April 7 - The case of JM

JM was born on November 8, 1990, and at birth had been diagnosed with complex heart disease. On April 7, Odim performed a hemi-Fontan procedure. JM was returned to the PICU with his chest left open, although covered by a silastic membrane. He was discharged home on April 14.

During the course of the operation, an issue arose between Odim and the anaesthetist involving the use of central venous lines. In the post-operative period, four other issues were identified that led to disagreement and conflict between the PICU staff in general (and Swartz in particular) and Odim. The disagreements centred on pain control, ventilation, antibiotics and the surgeon's monitoring lines. Two other areas of concern noted were post-operative bleeding and pacemaker malfunction. All of these issues were also noted in other cases.

Issues

Central venous vs peripheral lines

Anaesthetists need lines inserted into a patient's veins in order to have a ready route through which drugs and fluid can be quickly administered and to be able to monitor the patient's central venous pressure (the pressure in the large vein leading to the right side of the heart). This helps anaesthetists to ensure that the heart's filling pressures are adequate and that the patient's brain is being provided with an adequate supply of blood.

Such lines are often inserted into veins in the centre of the body, such as the internal jugular vein, and are called central venous lines. Other lines can be inserted into veins in the periphery of the body, such as an arm or a leg, and are called peripheral lines.

Both central and peripheral venous lines can be used to measure central venous pressures. However, using a peripheral vein, such as the femoral vein of the leg, decreases the accuracy of monitoring venous pressure from the central portion of the body. This is important when determining the adequacy of blood supply to the brain. Additionally, the greater the distance the vein is from the heart, the longer it will take for any drug to have the desired effect.

In the case of JM, the anaesthetist inserted a line into the child's internal jugular vein, a vein favoured by the anaesthetists at the HSC. They felt that a central line in the internal jugular was less likely to become dislodged and provided readings of greater accuracy than a peripheral line. Although the anaesthetists could have used the external jugular vein, Reimer said in his evidence that it was more difficult to obtain proper readings from a line inserted into this vein because of the twisting nature of the vein, as well as the presence of valves that could affect the accuracy of the readings. McNeill testified that internal jugular lines were commonplace and used by anaesthetists throughout Canada.

During JM's operation, the internal jugular line had to be adjusted because it conflicted with Odim's planned surgical procedure. This caused Odim to express his concern over the use of central lines. An agreement was reached that internal jugular lines would not be used in patients undergoing pulmonary or Fontan type procedures.

It appears that this issue was resolved in a satisfactory manner. However, the fact that the problem initially arose during the course of an operation is not satisfactory. This was yet another sign that not enough preparation had gone into the restart of the Pediatric Cardiac Surgery Program.

Pain relief

In the PICU, the practice had been to use a continuous infusion of narcotics or analgesia for pain relief. The advantage of this approach was that it provided continuous and even pain relief. Odim preferred intermittent administrations of narcotics. In the JM case, Swartz said that she followed Odim's approach but found that it did not provide stable analgesia. The following day she spoke to Odim about this issue. Swartz testified that Odim wanted to see any papers or articles that backed up her point of view. She recalled offering to provide them if Odim was serious in his request. She said he did not ask for them and she did not provide them. From that point, the staff in the PICU provided pain relief in a continuous, rather than an intermittent, fashion.

Ventilation

Another practice in the PICU had been to have children breathing on their own as soon as possible after an operation. Odim preferred to keep the patients' muscles fully relaxed with anaesthetic drugs until their chests had been closed, which meant that they would have to be artificially ventilated. Odim wanted JM to remain intubated and ventilated overnight. Reimer, who was the anaesthetist for the operation, had not known of Odim's preferences. Instead, he had anaesthetized JM in a manner that conformed to past practice. According to Reimer's testimony:

This child was basically left with a Fontan type of circulation. And with this type of circulation it is actually hemodynamically advantageous to have spontaneous breathing, that is for a patient not to be on a ventilator. And spontaneous breathing is better because pulmonary vascular resistance is lower and blood flow through the lungs is better than with controlled ventilation.

So my anaesthetic technique for this child was actually tailored in such a fashion as to allow early resumption of spontaneous ventilation at the end of this procedure. And so I had done that, the surgery was done, and at the end of the procedure Dr. Odim's opinion was that this took quite awhile, I think we should just sedate the child and ventilate him over night. And the intensivist's opinion was, look, we can re-establish spontaneous ventilation and extubate this child today. (Evidence, pages 18,795-18,796)

As a result, JM began to breathe on his own, shortly after returning to the PICU. Odim requested that Swartz keep him intubated and ventilated. She did not follow this approach, although she did provide him with intermittent pain relief (Evidence, page 15,343).

Antibiotics

In addition to these two concerns that were identified during the JM case, the PICU staff were also concerned about Odim's use of antibiotics. The practice in the PICU had been to discontinue the administration of antibiotics after 24 hours, unless there were signs of infection. The reason for discontinuing the antibiotics was to reduce the possibility of the patient developing organisms that were resistant to the antibiotic. Odim preferred to continue to administer antibiotics until all lines had been removed from the child. In this case, the PICU staff provided the antibiotics as Odim requested.

That Odim would have different approaches to these issues is not unexpected. Furthermore, this Inquest is not in a position to adjudicate between these approaches. However, the fact that these differences emerged during patient care is a sign of the failure to prepare properly for the relaunch of this program.