The Pediatric Cardiac Surgery Inquest Report



A desperate situation

On October 3, Erica's condition remained extremely unstable. Large amounts of clear yellow secretions were suctioned from her endotracheal tube and her mouth. In the evening, she had decreased chest expansion problems and an increase in the amount of carbon dioxide in her blood, with a resultant need for increased ventilation. The prostaglandin was also increased, with the result that her femoral pulses felt much stronger.

Erica's blood pressure dropped, but then improved with increased doses of dopamine. On admission to the HSC, she had been treated with five micrograms of dopamine per kilogram of body weight per minute. By the time she went to the operating room, she was receiving 20 micrograms per kilogram of body weight per minute. By that point, she was said to be 'inotrope dependent'. In other words, without the dopamine, Erica's heart could not have continued pumping. As Odim testified, this reduced her chances of surviving the operation. He said that from Saturday, October 1 onwards, her condition worsened:

The child then deteriorated over the next days to the point where the child was on a significant amount of inotropic agents and it became very difficult at that point because we all acknowledged that, boy, this is high risk. But it is sometimes very difficult, once you have made plans with the families, to then remove that last straw of hope two hours before going to the operating room. And it is a difficult decision, and we do think about it. (Evidence, page 25,657)

Odim was asked if he had discussed with the family the fact that what had been a high-risk case had become even higher.

Again, I don't remember. Except I remember coming in early in the morning to see the child and being amazed that a couple of hours before surgery, three or four hours before surgery, that we are on such massive doses of dopamine. And I certainly alerted the team members that many patients, most patients don't come out of the operating room when you go in. And I don't remember whether the family was there or I was able to get a hold of the family to present this to them. But we had already made plans to go to the operating room, and they had already told us to do the best we could for Erica. And you are right, it is difficult for a surgeon at the last second to pull out the rug of hope from underneath a family. (Evidence, page 25,658)

Both Cornel and Duncan were questioned about whether or not Erica had any chance of surviving surgery, given the level of her dependence on inotropes. Duncan suggested that in some cases, a child in that condition would not be taken to surgery. He testified:

Well, I think if the child requires that amount of support prior to doing a long operation, which leaves you with an imperfect result in the end, even if it's perfectly done, likelihood of survival is minimal.

Again, I have stated this had, that there may be pressures brought to bear on the team and the surgeon from the family to do anything, despite how desperate things may appear. And there is often pressures in that regard, but this child anatomically, looking at the specimen, the actual surgical techniques and anastomoses that were created appeared fine. I don't see any difficulty with anything that was done. But the heart muscle just ran out of gas. (Evidence, pages 41,444-41,445)

In his testimony, Cornel stated:

That probably of itself, the requirement for a large dose of dopamine leading up to surgery probably means that the risk was almost prohibitive of surgery, and I would probably not do a case under those conditions. But I don't mean to imply that it is wrong to try, but I think I've tried enough of those desperate cases to not want to do it anymore. (Evidence, page 44,869)

In discussing Erica's pre-operative status, Cornel wrote that:

This infant was never stable prior to surgery and the myocardial compromise must have been severe. The risk of surgery under these conditions is extremely high. I do not criticise the team for trying. (Exhibit 353, page 56)

Duncan commented in his report:

One wonders about the wisdom of an inexperienced surgical team attempting Norwood repairs, but it sounds as if the child would have died anyways before transfer might have been effected. (Exhibit 20, document 363, page 5)

In their joint report Cornel and Duncan wrote, "This was a very high risk procedure in a child already requiring potent drugs to maintain blood pressure prior to surgery." (Exhibit 354, page 12) They indicated that in some locations, these levels would be considered so high as to stop the surgeon from undertaking the procedure.

Soder, however, said that in 1994, at the Izaak Walton Killam Hospital for Children in Halifax, "I'm reasonably certain we would have encouraged the parents to go ahead with surgery with this anatomy." (Evidence, page 44,172)



Current Home - Table of Contents - Chapter 8 - A desperate situation
Next Preparation of the NICU
Previous Pre-operative status
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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