells. Overall the baby received 204 hours of oxygen with O2 saturation levels of 96-100% throughout. The baby was not referred at 4 to 6 weeks for routine screening to rule out retinopathy of prematurity (ROP) and was first seen by an ophthalmologist at the age of 7 months when a diagnosis of inoperable Grade 5 ROP causing blindness was made.
The parents sued the consultant paediatrician who handled the baby’s care post delivery.

Expert Opinion:

The baby had inappropriately high transcutaneous oxygen saturation levels and PaO2 levels for a period of 204 hours. During oxygen administration to premature infants, very high blood oxygen levels can develop if saturation levels rise above 96%. Weaning of the Fraction of inspired oxygen seldom occurred despite oxygen saturation levels of between 96% and 100%, indicating that the nursing staff had no protocol for weaning of oxygen according to oxygen saturation.

There was no record of screening for ROP at 4 to 6 weeks after birth as recommended. The baby developed severe ROP and blindnesss due to excessive oxygen administration. Negligence by both the paediatrician and nursing staff cannot be denied.
The case was settled for a substantial sum.

Points to Remember:

Care to be taken when administering oxygen to premature and low birth weight infants. There should be clear instruction to staff attending premature infants to monitor blood gas levels carefully.

Oxygen should be weaned when saturation levels are more than 95%. Recommended safe levels are between 86% and 92%. Unrestricted and prolonged oxygen exposure in very low birth weight infants is associated with severe grades of ROP.

What is Surfactant:

Surfactant forms a layer between the alveolar surface and the alveolar gas and reduces alveolar collapse by decreasing surface tension within the alveoli. Surfactant deficiency is almost always associated with the formation of hyaline membranes in the immature lung and the onset of respiratory distress syndrome (RDS)-a major cause of morbidity and mortality in premature infants. Without surfactant, alveoli may never inflate or may collapse on expiration and require inordinate force to re-expand on inspiration, leading to the development of RDS. In general, the more premature the infant, the less the surfactant production and the higher the probability for RDS. Direct tracheal instillation of surfactant has been shown to reduce mortality and morbidity in infants with RDS.

Surfactant replacement is undertaken in premature and underweight infants at the time of birth who are at risk of developing RDS.
Surfactant can be extracted from animal lung lavage and from human amniotic fluid or produced from synthetic materials.

Badri.

(This article is posted in the Medico-legal section as well)