The Pediatric Cardiac Surgery Inquest Report



Post-operative course

When Shalynn was admitted to the NICU after the operation, she was observed to have warm skin, good pulses in the lower part of her body and satisfactory urine output. Her condition remained stable until that evening.

At 2300 hours, Shalynn became extremely agitated and increasingly cyanotic. She immediately developed a slow heart rate that was unresponsive to the administration of atropine.

At 2311 hours she went into cardiac arrest. Closed chest compressions (external cardiac massage) were begun and continued intermittently over the next hour and a quarter, until 0025 hours. She was given multiple doses of atropine and epinephrine, without return of effective cardiac output. She was found to be acidotic and was treated with sodium bicarbonate.

Odim and Shalynn's parents were called to the hospital. Odim testified:

I came in promptly into the intensive care unit to lend assistance, and discovered that, indeed, she essentially had no blood pressure or pulse without chest compressors, despite the fact of having a rate and a rhythm. (Evidence, pages 25,287-25,288)

As resuscitation continued, Odim and Ward (who had also been called to the NICU) conducted tests in an effort to determine the cause of Shalynn's deterioration. Odim thought that there might be some bleeding around the heart. As a result, he inserted a needle into the pericardium in the hope of draining off any blood that might be compressing the heart (a condition known as cardiac tamponade).

An echocardiogram performed at 0130 hours, August 2, also ruled out the presence of any fluid around the heart (or pericardial effusion, a condition similar to tamponade, but not as serious). The echocardiogram showed that the left ventricle was pumping.

A chest X-ray showed that Shalynn's lungs were clear and her heart was decreasing in size (a sign that the heart's previous swelling was lessening), and indicated the absence of a pneumothorax. (This is a condition in which air accumulates in the space outside one of the lungs, the pleural cavity, compressing the underlying lung, which may then collapse.) The tests also indicated that there was no problem with the surgical repair of Shalynn's heart. After conducting these tests, the doctors still had not found the cause of her deterioration.

Shalynn was given an intravenous infusion of isoproterenol (Isuprel) for approximately thirty minutes, to increase her heart rate and her heart's ability to contract. In addition, she was given an infusion of epinephrine, and continued to receive an infusion of dopamine. Eventually her heart rhythm and blood pressure became normal.

Between 0500 and 0600 hours, Shalynn's blood pressure started to become unstable again. At 0600 hours, she once more appeared agitated and discoloured. Her blood pressure suddenly dropped, and she again needed external cardiac massage, from 0612 to 0635 hours. She was given maximum doses of inotropic drugs (epinephrine and dopamine infusions). An echocardiogram at 0900 hours showed the performance of her left ventricle to be worsening.

There were also serious concerns about the impact that the lengthy period of resuscitation had had on Shalynn. A neurologist, Dr. J. D. Reggin, was consulted. He found that her pupils were fixed and dilated, an indication that she might have suffered brain damage. Her skin was mottled, and the blood flow to her arms and legs was poor. An electroencephalogram (EEG) was done at 0930 hours. The results showed that Shalynn was having brain seizures, for which she was given phenobarbital, to reduce the seizures. The EEG was deemed markedly abnormal, indicating acute brain damage caused by lack of oxygen. In addition, Shalynn was having other major problems, with kidney failure and coagulopathy.

At 1625 hours on August 2, the NICU staff and Odim reviewed Shalynn's condition. They were still hopeful but made a recommendation not to resuscitate her if she suffered another cardiac arrest. They discussed their recommendation with Shalynn's parents, and received their agreement.

The next day, another EEG was performed. The results indicated serious brain damage. According to Reggin, Shalynn would have had a major neurological handicap if she survived. Odim met with the parents and grandparents to discuss Shalynn's condition and prognosis. The family agreed with the decision to stop treatment, and at 1825 hours, Shalynn died in her mother's arms.



Current Home - Table of Contents - Chapter 7 - Post-operative course
Next Post-mortem findings
Previous The operation-August 1
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
Search the Report
Table of Contents