Finding into death of Amir Mohammad Iran

<1y · Male·Hyaline membrane disease and pneumonia in the setting of pneumothorax

A 2-day-old term infant (2670g, small-for-gestational-age) presented with respiratory distress at 11 hours of life. A capillary blood gas at 1:14pm showed mixed respiratory and metabolic acidosis indicating decompensation, but this was not recognized or escalated in the medical notes. The infant deteriorated with cyanosis, requiring intubation, ventilation, and NICU admission. Bilateral pneumothoraces and persistent pulmonary hypertension were identified and managed. Surfactant was administered at 2:05pm on day 2, but at a suboptimal dose (90-100mg/kg vs guideline 150mg/kg for his weight) and without repeat dosing. The underlying diagnosis of hyaline membrane disease (HMD) was not adequately considered despite atypical presentation. The coroner found that earlier recognition of abnormal blood gas results, earlier consideration of HMD as a differential diagnosis, and administration of adequate surfactant doses with repeat dosing may have prevented deterioration and death.