Case #4023 Inappropriate Position of Catheter Lead to Irreversible Hypoxic Brain Injury
$5.5 Million Brain Injury
On October 9, the Infant Plaintiff was born at the Defendant Hospital at 30-4/7 weeks gestation, weighing 1350 grams with normal APGAR scores and a normal cord pH. That same day, she received an ultrasound of the head which was unremarkable. Shortly after birth, umbilical artery (UAC) and venous (UVC) catheters were placed for ongoing care. At 4:10 p.m., as a final step during UVC placement, a chest x-ray was taken to confirm proper placement of the catheter before it was secured in place.
Five minutes later at 4:15 p.m., a repeat chest x-ray revealed that the umbilical venous catheter had advanced into the heart, to the level of the right atrium. In accordance with the standards of care, umbilical venous catheters may not remain in the heart because they can result in damage, including cardiac irritation, perforation and/or tamponade. When a chest x-ray confirms catheter presence in the heart, it must be immediately withdrawn.
The Plaintiff alleged that the Defendant’s personnel negligently failed to properly reposition the catheter despite x-ray evidence of its improper location. Another repeat chest x-ray at 7:30 p.m. that same day confirmed that the umbilical venous catheter had advanced further so that its tip was high in the right atrium. Tragically, the second report was negligently ignored. On October 10, at 7:32 a.m., a third chest x-ray was taken which again confirmed the inappropriate position of the catheter, in violation of the standards of care.
Thereafter, at 8:00 a.m., the infant became hypotensive, with a dampened wave form which was not correlating with the non-invasive blood pressure. At 8:25 a.m., a doctor was finally called to assess her hypotension which now showed significantly a dampened waveform. As well, the nurses could not obtain any blood pressure in her lower extremities. By 8:30 a.m., the infant’s blood pressure was 18/15 — at which point she was hypoxic, severely hypotensive and markedly bradycardic. By 8:37 a.m., she was profoundly hypoxic with an oxygen saturation level of 49%, and a blood pressure of 29/24. Resuscitative efforts were begun with chest compressions and Epinephrine administration.
Finally at 8:50 a.m., the UVC was withdrawn. However, by that time, the infant suffered a large pericardial effusion due to catheter perforation, with cardiac tamponade confirmed by echocardiogram. The ongoing tamponade caused hypotension, bradycardia, and a profound decrease in cerebral perfusion, resulting in an hypoxic ischemic encephalopathy.
The Infant Plaintiff required pericardiocentesis which was finally performed at approximately 10:10 a.m. By then, she had suffered significant metabolic acidosis, acute tubular necrosis (kidney damage) and a severe hypoxic and ischemic event, which led to global and irreversible hypoxic brain injury.