Intra operative cardiac arrest

It is a rare but potentially catastrophic event that is associated with high mortality. The reported incidence of ICA varies considerably across studies.

1. Case presentation on Intra-operative Cardiac Arrest(ICA) Dr. Tenzin Yoezer (5/8/2019) Khesar Gyalpo University Medical Sciences of Bhutan

2. History 74 y/M Sustained cervical injury following RTA on 27/7/19 with C6-C7 dislocation with quadraperesis . Brought to OT to undergo Bolhmans triple wing with IBG Type 2 Diabetic and hypertensive patient On Metformin 500 mg tid , Glipizide 5 mg bid Off medication for HTN No other past medical hx No past anesthetic and surgery history

3. History Intubation was done with glideslope. (? Manual in line- no document) 1 st attempt success Put on prone position with Gardner well(G W) tong In the middle of surgery patients HR and ECG not recordable Time from induction of anesthesia -?missing Informed surgeon – released the traction Given one dose of epinephrine HR and ECG reappeared ECG – AF and ST depression RBS – 47 mg/ dL Started on D25

4. History Informed ICU for bed Surgery finished uneventful Started on amiodarone 300 mg IV bolus followed by 900 mg IV infusion over 24 h RBS after 1 hr -139 mg/ dL Extubated in PACU- (bed not ready in ICU) Fully conscious when transferred to ICU

5. History Systolic murmur in all pericodal areas Cardiac evaluation: Severe aortic stenosis EF -60% Mild LVH No thrombus

6. Possible diagnosis Diabetic neuropathy Nerve compression Cardiac arrest Hypoglycemic attack

7. Intraoperative Cardiac Arrest(ICA)

8. Background Rare but potentially catastrophic event that is associated with high mortality. The reported incidence of ICA varies considerably across studies. Reason: the incidence of ICA has decreased with improved technology and clinical practices – inconsistence report Study periods vary from 5 to 18 yr -thus the impact of changing technology and clinical practices may result in variation in the incidence of ICA across individual studies. Most studies are based on data from single institutions and consequently suffer from limited external validity Quality and the availability of health care Combined adult & pediatric incidence Combine incidence of cardiac risk suffering ICA & MI Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1. 2017 International Anesthesia Research Society

9. Thus the reported incidence of ICA ranges from 1.1 to 34.6 cardiac arrests per 10,000 anesthetics But, the case fatality of ICA has remained consistently high at approximately 60–80% since the 1950s However, the survival rate after intraoperative cardiac arrest is 34.5% and is higher than the 15-20% overall survival rate reported after in-hospital cardiac arrest In cases where cardiac arrest is solely attributable to anaesthesia the outcome is even more favorable when about 70-80% patients survive Cardiac arrest in the operating room. J. Andres. European society of anesthesiology Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1. 2017 International Anesthesia Research Society

10. Causes: Intraoperative haemorrhage – most common End-stage organ failure Thromboembolic events Cardiac events (myocardial infarction) Sepsis Anaesthesia – rare Charuluxanan S, Thienthong S, Rungreunvanich M. et al. Cardiac arrest after spinal anesthesia in Thailand: a prospective multicenter registry of 40,271 anesthetics. Anesthesia and Analgesia 2008

11. Anesthesia related ICA Of the 2,211 USA between 1999-2005 (2,211 pts),: 46.6% - overdose of anaesthetic drugs 42.5% - adverse effects from anaesthetics used for therapeutic purposes 3.6% - complications arising from anaesthesia during pregnancy, labour and puerperium 7.3% - other complications of anaesthesia Cardiac arrest in the operating room. J. Andres. European society of anesthesiology

12. MOA : Bradycardia, hypoxia & circulatory shock Bradycardia Vagal responses to surgical manipulation vagotonic anesthetics sympatholysis from anesthetic agents β-blockers Suppression of cardiac-accelerator fibers arising from T1 to T4 Hypoxia Difficult intubation Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1. 2017 International Anesthesia Research Society

13. Circulatory shock Hypovloaemia Inhalational & IV anesthetic overdose Neuraxial block LAST Malignant hyyperthermia Auto-PEEP Bronchospasm Air embolism Increased IAP Anaphylaxis Tension pnumothorax Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1. 2017 International Anesthesia Research Society

14. Prevention, pre-cardiac arrest issues, general principles of management Patients in the operating room are monitored extensively - should be no delay in diagnosing a cardiac arrest. However, recent data - delays of 2 minutes or more in identifying the need for and initiation of defibrillation in the operating room A high-risk patient will often receive invasive blood pressure monitoring -invaluable in the event of a cardiac arrest Cardiac arrest in the operating room. J. Andres. European society of anesthesiology Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1. 2017 International Anesthesia Research Society

15. If there is a strong possibility of a cardiac arrest- apply self-adhesive defibrillation patches before the induction of anaesthesia . Asystole and VF should be detected in the operating room immediately. However, the onset of PEA might not be so obvious and capnography, pulse oximetry and pulse check or arterial line analysis may be required to establish a diagnosis. A patient can deteriorate within minutes or hours in the intraoperative setting, and effective monitoring and correction of physiological variables (hypovolemia, hypoxemia, hypercarbia, dysrhythmias, heart pump failure) and surgical intervention are the key to intraoperative prevention and treatment Cardiac arrest in the operating room. J. Andres. European society of anesthesiology

16. To prevent a cardiac arrest an anaesthesiologist needs to control all the factors that affect cardiac output: Preload Aterload and contractility Avoiding auto-PEEP and gas trapping in patients with obstructive lung diseases It is important to recognize when a patient is compromised or that a crisis situation has developed and to ensure timely and appropriate action with a positive therapeutic response. Eg : a case of prolonged hypotension with systolic pressure of less than 90 mmHg Cardiac arrest in the operating room. J. Andres. European society of anesthesiology

17. Recognizing when to start CPR in the operating room may be even more difficult than might appear outside the operating room for a variety of reasons: false alarms from monitoring systems ECG lead disconnections Hypotension and bradycardia Above are common occurrences in the operating room and might be overlooked. Achieving optimal monitoring might not be possible for some patients – for example in cases of morbid obesity. Cardiac arrest in the operating room. J. Andres. European society of anesthesiology

18. Which patients are more prone to cardiac arrest during the perioperative period? The following factors are associated with increased perioperative complications: male gender Chronic heart failure, Hypotension (systolic blood pressure less than 90 mmHg) Chronic obstructive lung disease Renal failure Cancer and major surgery Cardiac arrest in the operating room. J. Andres. European society of anesthesiology

19. Management of ICA

20. Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1. 2017 International Anesthesia Research Society

21. Cardiac arrest in Neurosurgery: From “Management of cardiac arrest during neurosurgery in adults: Guidelines for healthcare providers “ Working Group of the Resuscitation Council (UK), Neuroanaesthesia Society of Great Britain and Ireland and Society of British Neurological Surgeons Date of first publication: August 2014 Date of Review: July 2019

22. Specific factors influencing CPR in neurosurgical patients These can be divided into three main groups: The surgical procedure. The position of the patient. Performing CPR on a patient with an open wound.

23. The surgical procedure Anterior hypothalamus Brain stem Cerebello -pontine angle Pituitary Trigeminal nerve Neuro-endoscopy use of irrigation fluid of the wrong temperature All are associated with arrhythmias, usually severe bradycardia with associated hypotension or asystole.

24. The position of the patient Neurosurgery is carried out with the patient in one of four positions; Supine Lateral Prone Sitting. Patients head is fixed (Mayfield skull clamp).

25. Chest compressions/ Debrillation with the head in the Mayfield® skull clamp Risks : injury to the scalp, skull and cervical spine as the torso is moved against a fixed head. Recommendation: removal “A faster and safer process may be to release the clamp from the operating table rather than trying to release the head from the pins “ Commence CPR whilst the surgeon supports the patient’s head. If defibrillation is required, then either the support for the head (‘horse-shoe’ type) must be attached to the operating table or the patient moved bodily along the table to provide a secure rest for the patient’s head.

26. Lateral position Can perform chest compressions in the lateral position but, its efficacy is unknown. Therefore the patient should be turned supine as quickly and safely as possible. If defibrillation is indicated in the left or right lateral position, application of the pad over the cardiac apex or below the right clavicle respectively, is likely to be impeded. Therefore use of the anteroposterior position is recommended; one pad over the left precordium and the other just inferior to the left scapula.

27. Prone position There is no immediate need to turn the patient to the supine position CPR should be started with the patient in the prone position. ( effective or superior than CPR on chest -In studies on small groups of patients in ICU ) the patient’s head is fixed in pins - remove. Patients with the frame (e.g. Wilson frame, Relton -Hall frame) or pillows – remove (no effective chest). Defibrillation in the prone position - pads can be applied either postero - lateral (one in the left mid-axillary line , the other over the right scapula) or bi-axillary positions.

28. Sitting position Chest compression – not possible Defibrillation- accessible The head will need to be removed from any fixed support, or if a clamp has been used, it should be removed or released from the operating table.

29. Performing CPR on a patient with an open wound Any patient with an open wound, who requires CPR, with or without the need to be turned into the supine position, should have any instruments removed to prevent accidental tissue injury. Protect the wound with a saline-soaked swab and then cover it with an adhesive dressing. Once this has been achieved, turn the patient supine. However, following successful resuscitation, control of bleeding from the surgical site, particularly a posterior one, may be problematic.

30. Specific roles: when turning to supine Scrub practitioner – soak a large swab in saline and obtain an adhesive dressing Lead surgeon – remove instruments, apply pack and dressing, and support the patient’s head Surgical assistant – if the head is held by the Mayfield ® clamp, disconnect, unlock and rotate it out of the way to gain more access to allow the patient’s head to be turned in line with their trunk Anesthetist – ensure ventilator tubing is free to allow the patient to be turned without accidental extubation . Ensure all vascular lines, monitoring, catheters, etc. are free to allow disconnection if required, before turning Anaesthetic assistant – release any devices used to secure limbs .

31. Specific roles: when turning to supine The theatre floor staff should: collect the horse-shoe head rest and make it available to surgical team obtain a trolley or bed get additional staff to help with turning of the patient collect a defibrillator if one is not already in the operating theatre

32. Turning the patient on to a bed or trolley The lead surgeon takes responsibility for the patient’s head and coordinates the turn. The trolley/bed is placed alongside the operating table, and the brake applied. Three members of staff stand on the far side of the patient. Three members of staff stand along the side of the trolley/bed with their arms placed on the top of the trolley/bed. If possible the operating table is tilted laterally to assist with the turn. The anaesthetist disconnects the ventilator tubing from the tracheal tube and any intravascular lines as necessary. The anaesthetist informs the surgeon that the patient is ready to be turned. The surgeon then gives the command for the staff against the side of the operating table to roll the patient on to the outstretched arms of the staff against the trolley/bed. Once supine, chest compressions must be resumed without delay. The anaesthetist reconnects the ventilator tubing and vascular lines. The ECG, arterial pressure and etCO 2 monitors are checked. Use etCO 2 and/or arterial waveform to ensure quality of chest compressions and detect signs of ROSC.

33. Post-resuscitation management Immediate surgical management The surgical and nursing team should ‘re-scrub’. Re-drape the patient or apply additional draping to minimise any further wound contamination. Irrigate the wound with copious volumes of warm (body temperature) normal saline or lactated Ringer’s solution. Haemostasis should be secured. Consider further surgical options: - Continue with the planned procedure - change the goals of surgical procedure - abandon surgery and expedited wound closure. Consider peri -operative imaging (ultrasound or MRI/CT) to assess for intraparenchymal haemorrhage , over drainage of CSF causing cortical collapse or a subdural haematoma . Consider antibiotic therapy to minimise the risk of infection due to wound contamination. There should be close liaison with the intensive care team regarding specific post- resuscitation care required.

34. Thank You