The Pediatric Cardiac Surgery Inquest Report



Pre-operative status

Daniel remained in the HSC from April 13 until his death on April 20, following his operation earlier that day. Daniel's health deteriorated throughout his stay in hospital. During the final two-and-a-half days preceding surgery, there was rapid deterioration.

On Thursday, April 14, Doyle wrote in the chart that Daniel remained stable overnight, with a heart rate of 160 beats per minute. However, he did require a dose of Lasix, for increased respiratory distress.

On April 15 Doyle described Daniel as being unchanged in his condition. He required intermittent doses of a diuretic for treatment of pulmonary edema related to high pulmonary blood flow. He also had a decrease in the strength of his pulses in his legs, which indicated a reduction in blood flow to his legs (Exhibit 12, page TER 27).

On April 16 Giddins noted that Daniel still appeared unchanged, although he was developing a difference in blood pressures above and below the aortic coarctation. Giddins also indicated that the parents had agreed to a plan for surgery on Tuesday or Wednesday. They were to come in for formal consent discussions on Monday, April 18. In her testimony, Danica Terziski indicated that she recalled that the operation had been originally scheduled for Monday, April 18 but was rescheduled to accommodate Vinay Goyal's surgery.

On Sunday, April 17, Daniel's condition deteriorated significantly. He struggled to breathe, with a respiratory rate of 80 to 90 breaths a minute. Each time he breathed he had subcostal in-drawing. He grunted with activity and was pale and jaundiced. He was also blue around his mouth, a further sign of deterioration. When his regular dose of diuretic did not relieve his rapid breathing, another dose was immediately given. At 0900 hours his blood pressure had dropped, but by mid-afternoon it had returned to normal.

Daniel's condition continued to deteriorate. The doctors could no longer feel a pulse in Daniel's femoral artery (in his groin), indicating that the circulation to his legs was worsening. A chest X-ray done at 0520 hours showed acute pulmonary edema. Subsequent X-rays done throughout the day showed signs that the lungs were becoming more dense, particularly in the left lower lobe, and losing lung capacity. After discussion with Giddins, Dr. Jacques Belik, one of the neonatologists, decided that Daniel should be artificially ventilated, in an attempt to decrease the workload of Daniel's heart. Daniel was therefore sedated and given a drug to relax his muscles, so that a breathing tube could be placed into his windpipe. The tube was then attached to a ventilator that took over Daniel's breathing.

During the course of the day, Daniel regurgitated some stomach contents. In his report, Cornel speculated that some of this liquid might have entered his lungs (a process known as aspiration). If Daniel had aspirated, this could have led to an infection in the lungs.

Later that evening, Daniel's condition was clearly unstable. His oxygen saturation was rapidly declining. As a result, the doctors decided that he required manual ventilation with 100 per cent oxygen. In manual or hand ventilation, the patient is disconnected from the ventilator. Using one hand, a doctor, nurse or respiratory technologist squeezes a bag connected to the breathing tube, thus controlling the rate of breathing and the size of each breath delivered. (This technique sometimes, but not always, offers better control of the delivery of oxygen than does mechanical ventilation, using a ventilator.) Daniel was also treated with Lasix (for worsening pulmonary edema) and dopamine (to strengthen the function of his heart).

Overnight, Daniel's condition was very unstable, with his heart rate dropping severely several times. Because his oxygen saturation was so low, hand ventilation was continued.

At 0800 hours April 18, Odim wrote in Daniel's chart: "Patient has shown signs of destabilization from single ventricle lesion with torrential pulmonary flow and obstructed systemic output via VSD." Daniel had congestive heart failure that required that he be intubated. In addition, he had a low urine output. According to Odim's note these factors had "increased his surgical risk appreciably." (Exhibit 12, page TER 37) He was scheduled for surgery on Wednesday, April 20.

At 2230 hours, Daniel's oxygen saturation fell dramatically and, despite manual ventilation, he continued to deteriorate. Air entry to his lungs was obviously greatly decreased and the amount of carbon dioxide in his blood was more than twice the normal. According to Cornel, this was a sign that Daniel was close to asphyxiating. His endotracheal tube had to be changed because it was blocked with yellow secretions. In his report Cornel referred to these secretions as a purulent mucus plug. In testimony he described such a plug as:

A very hard, thick collection of secretions that build up on an endotracheal tube, and it can-we try to keep them removed by suctioning but they don't always get removed. It's more likely to happen when there is ongoing infection. (Evidence, pages 44,797-44,798)

As a result of the presence of these secretions and a chest X-ray that showed increased areas of density in the right upper lobe, Cornel testified that:

I would have wanted the baby placed on antibiotics, cultures taken, and a period of ventilation, with controlled ventilation, and to try and reduce the pulmonary blood flow prior to surgery and get the baby as completely stable as possible. (Evidence, page 44,798)

Cornel, in his written report, concluded that

the infant was not in the most satisfactory possible condition for surgery. I believe a further delay of perhaps 24 hours to allow recovery from the severe hypoxic episode [the rapid decrease of oxygen in the blood] and to treat the possible respiratory infection would have been of benefit. (Exhibit 353, page 31)

This is one more case in which the consulting witnesses who appeared before this Inquest have raised the question as to whether or not a patient was taken to surgery with an infection.



Current Home - Table of Contents - Chapter 6 - Pre-operative status
Next Preparing the NICU staff
Previous Consent
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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