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Ignoring the cold foot

01 January 2012

Mrs T, a 40-year-old secretary, was overjoyed to find herself pregnant for the first time. Unfortunately, a detailed antenatal congenital anomaly scan identified that her baby had a severe congenital heart defect. The pregnancy was closely monitored by the regional cardiology team. Baby T was born in the regional teaching hospital, and first stage cardiac surgery was carried out in the first week of life.

Baby T recovered well from this initial surgery. Despite very slow weight gain and some feeding difficulties, she made good developmental progress. Her cardiac function was closely monitored, and definitive surgery was planned for 18 months of age.

One Friday just before her first birthday, baby T became increasingly breathless. She was admitted to her local hospital, where she was found to have heart failure thought to be secondary to a dysrrhythmia. Baby T was started on oral medication, but she deteriorated acutely, and the decision was made to transfer her to the regional Paediatric Intensive Care Unit (PICU).

On arrival at the PICU, baby T was assessed by Dr Q, a newly-appointed consultant. He noted her to be acutely unwell, breathless and hypotensive. Dr Q electively intubated her and proceeded to insert a right femoral catheter to enable intra-arterial blood pressure monitoring.

Two hours later, Dr Q reviewed baby T. He noted that the right foot was cold and poorly perfused. Dr Q elected to remove the right femoral artery catheter. Invasive blood pressure monitoring was still clinically indicated, and he therefore sited a catheter in the left posterior tibial artery. Dr Q recorded in the infant’s notes that the right foot was “slightly warmer but the general perfusion still poor”. Before leaving the unit for the weekend Dr Q asked the nurse looking after baby T to “keep an eye on that leg”.

Over the next 24 hours, baby T responded to medical management of her dysrrhythmia. However, on the Sunday morning ward round, she was fully examined for the first time since admission. Her right foot was noticed to be mottled and very cold. An urgent ultrasound demonstrated thrombosis of the right femoral artery. The vascular team was contacted.

Due to the delay in presentation, medical management with thrombolytics was deemed to be inappropriate. An embolectomy and fasciotomy were performed urgently but unfortunately were not successful. The limb was non-viable, and baby T required a below knee right leg amputation.

On reviewing the records, it became apparent that while nursing observations had recorded the look and temperature of the left leg throughout her stay on the PICU, no observations had been made on the right leg for over 24 hours. The medical records did not indicate that any specific examination of the right leg had been made by the junior doctor covering the unit for the weekend. There was no record of a formal handover from Dr Q to his consultant colleague covering the unit for the weekend.

A claim was made against Dr Q. Expert opinion was that Dr Q should have left specific instructions for the nursing staff to check on the right leg in addition to the left. The claim was settled for a high sum.

Learning points

  • Iatrogenic vascular thrombosis is a well-recognised complication of arterial catheterisation. The risk is particularly high in infants below two years of age. Where intra-arterial catheters are used for blood pressure monitoring, clear local guidelines should be in place for monitoring the insertion site and the limb distal to the insertion of the catheter for signs of potential vascular compromise. This includes a cold, pale limb with a prolonged capillary refill time and reduced or absent pulses. Arterial occlusion can quickly progress to gangrene.
  • When delegating to a colleague you must be satisfied that the person to whom you delegate has the qualifications, experience, knowledge and skills to provide the care or treatment involved.
  • It is inappropriate to assume that nurses will anticipate complications of a medical procedure, or to understand the significance of a clinical sign. Where any additional nursing observations are to be undertaken, this should be clearly and explicitly stated. Clear instructions and a good handover are essential.
  • In relation to medical negligence claims, good documentation makes the difference. “If it’s not in the notes it didn’t happen” is an aphorism worth remembering.
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