UK - Nurse Lucy Letby Faces 22 Charges - 7 Murder/15 Attempted Murder of Babies #12

[sapphireminds]

Where I live all medical notes are written on computer - prescriptions, notes taken during medical examinations, treatments in hospital, sick leaves ordered by doctors, etc.
Patients are given printouts if they want but
everything is done and sent digitally.

Samesies. I go and pick up babies at other hospitals that still have paper charting and I hate it because it's impossible to read what's written 90% of the time.

It's part of why the US made the requirement to go to EMRs instead, to cut down on errors from handwriting.

 

[marynnu]

I do have a question for those who have worked in units in the UK - in the US, D10 is kept as a stock fluid. I think there might be some D12.5 too, but anything over that has to be prepared by pharmacy. We do not mix our own high concentration glucose here, because of the risks involved. But I don't know if it is standard practice for RNs to be mixing their own higher concentrations of fluids there.

In the UK the nurses mix higher concentrations of glucose. You can't be waiting around for pharmacy to do this. And it's very straightforward compared to the drug calculations on NNU!

 

[katydid23]

Does it mean that ALL bags with glucose in the fridge were contaminated with insulin?

Sorry, I couldn't follow closely today.

I don't think they'd add the insulin until the last minute. LL signed off on the glucose bags for baby L I believe. And she helped the other nurse make up the 3rd one for sure.

LL had her own designated babies in room 1, alongside babies L and M. So she had plenty of access and the privacy needed to taint the bags at any time. JMO

 

[marynnu]

I suppose we could debate forever whether further doses of insulin were added to later bags, and if so how & by whom. Woud it be fair to say however that we agree somebody poisoned Baby L on 9th April?

 

[sapphireminds]

This is just my take on things. I think it's reasonable to assume that these episodes were discussed at the mortality & morbidity meetings. And of course they were examined in detail by Dr. Evans & checked by Dr. Bohin (who has extensive neonatal experience). For me personally, I feel if there were reasonable alternative explanations someone would have put them forward at some point.
Just an observation re. the gastric bleed - there may or may not have been mismanagement after the event, but IMO the central issue is why the bleed happened in the first place.

Dr. Bohin certainly has more current neonatal experience than Dr. Evans.

Dr. Evans claims it wasn't the bleed at all, but an air embolus as well, iirc.

I have a question please, in terms of getting more feed out than went in. You mentioned before this could be saliva and gastric fluid, and that the food wasn’t being digested.

Based on what we’ve heard so far, the stomachs are aspirated before a feed, so should start empty. In baby G’s case, the projectile vomit happened fairly quickly after the feed (I think within 15 mins?).
How quickly would the fluids you mentioned (gastric fluid) take to build up to such an extent that the amount out is double what went in? Could that reasonably occur in a time as short as 15 mins?

Also, how common is actual projectile vomiting in these babies?

It depends, there's multiple possibilities. Sometimes people think they have aspirated and gotten nothing or a small amount, but the tube adhered to the stomach wall, preventing aspiration, another possibility is mis-estimation of the volume vomited - which happens constantly. Nurses here also chart emesis and they can do it as occurrence with small, medium, large or try and estimate volume. The volume estimates are almost always way off - liquid is incredibly hard to estimate when it is not contained in a vessel. I don't know the exact amount of time it would take, but it can be reasonably rapidly.

Projectile vomiting has less to do with the volume, more involves the musculature of the infant involved. We get projectile vomiting from time to time, with and without pyloric stenosis (the typical cause of projectile vomiting). It's unusual for babies to have a strong enough pylorus and esophageal sphincter to have enough tone to be able to projectile vomit, no matter the volume. But sometimes babies like to surprise us.

That appears to be saying that it's assumed to be irreversible for the purposes of that study and for those calculations in it, rather than it being assumed in general to be irreversible. And that the reverse mechanism is debated and MAY be negligible, meaning it also may not be. Either way the study doesn't focus on whether any of the insulin does release from the plastic, it just assumes that if it does it would be negligible so doesn't include it in the calculations. Which is fair enough as that's not what the study was about. Plus this insulin was allegedly mixed with glucose so I'm guessing that might affect things too.Thanks for finding it though.


On a different note the previous explanation (from Magikarpmagikarp) makese sense - that if the bag was changed but the giving set wasn't changed, it could still contain up to around 20ml of the old bag's solution in the giving set's tubing , which the baby would continue to receive for a certain amount of time after the bag changed.

Reversible Adsorption of Soluble Hexameric Insulin onto the Surface of Insulin Crystals Cocrystallized with Protamine: An Electrostatic Interaction - Pharmaceutical Research to be able to reverse the adsorption, a fair amount needs to be done.

Yes, if the bag wasn't changed, there could be up to 25 ml if they were using a standard infusion set. Usually a set would be changed in these circumstances to not continue to give the lower amount of glucose, but it is definitely possible that could have happened.

Edited to add: insulin is always mixed with glucose for neonates when it is administered, usually D5. We only administer insulin to babies as drips, not as individual doses.

Thanks to Mary for pointing out that I was being unclear - we never administer insulin without also administering glucose, usually D5W, which is 5% dextrose in water. Sometimes we will give more than D5, but we would never administer insulin without a concurrent dextrose infusion. It mixes in the line, so insulin is mixed with glucose. In the syringe itself, it is diluted with normal saline

 

[marynnu]

I have a question please, in terms of getting more feed out than went in. You mentioned before this could be saliva and gastric fluid, and that the food wasn’t being digested.

Based on what we’ve heard so far, the stomachs are aspirated before a feed, so should start empty. In baby G’s case, the projectile vomit happened fairly quickly after the feed (I think within 15 mins?).
How quickly would the fluids you mentioned (gastric fluid) take to build up to such an extent that the amount out is double what went in? Could that reasonably occur in a time as short as 15 mins?

Also, how common is actual projectile vomiting in these babies?

Re. projectile vomiting in NNU babies, it does occur, though IMO it's normally due to a massive burp after a bottle feed! I've seen lots of babies be sick, but for me I fail to see why this baby vomited so spectacularly after a tube feed with minimal aspirates. Also, as I recall the equivalent of a full feed was aspirated afterwards. I'm not sure how that would work.

 

[WaxLyrical]

It depends, there's multiple possibilities. Sometimes people think they have aspirated and gotten nothing or a small amount, but the tube adhered to the stomach wall, preventing aspiration, another possibility is mis-estimation of the volume vomited - which happens constantly. Nurses here also chart emesis and they can do it as occurrence with small, medium, large or try and estimate volume. The volume estimates are almost always way off - liquid is incredibly hard to estimate when it is not contained in a vessel. I don't know the exact amount of time it would take, but it can be reasonably rapidly.

Projectile vomiting has less to do with the volume, more involves the musculature of the infant involved. We get projectile vomiting from time to time, with and without pyloric stenosis (the typical cause of projectile vomiting). It's unusual for babies to have a strong enough pylorus and esophageal sphincter to have enough tone to be able to projectile vomit, no matter the volume. But sometimes babies like to surprise us.

(Snipped by me)
Thanks. In this case, iirc, the feed was 40ml and then they aspirated 40ml after the vomit, which is why they can say with certainty that more came out than went in. However, I take the point that the initial aspiration might not have been done correctly.

Something that was discussed in here at the time was whether a feed that exceeds the stomach capacity can happen by accident, given how feed are typically administered, or whether liquid that exceeds the stomach volume would have to be forced into the stomach. Do you have any thoughts on that?

 

[marynnu]

Dr. Bohin certainly has more current neonatal experience than Dr. Evans.

Dr. Evans claims it wasn't the bleed at all, but an air embolus as well, iirc.



It depends, there's multiple possibilities. Sometimes people think they have aspirated and gotten nothing or a small amount, but the tube adhered to the stomach wall, preventing aspiration, another possibility is mis-estimation of the volume vomited - which happens constantly. Nurses here also chart emesis and they can do it as occurrence with small, medium, large or try and estimate volume. The volume estimates are almost always way off - liquid is incredibly hard to estimate when it is not contained in a vessel. I don't know the exact amount of time it would take, but it can be reasonably rapidly.

Projectile vomiting has less to do with the volume, more involves the musculature of the infant involved. We get projectile vomiting from time to time, with and without pyloric stenosis (the typical cause of projectile vomiting). It's unusual for babies to have a strong enough pylorus and esophageal sphincter to have enough tone to be able to projectile vomit, no matter the volume. But sometimes babies like to surprise us.



Reversible Adsorption of Soluble Hexameric Insulin onto the Surface of Insulin Crystals Cocrystallized with Protamine: An Electrostatic Interaction - Pharmaceutical Research to be able to reverse the adsorption, a fair amount needs to be done.

Yes, if the bag wasn't changed, there could be up to 25 ml if they were using a standard infusion set. Usually a set would be changed in these circumstances to not continue to give the lower amount of glucose, but it is definitely possible that could have happened.

Edited to add: insulin is always mixed with glucose for neonates when it is administered, usually D5. We only administer insulin to babies as drips, not as individual doses.

You might want to edit your comment "insulin is always mixed with glucose for neonates when it is administered" - I assume a slip of the finger!

 

[sapphireminds]

(Snipped by me)
Thanks. In this case, iirc, the feed was 40ml and then they aspirated 40ml after the vomit, which is why they can say with certainty that more came out than went in. However, I take the point that the initial aspiration might not have been done correctly.

Something that was discussed in here at the time was whether a feed that exceeds the stomach capacity can happen by accident, given how feed are typically administered, or whether liquid that exceeds the stomach volume would have to be forced into the stomach. Do you have any thoughts on that?

Yes, it can happen on accident and it would not need to be forceful. If you just take the babies of overfeeding themselves, you can see that. Babies in withdrawal from opioids tend to frantically want to eat and they are definitely a type of patient that we might restrict feeds on, because they eat so much they make themselves throw up constantly.

But your stomach is like a balloon - it is very easy to inflate with anything really. They will easily stretch to massive proportions.

You might want to edit your comment "insulin is always mixed with glucose for neonates when it is administered" - I assume a slip of the finger!

What do you think is a slip of the finger? It is mixed with D5 when it is administered.

 

[marynnu]

I

Yes, it can happen on accident and it would not need to be forceful. If you just take the babies of overfeeding themselves, you can see that. Babies in withdrawal from opioids tend to frantically want to eat and they are definitely a type of patient that we might restrict feeds on, because they eat so much they make themselves throw up constantly.

But your stomach is like a balloon - it is very easy to inflate with anything really. They will easily stretch to massive proportions.

What do you think is a slip of the finger? It is mixed with D5 when it is administered.

I don't know what D5 is. I was just trying to point out that insulin is mixed with saline.

 

[WaxLyrical]

Yes, it can happen on accident and it would not need to be forceful. If you just take the babies of overfeeding themselves, you can see that. Babies in withdrawal from opioids tend to frantically want to eat and they are definitely a type of patient that we might restrict feeds on, because they eat so much they make themselves throw up constantly.

But your stomach is like a balloon - it is very easy to inflate with anything really. They will easily stretch to massive proportions.

What do you think is a slip of the finger? It is mixed with D5 when it is administered.

Thanks. I think this baby was fed via tube, and so wasn’t over feeding itself. I think the milk just goes into the stomach via gravity? Is it still possible to overfeed in these circumstances?

 

[sapphireminds]

I
I don't know what D5 is. I was just trying to point out that insulin is mixed with saline.

I see what you're saying - I'm sorry, you're correct, I was not being accurate in how I was saying it - it made sense in my head - I will edit - it's never given without glucose, I was thinking in the line, not the syringe

Thanks. I think this baby was fed via tube, and so wasn’t over feeding itself. I think the milk just goes into the stomach via gravity? Is it still possible to overfeed in these circumstances?

Yes, it is possible. I was just giving the comparison to self overfeeding as a way we know how babies react to it

 

[WaxLyrical]

I
I don't know what D5 is. I was just trying to point out that insulin is mixed with saline.

Can I ask you a question about the mixing of the higher glucose bags? From my extremely limited understanding, you start off with a standard 10% glucose bag, but if you need a mixture of, say, 15%, you’d remove some of the liquid in the 10% bag and replace it with higher concentration liquid, to end up with an overall 15% bag? Is that correct?

If so, where is the higher concentration liquid stored? Are those separate bags? Eg, do you discard the remaining high concentration liquid after mixing a new bag, or is there a constant source you draw from?

I’m still questioning whether the likelihood here is that the higher concentration liquid was poisoned with insulin, rather than a bunch of 10% bags in the fridge.

 

[marynnu]

Thanks. I think this baby was fed via tube, and so wasn’t over feeding itself. I think the milk just goes into the stomach via gravity? Is it still possible to overfeed in these circumstances?

In my opinion it's hard to overfeed massively with gravity feeding. It would either stop going in or the baby would start to be sick, or both.
(Just in passing, if it were easy to overinflate the stomach, we wouldn't need to restrict feeds to stop babies vomiting would we? JMO.)

 

[Dotta]

I
I don't know what D5 is. I was just trying to point out that insulin is mixed with saline.

D5
Dextrose 5%

 

[WaxLyrical]

In my opinion it's hard to overfeed massively with gravity feeding. It would either stop going in or the baby would start to be sick, or both.
(Just in passing, if it were easy to overinflate the stomach, we wouldn't need to restrict feeds to stop babies vomiting would we? JMO.)

The idea of gravity feeding allowing double the volume of the stomach in a short period of time does certainly go against intuition in my opinion.

However I fully accept that a baby feeding on their own can and will take in more than their stomachs can handle. I’ve been doing this regularly myself since I was a baby

 

[JosieJo]

The idea of gravity feeding allowing double the volume of the stomach in a short period of time does certainly go against intuition in my opinion.

However I fully accept that a baby feeding on their own can and will take in more than their stomachs can handle. I’ve been doing this regularly myself since I was a baby

I agree the amount required is unlikely to be administered via gravity.

Plus the nurse documented 40 ml administered..so overfeeding didn't happen

 

[marynnu]

Can I ask you a question about the mixing of the higher glucose bags? From my extremely limited understanding, you start off with a standard 10% glucose bag, but if you need a mixture of, say, 15%, you’d remove some of the liquid in the 10% bag and replace it with higher concentration liquid, to end up with an overall 15% bag? Is that correct?

If so, where is the higher concentration liquid stored? Are those separate bags? Eg, do you discard the remaining high concentration liquid after mixing a new bag, or is there a constant source you draw from?

I’m still questioning whether the likelihood here is that the higher concentration liquid was poisoned with insulin, rather than a bunch of 10% bags in the fridge.

Your comment about mixing the bags is 100% correct.
The higher concentration fluid - 50% glucose - comes in glass bottles. They have a rubber top so you withdraw using a needle & syringe. It's stored in a drug cupboard normally, though I can't speak for CoC of course.
You withdraw what you need then discard. (If 2 babies happened to need it at the same time you could use the same bottle, obviously).
IMO putting insulin in this wouldn't be something anybody would do. Apart from anything else, the baby would have to be significantly hypogycaemic already for 50% glucose to be used. And I have a feeling the rubber cap is covered with a metal ring pull in any case, though I might be making that up! (I retired 7 years ago).

 

[JosieJo]

Personally I feel the projectile vomiting charge is one of the strongest second to the insulin cases

Bowel problems were ruled out

Aspiration had been occurring regularly with no problems.

The stomach was aspirated prior to being given 40 ml via gravity

A small amount was aspirated to test PH so unlikely a problem with tube

The pH of the aspirate prior to the feed indicated no milk residue

The vomit was so severe the baby crashed.

Despite not being able to accurately measure the vomit ..it was enough to travel.to the chair and floor and still aspirate the original 40 ml.

<modsnip: sub judice>

 

[sapphireminds]

Personally I feel the projectile vomiting charge is one of the strongest second to the insulin cases

Bowel problems were ruled out

Aspiration had been occurring regularly with no problems.

The stomach was aspirated prior to being given 40 ml via gravity

A small amount was aspirated to test PH so unlikely a problem with tube

The pH of the aspirate prior to the feed indicated no milk residue

The vomit was so severe the baby crashed.

Despite not being able to accurately measure the vomit ..it was enough to travel.to the chair and floor and still aspirate the original 40 ml.

<modsnip: sub judice>

What do you suppose the medical mechanism of vomiting killing the baby was?