The Pediatric Cardiac Surgery Inquest Report



Post-operative course

Gary was transferred to the PICU at 2155 hours.

Within forty minutes of his arrival in the PICU, Gary's blood pressure suddenly dropped. He was rapidly given blood products and calcium. Despite this treatment, his condition deteriorated and he had a cardiac arrest at 2242 hours. He was successfully resuscitated with internal cardiac massage, epinephrine and lidocaine.

Gary remained in critical condition, with low blood pressure and high pulmonary pressure. He required the continuous administration of drugs to maintain a stable blood pressure during his entire stay in the unit. He suffered two additional cardiac arrests during the night, both of which required treatment with open cardiac massage and the administration of multiple bolus injections of blood products.

Early in the morning of March 15 Odim decided to close Gary's chest. This created considerable consternation for the PICU nursing staff. According to Feser, closing a chest is generally considered to be an OR procedure at the HSC. She was asked if the PICU staff had been trained to assist with this procedure.

No, they are not. They are not something that we are trained in or trained for. We are not OR trained nurses, we are not trained in OR setups, how to handle things in that respect. (Evidence, page 29,850)

Feser said she was "flabbergasted" by the development. She felt that the PICU nurses had not been given the proper notification that this procedure would be undertaken. She said that in the past Duncan would have provided notification for far less significant procedures. She also said that the PICU was not properly equipped to reopen or close a patient's chest. At the time, Feser told Odim that the normal procedure was to send a patient to the OR and have an anaesthetist present when the chest was being closed. Despite her concerns, Odim proceeded to close Gary's chest, with the assistance of PICU staff. An anaesthetist was not asked to attend.

Nitric oxide was administered at 0920 hours, with no effect on Gary's pulmonary pressures. The PICU resident noted that Gary had decreased blood pressure, decreased kidney function, decreased liver function and a coagulopathy. A chest X-ray report stated, "There is a further increase in pulmonary density on both sides, most likely the result of a combination of edema and pneumonia, although a significant atelectasis [or collapse of lung tissue] might also be present." (Exhibit 5, page CAR 113)

Later that day, after concluding that Gary was suffering from acute kidney failure and fluid overload, the PICU doctors consulted the Nephrology Service. The nephrology consultant decided to drain some of the fluid in Gary's abdominal area by performing a procedure called peritoneal dialysis. This is the term used to describe a form of dialysis (or artificial kidney function) in which the patient's own abdominal (or peritoneal) cavity is used as the container for the dialysis fluid. The actual procedure involves inserting a catheter into the abdominal cavity and draining off any fluid that might have accumulated there (termed ascitic fluid or ascites). The abdominal cavity is then filled with the dialysis fluid, which cleans the blood of waste products through contact with adjacent blood vessels. After allowing time for the waste products (normally removed by the kidneys) to move into this fluid, the dialysis fluid is then drained out, taking the wastes with it.

The procedure began at approximately 2020 hours, and was carried out by Dr. Paul Grimm, a nephrologist, and his assistant, Dr. Birk. Two hundred and forty millilitres of peritoneal fluid was removed from the abdominal cavity. While the procedure was taking place, however, Gary suffered a significant episode of hypotension (low blood pressure), and his condition quickly deteriorated to the point where the doctors started external massage of his heart. He died at 2209 hours.



Current Home - Table of Contents - Chapter 6 - Post-operative course
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Previous The operation - March 14
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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