The Pediatric Cardiac Surgery Inquest Report



The assessment of the consultants

Cornel, in his written report, stated that the general plan for the operation was consistent with good practice. However, he identified a number of concerns with the actual procedure.

The nasopharengeal [sic] temperature was as much as three degrees C above rectal during cardio-pulmonary bypass. (Exhibit 353, page 31)

In testimony, Cornel explained that this may have been of limited significance. It is, however, an indication that that body was not cooled uniformly.

The circulatory arrest time of one hour 42 minutes was very long and surprisingly so in view of what appears to have been satisfactory anatomy. (Exhibit 353, page 31)

In his testimony, Cornel said the favourable aspect of the anatomy he was referring to was the fact that the descending aorta was near-normal in size. This provided a relatively large vessel wall on which to sew the patch. In testimony, Cornel commented:

In his operative report, Dr. Odim didn't mention any particular technical difficulties, so it's a little hard to figure out where the time went. (Evidence, page 44,810)

The choice of a 3.5 mm graft for a Blalock shunt was unnecessary and more appropriate for a central shunt. Changing the shunt added almost 1 hour to what was already a very long cardiopulmonary bypass time (total five hours fifty-nine minutes). (Exhibit 353, page 31)

Cornel testified that he believed a larger graft would have been more appropriate and easier to attach.

In his report to this Inquest, Hudson commented on the length of the operation.

The duration of CPB was very long, in part because of the need to revise the Blalock-Taussig shunt twice before satisfactory pulmonary blood flow could be achieved... The long duration of CPB could have contributed to the eventual outcome. Also, the duration of TCA was much longer than is generally accepted at 18íC. If the patient had survived, he would have had an increased risk of major neurologic morbidity. (Exhibit 307, page 4.10)

In his testimony Odim said that the operation was longer than expected because Daniel's tissues were friable (tore easily). This required that he take extra care-and time-in his suturing.



Current Home - Table of Contents - Chapter 6 - The assessment of the consultants
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Previous Untoward events during surgery
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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