The Pediatric Cardiac Surgery Inquest Report



The case of JR - December 2

JR was born on November 21, 1994. At birth, he was diagnosed with an atrial septal defect, a ventricular septal defect and tricuspid atresia. He also suffered from a clotting disorder that was not diagnosed until after his first operation on December 2, 1994. He was transferred to the HSC on November 25. Following his transfer to the HSC, he underwent a balloon atrial septostomy and two separate operations. The septostomy took place on November 25. The first operation took place on December 2 and the second on December 8. After surgery, JR was transferred to the NICU, with an open chest. His chest was closed on December 14. He remained in the HSC for a further six months, because of coagulation problems and his ongoing cardiopulmonary distress. In the spring of 1995 JR was transferred to Saskatoon, where he underwent additional cardiac surgery. He was then returned to the Winnipeg PICU for further care.

On December 2, 1994, JR's oxygen saturation had fallen dramatically. It was felt that if a Blalock-Taussig shunt was not inserted, JR could have a cardiac arrest on the ward. Odim was consulted, and the child was scheduled for emergency heart surgery in the Children's Hospital.

The placement of a Blalock-Taussig shunt was a closed-heart procedure that did not require that the child be put on CPB. However JR was a neonate whose condition was fragile. Obviously there was concern about the state of his health and about his ability to withstand the operation.

More important, however, was the concern that, while the placement of a Blalock-Taussig shunt was a closed procedure, there was always an inherent risk that the shunt would not do what was expected of it. For any one of a number of reasons, the chances of having the operation suddenly become one where open-heart procedures would be required, while perhaps remote, were real. There was a clear possibility that the team might require the use of the CPB machine.

As a result of the speed at which the case proceeded, however, the operation could not take place in OR Theatre 2. This was the usual pediatric cardiac operating room, but it was being used for another operation. Instead, JR underwent his operation in OR Theatre 1. Both Wong and McGilton were worried about proceeding with the operation, since the OR they would be using lacked equipment that was available only in OR Theatre 2. McGilton and Wong were particularly concerned because, if bypass became necessary, the perfusion equipment that would be needed could not fit into OR Theatre 1.

Wong said that, once he became aware of the emergency nature of the case, he agreed to go ahead with the procedure. While Wong was the anaesthetist initially, Ullyot replaced him later in the procedure. There was nothing unusual in this, since the operation was a closed heart, as opposed to an open-heart, procedure. Ullyot said that she had had considerable past experience with the placement of B-T shunts, although this was the first time that she had worked with Odim.

At approximately 1645 hours, Odim announced that the shunt was open. It was expected that this would cause a decrease in blood pressure and an increase in oxygen saturation. However, this did not happen. At the time, Odim said that he could feel blood flowing through the shunt. Eventually the blood pressure and the oxygen saturation reached acceptable levels, and at 1730 hours Odim began to close the chest. When he finished closing the chest at 1800 hours, both the blood pressure and the oxygen saturation fell. At Ullyot's suggestion, Odim loosened the sutures and opened the chest. However, JR's oxygen saturation and blood pressure did not improve.

Odim examined the shunt and found that it had clotted, even though he had treated JR with heparin. After attempting, without success, to unblock the shunt and after having consulted with Giddins by telephone, Odim decided to construct a central shunt. (This central shunt would connect the aorta to the main pulmonary artery.) Once this shunt was in place, however, the pressure and oxygen saturation problems were still not resolved.

Odim considered going on bypass and putting in a third shunt. In preparation for this, a call was put out for a perfusionist. Todd Koga, who was on call, was paged and rushed from home to the Children's Hospital. By the time he arrived, Odim had decided not to put in a third shunt. Instead he found he could maintain JR's oxygen saturation at an acceptable level by treating JR with inotropic medication. JR was taken to the NICU with his chest open.

Following that operation, a heart catheterization was undertaken. According to Reimer, who gave the anaesthetic for the catheterization, JR was unstable and suffered two cardiac arrests during that procedure.

In the NICU, JR's shunt once more became clotted. Tests were conducted and the results indicated that JR had a blood condition that increased the tendency of his blood to clot. He was treated with anti-coagulants and a decision was made to put in a third, larger shunt. This operation took place on December 8.

At that time Odim placed a 4-millimetre shunt, larger than the 3.5-millimetre shunts he had used previously. He hoped that a larger shunt would be less likely to become blocked or occluded. As a result of the larger shunt and the anti-coagulation medication, JR's oxygen saturation improved. However, he was once more returned to the NICU with his chest open.

JR's previously undiagnosed blood condition contributed to the fact that his initial operation was very long, particularly for what was expected to be a relatively straightforward shunt procedure. The case was a matter of concern for the nursing staff in both the OR and in the NICU. McGilton testified that she had never seen a shunt become blocked in that manner, had never seen an eight-hour shunt operation and had never seen a shunt patient sent to the NICU with an open chest.

Armitage testified that the clotting of the shunt created a chaotic situation in the NICU. She said that Odim once again requested equipment that was not kept in the unit. She testified that many NICU nurses were becoming alarmed by the fact that so many of the cardiac patients were coming back from the OR in very serious condition. While it would appear that there were reasonable explanations for the problems that arose in this particular case, the atmosphere had become so tense and suspicious in the hospital about the program that even explainable events were given only negative interpretations.



Current Home - Table of Contents - Chapter 8 - The case of JR - December 2
Next Blanchard's meeting with Unruh and Odim - December 5
Previous The impact of the Maguire case
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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