Medico-Legal Risks – NeoPed Quality

Pediatricians, neonatologists, and intensivists who treat severely ill newborns often use mechanical ventilation to maintain the function of vital body organs. This respiratory therapy is often needed in premature and full-term sick babies. Due to the complex nature of this therapeutic technique, medical providers make many less or more severe mistakes. Some of these errors may have long-term consequences for the patients. Introduction: The Critical Role of Mechanical Ventilation in NICU Mechanical ventilation can be a life-saving therapy for the babies. Humans need constant delivery of oxygen. In addition, we also must excrete carbon dioxide from our bodies. Efficient and regular breathing is responsible for this continuous gas exchange necessary for survival. Premature babies have immature lungs in which gas exchange is inefficient and makes it harder for babies to breathe. Due to their sicknesses, such as infections or neurological and metabolic diseases, some full-term babies also have inadequate gas exchange and need our (doctors) help. We can support babies' gas exchange through many respiratory techniques. Some are mild, like nasal cannula with additional oxygen, and others are more advanced and aggressive, such as ventilators. All require skill, experience, and specialized equipment. A detailed discussion of them exceeds the scope of this article, but interested readers can learn more from this scientific source. The goal of mechanical ventilation in the NICU is to provide adequate oxygenation to the baby, allow for the removal of carbon dioxide, and decrease the work of breathing for the patient. Common Errors in Mechanical Ventilation Management Administering mechanical ventilation in the NICU is a complicated task. Below, I will discuss potential deviations from standard practices I found during my neonatal chart reviews. Indications to start mechanical ventilation Many indications exist that necessitate starting mechanical ventilation in a newborn baby. The most common and important one is respiratory failure and excessive work of breathing. The inability or failure of a patient to maintain healthy levels of oxygen and carbon dioxide in the body should prompt us to initiate mechanical ventilation. Unfortunately, doctors often wait too long, hoping that less aggressive respiratory support could be sufficient. If babies are exposed to less than optimal oxygen or carbon dioxide levels, they may endure various short and long-term complications affecting their lungs and central nervous system. Intubation Intubation is a procedure during which we place a breathing tube (called Endotracheal Tube = ET) into the baby's trachea. Sometimes, doctors have problems succeeding and put this tube in the wrong place (esophagus). If that occurs, the air with oxygen pushed by a ventilator will enter the stomach instead of the lungs, and the baby will suffocate. Medical providers can confirm the correct position of the ET tube using physical examination techniques, observing vital signs changes, and x-rays. (My full article on radiological imaging and malpractice in NICU). I have reviewed many cases in which a pediatrician or nurse practitioner placed an ET tube during resuscitation, and later, a more experienced person arrived and claimed that the ET tube was not in the trachea. I want to emphasize that NRP guidelines suggest that less experienced providers use laryngeal masks for resuscitations rather than trying multiple times to intubate patients (my article). Equipment (Ventilator machine, software, and power) To start a patient on mechanical ventilation, we must have available ventilators, electric power, compressed air, and oxygen. Sadly, some hospitals fail to maintain these resources properly. In my 30 years as a clinician, I often found myself frustrated by numerous issues related to unavailability or malfunctioning ventilators. The unit directors and hospital administrators must take these deficiencies very seriously. They must expect situations when there is a sudden surge in patient volume or when the only one-owned ventilator breaks. Each hospital must also have backup batteries and gas tanks with oxygen. Settings on the ventilator machine Ventilators are machines comprising a mixture of mechanical parts with a sophisticated computer. Respiratory therapists and doctors need specialized knowledge of numerous settings such as pressures, volumes, oxygen concentration, gas flow, and various safety alarms. Depending on the age of the baby and its condition, settings will differ. The most egregious error while using ventilators is not utilizing the safety alarms correctly due to lack of knowledge or because they create "nuisance noise" and staff turn them off. The other obvious mistake would be dialing erroneously high inspiratory pressure that leads to pneumothorax. Oxygen delivery Oxygen should be treated as a medicine. Like any other medicine given orally or intravenously, oxygen has benefits and risks. We do know that oxygen is necessary for us to live. On the other hand, exposure to unnecessary high oxygen levels may lead to various side effects, most notably in the eyes, lungs, and brain. A disease of the eyes related to previous exposure to oxygen is called Retinopathy of Prematurity. In rare cases, ROP may result in blindness. In the NICU, we can monitor the amount of oxygen in our bodies using two techniques. The first one, called oxygen saturation, is a non-invasive technique and can be used continuously. Any baby receiving respiratory support in the hospital should always be on the oxygen saturation monitor. The second technique is more aggressive because it involves drawing the baby's blood and checking actual levels of acid, oxygen, and carbon dioxide. It provides the most precise measurements. It is called "blood gases." The frequency of blood gases will depend on the severity of the baby's respiratory disease and the respiratory support needed for treatment. We usually obtain blood gases several times a day in premature babies during the first few days of life. A month later, when they have a chronic lung disease and require stable ventilatory settings, we may do that only once every other day. Monitoring the patient (saturation, blood gases, x-rays) Every patient receiving mechanical ventilation should be considered seriously sick and at risk for sudden deterioration. We must monitor such patients continuously for their response to treatment. We need to follow their gas levels (oxygen and carbon dioxide), ensure the proper location of the ET tube, and monitor for the development of complications, particularly one that can be life-threatening, called pneumothorax. Diligent doctors will perform frequent bedside assessments and utilize saturation monitoring, blood gases, and chest X-rays when needed. Lack of appropriate policies and guidelines for monitoring, short-staffed laboratories and radiology departments, and malfunctioning equipment may lead to hospitals being found liable in malpractice suits (my article on this subject). Discontinuation of the treatment Ventilators save lives but also cause complications and chronic health conditions. We should discontinue mechanical ventilation and switch to less aggressive therapy as soon as feasible. In most cases, babies will be put on CPAP or nasal cannulas to facilitate this change in respiratory support. Some babies will tolerate it well, and others will be placed back on the ventilator. As with any significant change in therapy, close follow-up and patient observation is critical. Failure of medical providers to recognize early the need to return a baby back to the ventilator may lead to devastating outcomes. Mechanical ventilation mismanagement and malpractice cases According to Elsevier's manual: "Mechanical ventilation may contribute to an acute or a chronic respiratory tract injury, such as atelectrauma, volutrauma, barotrauma, oxygen toxicity, and a pulmonary or systemic inflammatory response to lung trauma." The most frequent errors in managing mechanical ventilation that may lead to malpractice in the NICU are listed below: Placement of the ET tube in the esophagus instead of in the trachea Not performing an X-ray after intubation (placement of the ET tube) Dialing too high inspiratory pressures on the ventilator Dialing too high inspiratory volumes on the ventilator Not reevaluating a patient who needs a significant increase in respiratory settings on the machine. Not using the alarm settings properly Not adjusting the settings correctly on the ventilator after blood gases Not adjusting oxygen concentration according to oxygen saturation levels Malfunctioning equipment Lack of training and experience among staff administering mechanical ventilation Not arranging to transfer a patient needing ventilatory support in level 1 or level 2 nursery Missing early signs of pneumothorax Ensuring Safe Mechanical Ventilation Practices in NICUs The hospital administrators, unit directors, and supervisors must ensure that only trained and experienced personnel administer mechanical ventilation. In addition, they must develop appropriate policies and guidelines for this therapy. The policy should state who can, when, and how to utilize this therapy. Nurses and respiratory therapists should know when to alert a doctor about patient status changes. Administrative and medical directors must conduct periodic reviews of relevant documentation to ensure the safe utilization of mechanical ventilation and other forms of respiratory support in their nurseries and NICUs. Finally, we must know that sometimes a newborn will come to the hospital from home, and the emergency physician will be the one who will be responsible for the treatment of such a patient. Experience regarding mechanical ventilation in an emergency room often needs to be improved. Therefore, frequent training and emphasis on creating guidelines for using it and consultation with neonatologists or pediatric intensivists is necessary.