The Pediatric Cardiac Surgery Inquest Report



May 11-12-the case of FE

FE was a one-year-old child who underwent two open-heart operations in May 1994. The second operation was because of severe bleeding after the first operation.

FE was born on May 19, 1992. At birth he was diagnosed with tricuspid atresia and needed an immediate operation. He was given a right modified central systemic to pulmonary artery shunt (Blalock-Taussig) and also underwent a balloon atrial septostomy.

On December 7, 1993, a cardiac catheterization revealed severe hypoplasia of the right ventricle. Both the tricuspid and pulmonary valves were dysplastic and stenotic. There was moderate to severe tricuspid regurgitation, severe right pulmonary artery stenosis and mild mitral valve regurgitation. There was a small ventricular septal defect with a predominantly left to right shunt. The central aortic right pulmonary shunt was patent.

At the pediatric cardiac surgery conference on April 6, 1994, FE was described as cyanotic, with clubbed fingers and slow growth. It was suggested that he was a candidate for a Fontan procedure.

On May 11, Odim chose to replace FE's aortic shunt with a Glenn shunt. During this procedure, his heart was opened to allow Odim to remove the atrial septum. This ensured that blood coming back to the right atrium would have an outlet. As in a number of other operations, FE had bleeding problems. The problems were thought to be due to a coagulopathy, since they were treated with special transfusions. However, the bleeding problems were to recur.

By the early morning of the next day, FE showed signs that he could not tolerate his new shunt. His oxygen saturation was very low, and he suffered what witnesses described as a major hemorrhage from his chest tubes. Although he received a transfusion, the decision was made to re-operate. As a result, most of the surgical team was recalled and FE was taken back to the OR.

Initially a number of drugs, including nitric oxide, were used to try to increase the blood flow to his lungs. When this failed to have the desired result, Odim attempted to open up FE's narrowed pulmonary artery. When this brought no relief, Odim decided to create a new shunt in addition to the Glenn shunt.

FE was returned to the PICU in stable condition with his chest open. The sternum was closed on May 16 and he was discharged from the PICU on May 30, 1994. Several witnesses expressed concern over the amount of bleeding that FE experienced.

Swartz had earlier expressed her concern that Odim appeared often to assume that bleeding problems were due to a coagulopathy, rather than to any surgical problems. This concern had arisen in the Goyal case. However, according to her notes, this concern also arose in the FE case. When FE was taken back to the OR, she wrote:

There appeared to be sites of bleeding and other sites were very dry, yet it was only with the assistance and insistence of the assistant surgeon that these bleeding sites were finally identified and treated appropriately. The surgeon said he couldn't really see any bleeding sites. (Exhibit 127)

The FE case also increased Feser's concerns about the amount of post-operative bleeding suffered by pediatric cardiac cases arriving in the PICU from the OR. Gary Caribou had lost 200 millilitres of blood in his first hour in PICU, while Jessica Ulimaumi had lost over 600 millilitres in her first 24 hours in the PICU. FE lost 687 millilitres in his first hour in PICU. Feser testified that in her experience, a loss of at most 20 millilitres an hour was acceptable.

In his evidence, Odim suggested that post-operative bleeding was not excessive, although it might have been higher than what the PICU staff had experienced under Duncan. Odim said that he (Odim) tended to send his patients to the ICU earlier than Duncan did. Odim admitted that he felt that patients should be transferred out of the OR and into the ICU as soon as possible, because he felt that the ICU staff was better equipped to address post-operative issues than was the operating-room staff.



Current Home - Table of Contents - Chapter 6 - May 11-12-the case of FE
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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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