Alarming medication error with prostaglandin E1 (PGE1) in a term neonate with critical congenital heart disease

Abstract

An outborn full-term female newborn with birth weight 2.45kg was admitted to our centre at 24 hours of life with respiratory distress and cyanosis. The baby had tachycardia and oxygen saturation (SpO2 ) 40% at admission to neonatal intensive care unit (NICU). She was mechanically ventilated on synchronized intermittent mandatory ventilation (SIMV) mode. Clinical evaluation raised suspicion of critical congenital heart disease; echocardiogram revealed transposition of the great arteries with 6mm ostium secundum atrial septal defect and small patent ductus arteriosus. The baby was started only on intravenous prostaglandin E1 (PGE1) as per unit protocol, where 1 ampoule (500 µg) of PGE1 is mixed in 49mL of 5% dextrose yielding a concentration of 10 µg/mL and is then started using an infusion pump at a rate of 0.6mL/kg/hour to provide a dose of 0.1 µg/kg/min. She developed tachycardia along with confluent erythematous macules over the scalp, face, neck and trunk, 10 hours after starting PGE1 infusion (figure 1). There was no associated fever or hypertension, while lowest blood pressure recorded was 52/30mm Hg. The skin rash, characterised by bright erythematous macular lesions, rapidly spread to the extremities. It was noticed that PGE1 was wrongly administered at 10 times the expected dose for the last 2hours prior to the cutaneous manifestation. The infusion was immediately stopped, and the baby was given