The Pediatric Cardiac Surgery Inquest Report



Post-operative course

On admission to the PICU, Alyssa was very puffy, especially around her eyes. Her fluid balance at the end of bypass was 800 millilitres more than it had been at the start of the operation. Such a degree of fluid overload would make ventilation more difficult and would also make the heart muscle stiffer.

Alyssa was placed under a warming blanket because she was very pale and her arms and legs were cool, with pulses that were only weakly felt. Her blood pressure was moderately decreased and the output from her heart was low. The admitting nurse noted that her air entry was clear but decreased on the left side. Alyssa had a metabolic acidosis, which was being treated with sodium bicarbonate. She was also making occasional jerking movements of her chest. Kesselman testified that the jerking was most likely the result of one of the anaesthetic drugs wearing off.

While Odim had described Alyssa as being in stable and excellent condition on admission to the PICU, Kesselman gave a different perspective in his testimony.

Well, she was, based on those findings of somewhat impaired cardiac output and edema and everything, she was not-I was going to say critical, she wasn't critical in the sense that things were changing, but she needed close attention, and gradually improved over the next several hours.

Q: Was she stable when she came to ICU?

A: Stable in the sense that nothing was changing, yes, but things were not as perfect as one would like, but I would say that her condition was adequate and not unexpected for a post-op repair early on. (Evidence, page 33,957)

In the radiology report of a chest X-ray taken post-operatively in the PICU, Reed noted, "The heart is normal in size. There are abnormal densities throughout most of the right lung, but the left lung looks essentially clear. Interpretation: There are abnormal densities in the right lung, which probably represent retained secretions." (Exhibit 11, page STI 63) In his testimony, Reed said that:

It is quite common to see abnormal densities in the lungs following general anaesthesia, particularly if the surgery lasts for awhile. It is not surprising to see it after cardiac surgery. (Evidence, page 37,421)

He said that the densities were not likely to be pneumonia.

During the evening and most likely before 2000 hours (there is no time on the note) Giddins wrote, "Probably fluid overloaded with high likelihood of pulmonary edema." (Exhibit 11, page STI 46) He noted that Alyssa was quite puffy, with an increased heart rate of approximately 160. He suggested that the dose of dopamine be adjusted downwards and a diuretic started within 12-14 hours.

At 0100 hours on May 6, Colleen Kiesman, who was the bedside nurse, noted that Alyssa had a strong cough when she was suctioned. This procedure involves inserting a catheter through either the patient's nose or mouth to suction secretions out of the airways. If the patient is intubated, the catheter is slid down through the endotracheal tube. Because of the secretions in Alyssa's lungs, it was necessary for the nurse or a respiratory therapist to suction her airways. In the instructions for treatment that were left by Odim, there was no indication that Alyssa should be provided with any special treatment before being suctioned.

Odim said he did not believe Alyssa's cough at 0100 hours was related to her pre-operative cough. Nor did he think that the thick secretions that were being suctioned were related to the pre-operative condition. He said the more frequently a patient is suctioned, the less likely it is for the secretions to be very thick. Kesselman also testified that "Anyone who has a tube in and is suctioned is going to cough." (Evidence, page 33,960) He also testified that thickened secretions were not abnormal in this situation.

In a later entry note, Kiesman wrote that Alyssa was stable until 0342 hours, when she opened her eyes and started coughing. A respiratory therapist hand-ventilated her while Kiesman suctioned out a small to moderate amount of blood-tinged, thick secretions (Exhibit 11, page STI 48). Alyssa's heart rate and blood pressure began to drop. Kesselman was called to her bedside. At that point, the respiratory technologist was hand-ventilating Alyssa. Kesselman checked Alyssa's airway and chest for blockages and could not detect any. At this point Kesselman connected the pacemaker:

All the children post-operatively have transthoracic pacing wires that are taped to their chest if the need for pacing should arise. So you have to disconnect these, they are taped in place, you take the tape off and connect the leads to the pacemaker box. And so I would have done that and turned the pacemaker on, which is just flicking a switch and turning a dial to turn it to full output. And with that there was no response in the heart rate, in that the pacemaker didn't capture the heart, meaning it didn't-the electrical impulses from the pacemaker box didn't cause the heart beat to stimulation. (Evidence, pages 33,962-33,963)

Kesselman initiated external cardiac massage at 0350 hours. At that point, the heart rate was 23 beats per minute. In addition, medication was delivered in an attempt to stimulate the heart. Odim arrived at 0406 hours and opened the chest four minutes later. He began internal cardiac massage at 0414 hours.

Odim also requested epicardial pacing wires and an internal defibrillator. These were not kept in the PICU. Youngson testified that she received a phone call at 0400 hours from a PICU nurse who was looking for pacing leads in the OR. She was also looking for internal defibrillator paddles. The wires were located and attached; however, the pacemaker still did not capture Alyssa's heart.

Those at Alyssa's bedside attempted defibrillation once at 0423 hours and three times at 0429 hours. At 0430 hours on May 6, the Stills received a phone call at Ronald McDonald House. They immediately went to the hospital where they were met by Odim, who told them Alyssa was in trouble. At 0501 hours, resuscitation was stopped. Alyssa was declared dead.

According to Kiesman's testimony, Odim then said that it was the suctioning that caused the cardiac arrest. Kiesman testified:

I probably turned white, being the bedside nurse. But Dr. Kesselman had said that wasn't my fault after Dr. Odim had left, Dr. Kesselman said that he didn't know whether he would have done anything different in the situation. (Evidence, page 32,294)

Kesselman testified that he recalled hearing Odim tell Kiesman that it was the "suctioning that did it." (Evidence, page 33,984) Kesselman testified that he then reviewed the bedside monitor to determine if there were unappreciated events before the arrest. He said that he could not find any.


Did suctioning contribute to Alyssa's problems?

One of the central questions in this case is whether or not the suctioning was the cause of Alyssa's death. Odim testified that he never made any statement to Kiesman that her actions were responsible for Alyssa's death. However, this was how both Kiesman and Kesselman understood his comments. Clearly, they were left with the impression that Odim felt that Kiesman had done something wrong. As a result, Kesselman, who believed that Kiesman had not contributed to the death, felt compelled to try to reassure Kiesman.

Kiesman also testified that after Alyssa died, Odim asked her and Kesselman if Alyssa had been treated with atropine before being suctioned. Kiesman said that Odim indicated that if Alyssa had had such treatment, she might not have developed a slowing of her heart rate. Kiesman said that no such treatment had been given, nor had it been ordered, nor was it standard procedure in the PICU. Kesselman could not recall the conversation. He did indicate that the PICU would not normally have pre-treated Alyssa with atropine, since it would increase the heart's energy consumption. Odim testified that it was his experience that anaesthetists pre-treated with atropine. He also indicated that he believed Alyssa had been treated with atropine during the period when Kesselman was trying to revive her. Soder testified that atropine is used to prevent vasovagal episodes under what he described as very rare circumstances.

It is noteworthy that the medical chart does not indicate that atropine was either ordered or administered to Alyssa at any point that evening. It seems reasonable to conclude, for the reasons cited by Soder, that it was not something that was given to patients as a matter of course.

Odim's comments left Kiesman with the impression that she might have contributed to Alyssa's death. There is no reason to believe that that was in fact the case. There is a considerable body of evidence to suggest that patients who are intubated will experience coughing spells in conjunction with suctioning. There is also medical evidence to support the conclusion that the administration of atropine was not something that was done as a matter of course. There is nothing in the evidence to suggest that the manner of suctioning that Kiesman used for Alyssa that evening was out of the ordinary. Finally, there is evidence that the failure of the pacing wires to assist the heart to capture a proper rhythm was the most serious issue that the team faced that evening. The failure of the pacemaker or pacing wires to perform properly was a recurring complaint that ICU staff had about Odim's patients.

Shortly after 0501 hours, Odim met with the Stills. He told them that the problems started when Alyssa started coughing, and her heart started to slow down. Odim said:

I think we were all very, very shattered and disappointed because she had been doing so well and the mom was there and I think the grandma was there and we were all shaking our heads. We couldn't understand what had happened.

I tried to relay the events of the evening to mom and grandma and what we tried to do to reverse things, but we really were not-we were at a loss for an explanation save potential vasovagal response from suctioning and and/or pulmonary hypertensive crisis that we couldn't turn around. (Evidence, pages 24,921-24,922)

Donna Still consented to an autopsy. The Stills left Winnipeg on May 7, 1994. At the time no one could explain to her why her daughter had died. On the Sunday following their return to Thunder Bay, Giddins called and spoke to Shirley Mae and expressed his sympathy.



Current Home - Table of Contents - Chapter 6 - Post-operative course
Next Autopsy findings
Previous The operation-May 5
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
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