Woodcock 2011 06 14 12 49 10 862

Male·Myocardial failure resulting from excessive pulmonary blood flow and consequential loss of systemic blood flow upon a background of major congenital heart disease

One-month-old Liam Woodcock, born extremely prematurely at 27.5 weeks gestation weighing approximately 1 kilogram, died from myocardial failure secondary to excessive pulmonary blood flow in the context of severe congenital heart disease (pulmonary atresia with intact ventricular septum and right ventricular hypoplasia). He required prostaglandin infusion to maintain patency of a critical ductus arteriosus essential for systemic blood flow. The coroner identified several clinical management concerns: absence of blood pressure and blood gas monitoring during prostaglandin administration; possibly excessive prostaglandin dosing that created an imbalance favoring pulmonary over systemic circulation; a two-hour delay in intubating once clinical deterioration became obvious; and use of propofol for sedation during intubation, which may have contributed to myocardial depression. Despite these management issues, the infant's prognosis was grave from birth. Key lessons: implement close hemodynamic monitoring during prostaglandin use in ductal-dependent circulation, avoid propofol in cardiac-compromised neonates, and escalate intubation decisions promptly.