Case Analysis – NeoPed Quality

HIE (Hypoxic Ischemic Encephalopathy) is a severe brain injury that may affect 1.5-2.5 babies per 1000 live births in developed countries. It occurs due to decreased oxygen and low blood flow to the brain. We can diagnose it based on carefully taken history regarding labor, newborn resuscitation, and the baby’s presentation in the first few days after birth. The hypoxic-ischemic injury often affects multiple organs (not only the brain), leading to failure or malfunction of the heart, lungs, liver, or kidneys. Diagnosis of HIE almost always has severe repercussions for the affected baby and hospitals. According to historical data, by the age of 2 years, up to 60% of newborns diagnosed with HIE may die or will have severe disabilities (Cerebral Palsy, seizures, or intellectual developmental delays). Given the high incidence of bad outcomes associated with the diagnosis of Hypoxic-ischemic encephalopathy, it will not surprise us that it also frequently leads to medico-legal cases (source article). In my article, I will discuss common mistakes we should avoid while reviewing the neonatal chart of a baby diagnosed with HIE. Focusing only on the neonatal chart As a neonatologist, I always want to learn about the care the mother of my patient received during pregnancy and labor. Her past medical history and complications of labor may affect the baby’s condition at birth. Specific genetic or metabolic conditions in the family may point to the correct diagnosis in the baby. Even when the baby is born with a low Apgar score and presents initially with muscle tone abnormalities or seizure, it does not always mean that the baby has Hypoxic-ischemic Encephalopathy. As a neonatologist, I do not give my clients expert opinions on obstetrical care. However, experienced neonatal chart reviewers will always want to review detailed maternal charts. This is why I do not work for lawyers based on the “per hour rate” and give them an estimate of my total consultation fee upfront. I want to be able to review all necessary documents rather than be constrained to the baby’s chart only for the sake of lawyers saving money on expert review expenses. Assuming that resuscitation of the baby was done correctly Some “experts” assume that the baby that was born without a heart rate and received resuscitation and survived always received proper care. Unfortunately, this is not always the case. Numerous errors may occur during resuscitation, and several institutional problems may contribute to poor neonatal outcomes in babies that require resuscitation. For a detailed analysis of newborn resuscitation, I refer you to my separate article and here, I will list only some of the most common issues: Lack of personnel capable of conducting newborn resuscitation (some professionals are not available on-site or arrive late) Lack of equipment, malfunctioning equipment, or people need to learn how to use equipment correctly. Lack of skills to provide appropriate airway (intubation or LMA mask) Not inserting UVC or IO lines to give epinephrine. Delay in starting PPV (positive pressure ventilation), chest compressions and epinephrine administration Not providing complete information about resuscitation difficulties to parents Not knowing the level of care assigned to the birth hospital In my previous article, I explained the meaning and importance of the levels of care assigned to hospitals where pregnant mothers and newborns receive their treatments. A treatment modality called whole body or brain hypothermia is only available in level 3 or level 4 NICUs. Furthermore, to be effective, hypothermia should be started in a baby diagnosed with HIE within 6 hours of birth (the earlier, the better the outcomes). That’s why knowing the level of care for the birth hospital is so crucial. If a baby was born in a level 1 or level 2 hospital, we need to learn whether efforts to transport this patient to a higher level of care NICU were timely and appropriate. Assessing only the treatment but not its timeliness Many therapies provided to pregnant women and newborns work best if initiated immediately after diagnosing a problem. Documentation of administered therapies should always include the time when they were done. I have included a few examples below to emphasize my point. A. A pregnant woman is under continuous observation in the labor unit. Nurses identified an unfavorable pattern in fetal heart rate, and the obstetrician decided to perform an urgent cesarean section. The surgery was done 1 hour later. The timing of the operation was delayed in this case because usually urgent cesarean sections are expected to be performed within 30 minutes from the decision point. B. A newborn baby was born without a detectable heart rate. The pediatric team conducted resuscitation. It was documented in the chart that chest compressions were initiated at 5 minutes of life. This is a significantly delayed intervention. According to NRP, after the initial steps of stabilization (warming, drying stimulation), if the baby does not have a heart rate, the team should have positive pressure ventilation, and after 30-60 seconds of that, chest compressions should have been started. Therefore, chest compressions ideally should have been started no later than 1-2 minutes after birth, provided the patient still did not have a detectable heart rate despite positive pressure ventilation. C. The newborn baby was born with an Apgar score of 0 at 1 minute, 1 at 5 minutes, and 1 at 10 minutes. Subsequently, after resuscitation and admission to NICU, the baby was diagnosed with severe HIE and had seizures at 1 hour of life. The team at Level 2 NICU decided to transfer this baby to Level 3 NICU for whole-body cooling therapy (hypothermia). The decision was made at 24 hours of life. I believe this decision was significantly delayed compared to the recommended timeline for initiating this important treatment modality. Considering only HIE and not other differential diagnoses Different etiologies may cause encephalopathy other than hypoxic and ischemic factors. The diagnosis may be challenging if the baby’s Apgar score was low at birth, the baby required some resuscitation after birth, or there were observed fetal heart rhythm abnormalities during labor. We must remember that a baby with severe degenerative or developmental abnormality in the brain may also have irregular fetal heart rhythm or may require resuscitation after birth. Therefore, not all such cases can be considered as HIE. Modified list for differential diagnosis of HIE in newborns: Sepsis Meningoencephalitis Arterial ischemic stroke Cerebral venous sinus stroke Intracranial hemorrhage Metabolic disturbances Endocrinopathies Inborn errors of metabolism Intrauterine drug exposure Prenatal medication exposure Intrapartum medication exposure Postnatal medication exposure Acute seizures Neonatal onset of epileptic encephalopathy Systemic genetic syndromes Congenital neurological malformations Not analyzing symptoms from other organs than just the brain Hypoxia and ischemia affect central and peripheral neurological systems, and we should try to assess the degree or severity of symptoms in these areas: Level of consciousness Muscle tone Posture Deep tendon reflexes Suck Moro reflex Autonomic nervous system (Heart rate, breathing patterns) Presence of seizures The effects of hypoxic-ischemic injury are more often than not present in organs other than the brain and will help us confirm the diagnosis. If those other associated symptoms are not present, we should go through the detailed process of excluding all differential diagnoses. Table: Consequences of hypoxia and ischemia in various organs of the affected newborn. OrganSymptomsAssessmentBrainSymptoms of Encephalopathy (seizures, tone changes)EEGImaging studies of the brainKidneysAcute tubular necrosisUrine output changes (no urine)Urine analysisKidney USLungPulmonary HypertensionNeed for Oxygen therapyX-raysUS of the heartLiverLiver injuryLiver enzymesBilirubin levelsIntestinesNecrotic EnterocolitisBlood in the stoolX-raysSurgical evaluationsParathyroidLow Calcium levelsCalcium in bloodSerum and urine osmolalityLow or high sugar levelsGlucose levels in the bloodMuscleRhabdomyolysis (destruction of muscle cells)Muscle enzymesSkinSubcutaneous fat necrosisAppearance of the skinBlood systemTendency to bleedingCoagulation profilesHypothalamusSIADH (hormonal abnormalities)Serum and urine osmoplalityHeartHeart muscle dysfunctionsSerum and urine osmolalityAdrenal glandHemorrhageUS of the glandHormone levelsBlood pressure Not assessing systemic factors in healthcare Diagnosis of hypoxic-ischemic encephalopathy in a newborn often has devastating consequences on its life or for future development. It has been my experience that systemic factors usually contribute to inadequate quality of care provided to patients in hospitals. The most common external and systemic factors are mentioned below: Lack of equipment or malfunctioning equipment Personel not know how to use medical equipment Personnel not available immediately for resuscitation or to evaluate and treat patients Lack of proper policies dictating when and how to arrange for the transport of a baby to a higher level of care Inadequate supervision of nurses or junior doctors Lack of ongoing quality improvement processes Hacked and malfunctioning computer information systems Summary: HIE is a common cause of medico-legal litigation. Proper review of the neonatal chart plays an important role in ensuring that a lawyer is equipped with all the information needed to win a case. On the other hand, risk management departments representing the hospital should make sure that they do not get sued for cases of assumed HIE, which can be explained by other etiologies, such as genetic or metabolic factors. Honest chart review and evaluation of all the information will be crucial to both sides.