ICU vigilance urged as cardiac arrest went unnoticed

The lawmaker representing the medical sector on Sunday called for stricter alarm awareness and safety checks, following an incident in which a child in intensive care was in cardiac arrest for nine minutes before a nurse discovered it. David Lam made his remarks after the Hong Kong Children’s Hospital reported the incident that happened last Thursday. The hospital said the boy, 6, who had a rare underlying disease, was in its paediatric intensive care unit, sedated and on a ventilator. His heart stopped at 7.20am. At 7.29am, a nurse found him in cardiac arrest. During resuscitation, staff discovered that the connector linking the breathing tube in his windpipe to the ventilator had come loose. They reconnected the ventilator circuit, and the boy’s heartbeat returned. Lam said all ICU machines have alarms to alert staff if there’s a disconnection or changes in a patient’s pulse, blood pressure or oxygen level. “There are alarms in place with all these machines. So the first thing to do is to make everyone who will be taking care of children or adults in ICU to be extra vigilant of these alarms, and to check if all these machines have the alarms working at the moment,” he told RTHK. The hospital said the patient developed seizures, but initial neurological tests showed no abnormalities so far. Lam said it's too early to determine whether any damage has occurred. “There's possibility of a long-term consequence to the incidence of epilepsy or seizures. We are not very sure if that could affect the level of consciousness of child and also the intellectual ability in the long term if there is serious hypoxia for a prolonged period of time. So it takes time to really understand the long-term consequences, if any,” he said. The hospital says it is deeply concerned about the incident and will set up a panel to look into it. Edited by Edmond Fong