The Pediatric Cardiac Surgery Inquest Report



Operative reports

Odim prepared two summaries of this operation. One was his operative report; the second was a letter that he wrote on September 14 to Grewar. In both he indicated that there were no technical difficulties during surgery. In the letter to Grewar, he wrote that Marietess's condition on return to the PICU was "satisfactory but critical." He also wrote:

Of concern in the Intensive Care Unit was an increase in venous pressure on the left side with accompanying signs of superior vena cava syndrome.

The left-sided pressures which had been corresponding to the right-sided central venous pressures shortly after operation peaked at 35 cm of water. With infusion of Nitroglycerin through the system on the left side these pressures started to drop and her clinical condition improved. (Exhibit 5, page CAP 52)

He stated that after a period in which Marietess's condition moved in what he thought to be the right direction, Marietess experienced high central venous pressures, poor ventilation, and a collapse of her lungs. He wrote that:

We considered taking her back to the operating room to take-down this Fontan type connection and reconstruct a systemic to pulmonary artery shunt but felt that she would not survive another bypass run. (Exhibit 5, page CAP 52)

Odim indicated that if any new information emerged from the post-mortem, he would forward it to Grewar.

In his operative report, Odim stated:

In the head up position there was some clinical improvement of the upper head edema and we returned to the Intensive Care Unit where Nitroglycerin was selectively infused into the left venous side with evidence of resolving high venous pressure. (Exhibit 5, page CAP 87)

In his testimony, Cornel stated that the bleeding that preceded coming off bypass was an important problem that took considerable action to correct. In his report, he wrote:

The surgeon did not report any technical difficulties with venous cannulation but judging from the anaesthetic record there were significant difficulties and cannulation problems with these cases represent [sic] serious technical complications. (Exhibit 353, page 52)

In his report for this Inquest, Dr. Robert Hudson noted that in neither his operative report nor his letter to Grewar did Odim discuss the incident of hypotension (low blood pressure) that occurred at the time of initial cannulation in the OR. He noted that "severe hypotension just prior to CPB can aggravate the adverse effects of CPB on the heart." (Exhibit 307, page 8.11) Hudson also stated that he could find no evidence in the record to suggest that the nitroglycerin infusion resolved the high venous pressure as Odim suggested. Throughout her stay in the PICU, Marietess's pressures remained high. Soder was asked if he believed that the pressures were ever resolved. He pointed out that, throughout her stay in the PICU, Marietess's venous pressures were above 20, often by significant amounts.

We get very concerned with pressures over 20, we are moderately concerned between 15 and 20, 20 is kind of the upper limit of what is acceptable. And even if you have pressures around 20 after one of these, you would like to see them over the next 24 hours come down into the mid teens.

So, in my opinion, the fact that the pressures were in that range and the patient was doing very, very poorly in terms of being acidotic, there clearly was much evidence that this was not going the way it should. (Evidence, page 44,156)

The evidence would therefore seem to suggest that both the operative report and the letter to Grewar were incomplete and misleading. Contrary to the indication in those documents, there were serious technical difficulties during this operation. Those difficulties lengthened the operation and may have put stress on Marietess's heart. Odim should have mentioned the hypotension and the bleeding that occurred during cannulation. The letter to Grewar also left the impression that the SVC syndrome was identified in the PICU rather than in the OR. Neither the letter nor the operative report mentioned Swartz's proposal to have tests done in the OR to determine the cause of the SVC syndrome.

In the letter to Grewar, there is mention of a discussion in the PICU about whether or not Marietess was strong enough to be returned to the OR. This was a discussion that Swartz testified she did not take part in or was even aware of. If Odim thought it appropriate to mention this later discussion (whose conclusion appears to have been foregone), one has to wonder why he failed to mention the earlier discussion in the OR with Swartz.

There was nothing satisfactory about Marietess's condition when she arrived in the PICU. Her perfusion was poor and never significantly improved. The evidence suggests that the treatment that Odim and Giddins settled upon did not address her underlying problems. Those problems were only identified at her autopsy.



Current Home - Table of Contents - Chapter 8 - Operative reports
Next Post-mortem findings
Previous The family on the day of surgery
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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