The Pediatric Cardiac Surgery Inquest Report



Untoward events during surgery

Preparation of the homograft

McGilton testified to one complication during Daniel's surgery.

I remember we used homograft for Daniel and I remember telling Dr. Odim several times during the case to give us lots of warning because there is a certain protocol that you have to follow for thawing it out. It's kept on dry ice and it's protocol that you follow, circulating nurse will get it, thaw it in the sterile package then it will be put on the scrub nurses' table and kept in saline for I think it's ten minutes. It's very, very carefully timed. It's very, very important. It's a very, very important-I don't want to say piece of equipment, it's part of a child, that you can't waste it, you know, you want to do it right. And I remember telling him several times please tell us when you think you're going to need it ... (Evidence, page 10,519)

McGilton testified that she reminded Odim of the need to give her sufficient notice several times during the course of the operation. Despite this, she said, she did not receive adequate notice.

It got to the point where, okay, we need it, we need it now, where is it and, you know, it was a big panic and a big rush to get it and he wanted it and I didn't want to give it to him and it was-oops, so he ended up I think putting it in maybe a minute or two ahead of when he should have. (Evidence, page 10,520)

Odim acknowledged that, as he recalled the event, he had not given enough notice, but felt he had waited the appropriate period of time before applying the homograft.


Removing the cap from the line

At another point in the operation, Odim wanted to check a pressure by connecting the aortic cannula to a transducer. Normally the surgeon does this by either removing a cap on or a connector in the line and then connecting the cannula to a line to the transducer. To ensure that there is no blood loss, the cannula is clamped for a brief period of time while the surgeon removes the cap from the line. Youngson and McGilton testified that Odim struggled to remove the cap. Youngson testified that after a time Maas indicated that they had to unclamp the line to allow blood to flow to the patient. The clamps were removed and then, unexpectedly, Odim took the cap off. Youngson gave the following description of events.

It finally comes right off in his hand, and now we have got blood shooting out of this cannula, because this is where the blood is coming back from the pump under, not a lot of pressure, but there is some pressure behind this flow of blood, and potentially air going into the aortic cannula. And I remember it was just a mad scramble to get this thing back on, stop the pump again, just make sure there is no air, for just a second or two, and then carry on. It was just a very startling incident. (Evidence, page 8,435)

It does not appear that the event caused any medical issues for the patient.


Problems with the shunt

While Daniel was being rewarmed, Odim constructed a 3.5 millimetre Blalock-Taussig shunt. The purpose of this shunt was to allow blood to flow from the ventricle to the lungs. The shunt was connected to the aorta (which had been reconstructed) and the pulmonary artery. After placement of this shunt, Daniel was taken off bypass. His oxygen saturation was found to be low (60 per cent as opposed to an anticipated 80 per cent). This was a sign that the shunt was not allowing enough blood to flow through. As a result, Daniel was put back on bypass. Odim then adjusted the shunt. Daniel was taken off bypass and Odim discovered that the shunt was still not permitting sufficient blood flow. As a result, Daniel was placed on bypass a third time, at which point a new four-millimetre Gortex shunt was put in place. Odim's operative report describes only one of these two revisions. These events added considerably to the length of time Daniel spent on bypass.

Odim also delayed closing Daniel's chest, choosing to use a silastic sheath. In his note, Odim wrote that Daniel's condition was stable on transfer to the NICU at 1901 hours. In testimony, Reimer agreed with this assessment, although he added that 'stable' was a generous term when one was speaking of a child who had undergone this particular operation.



Current Home - Table of Contents - Chapter 6 - Untoward events during surgery
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Previous The operation-April 20
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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