The Pediatric Cardiac Surgery Inquest Report



Post-operative course

Overall condition

Vinay remained in the PICU for 31 days until he was taken back for a second operation that was required because of a leak in the patch over the VSD. That leak was not confirmed until two weeks after surgery. During Vinay's time in the ICU, his course was complicated and his condition fragile. He suffered recurring respiratory difficulties and, except for the week from March 23 to 30, he remained intubated and ventilated. A series of chest X-rays taken during his month-long stay in the PICU indicated that at various times Vinay was suffering from pulmonary edema (a fluid buildup into the lungs from the heart), atelectasis (a collapse of lung tissue) and/or pneumonia. Treatment of the pulmonary edema started to compromise his kidney function. He had episodes of heart block with a slow heartbeat, which required treatment with a pacemaker. (Heart block occurs when there is a blockage or interruption of the electrical impulses that regulate the heart beat.) He also had recurring fevers and infections that were treated with antibiotics.


Breathing problems

Shortly after Vinay was transferred to the ICU, the Goyals spoke with Odim. They were told that the two to three days immediately after surgery were the most difficult. After Vinay was extubated, he received oxygen by facemask. By March 25 the lower lobe of his left lung had collapsed and a special pressure mask was placed on his face to assist him with his breathing. Sheena Goyal testified that he looked very uncomfortable under this mask.

One day he was okay, and the next morning when I went in, he had that pressure mask on his face, and it was giving [him a] really hard time to breathe. So he couldn't sleep for four days and four nights when the mask was on his face, and his tongue was out, like he was wanting me to take it out (indicating), but, like I was helpless, I couldn't do anything. I just sat there. (Evidence, page 936)

She asked if the decline in his condition meant that there were problems with the initial operation. According to her testimony, she was assured that all was well. Eventually her son again needed to have mechanical ventilation.


Heart problems

In time Vinay developed biventricular failure, where both ventricles failed to perform their pumping adequately, and required almost continuous inotropic support to sustain his struggling heart. Echocardiograms done on March 21 and March 25 showed a small VSD patch leak. While this leak was possibly tolerable, a March 29 echocardiogram and March 30 cardiac catheterization indicated there was a buckling of the VSD patch. There appeared to be two leaking sites in the VSD patch.

Vinay was suffering from what was termed volume overload-in this case, an excess of blood in his right ventricle. This excess of blood was likely coming from the VSD (which was not fully patched) and through Vinay's pulmonary valve opening. Blood could flow through that valve opening in the incorrect direction because the valve leaflets, which had not been properly formed, had been removed during surgery.



Current Home - Table of Contents - Chapter 6 - Post-operative course
Next Concerns of the nurses and the family
Previous The operation-March 17
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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