Cardiac arrest in the operating room requiring prolonged resuscitation

Purpose

Prolonged cardiopulmonary resuscitation (CPR) is often associated with limited success and poor long-term outcomes. The purpose of this report is to present the case of a patient who suffered an unanticipated cardiac arrest in the operating room and survived following a prolonged period of CPR.

Clinical features

A previously healthy 53-yr-old male with inflammatory bowel disease was diagnosed with a perforated bowel and underwent emergency exploratory laparotomy under general anesthesia. Approximately two hours after induction of anesthesia, the patient experienced cardiac arrest, and for 55?min, he underwent CPR and defibrillation according to the Advanced Cardiac Life Support (ACLS) protocols. As the decision to terminate CPR was being considered, a return of spontaneous circulation was detected 56?min after the onset of cardiac arrest. The patient survived with no major organ failure or adverse neurological outcome. No definitive cause of cardiac arrest was diagnosed in the postoperative period. At the follow-up 14?months after the event, the patient had returned to the pre-arrest level of functioning. The results of our literature search showed that no upper limit for the duration of CPR has been defined. Good outcomes after prolonged CPR depend on the patient??s pre-arrest condition and the etiology of the cardiac arrest.

Conclusion

Perioperative cardiac arrests are rare events, and there is little evidence to suggest an upper limit for the duration of resuscitation. Unknown etiologies and the presence of good patient predictors may support the continuation of prolonged CPR with good outcomes.     

Cardiac arrest in the OR: How are our ACLS skills?

Purpose

While advanced cardiac life support (ACLS) training is widely available, it is not mandatory for all anaesthetists, We hypothesised that adherence to ACLS guidelines during resuscitation of ventricular fibrillation (VFib) as assessed in a simulator environment would be poor by anaesthetists not trained in ACLS compared wrth those who had received training,

Methods

With approval by the ethics review board, 89 subjects participated in the study. The simulation system consisted of a computer controlled mannequin with lifelike qualities set in a mock operating room. Each subject was given a test scenario that contained several standard anaesthetic problems. A VFib cardiac arrest occurred after approximately one hour into the simulation. A perfect score (score = A) defined complete compliance with the ACLS guidelines, whereas minor deviations (score = B) included changes in energy levels, drug doses or treatment order. The failure to discontinue the anaesthetic, defibrillate or administer epinephrine were considered major deviations (score = C).

Results

Eight subjects followed the ACLS guidelines (9%, score = A), while 27 subjects showed minor (30%, score = B) and 54 subjects major deviations (61 %, score = C). Sixty-two of the 89 participants (70%) had taken the ACLS course and achieved higher scores than did anaesthetists without such training (P < 0.05). Forty-two participants (47%) did not discontinue the anaesthetic, 10(11%) never gave epinephrine and 5 (6%) never used the defibrillator.

Conclusion

Adherence to ACLS guidelines was poor. A greater proportion of subjects wrthout previous ACLS training had deviations from protocol than did subjects who had received training. We need to consider ways to ensure that anaesthetists obtain and retain resuscitation skills according to ACLS guidelines.     

Which Adverse Events are Associated with Mortality and Prolonged Length of Stay Following Colorectal Surgery?

Introduction

There has been increased attention focused on reducing postoperative length of stay and mortality following colorectal surgery. We sought to identify adverse events associated with prolonged length of stay and mortality.

Methods

We evaluated postoperative “adverse events,” prolonged length of stay, and mortality within 30 days of colorectal surgery in the National Surgical Quality Improvement Program (NSQIP) hospitals from January 2005 through December 2008. We then used multivariate models to establish the associations between adverse events and prolonged length of stay and mortality.

Results

A total of 54,237 patients underwent colorectal surgery: 39,980 (74 %) experienced no postoperative adverse events, while 14,257 (26 %) experienced one or more adverse events. Length of stay was prolonged (longer than 10 days) in 38 % of patients who experienced a postoperative adverse event and in 15 % of patients without events. Mortality increased with the number of postoperative adverse events. In multivariate models including preoperative comorbidity, patient risk factors, and adverse events, patients who experienced a cardiac arrest, septic shock, stroke, myocardial infarction, and/or renal failure were at highest odds of dying within 30 days of surgery.

Conclusions

Patients with cardiac arrest, septic shock, stroke, myocardial infarction, and/or renal failure are at highest risk of mortality following colorectal surgery.     

Management of sleep apnea in adults - functional algorithms for the perioperative period: Continuing Professional Development

Purpose

Obstructive sleep apnea (OSA) is defined by repetitive partial or complete upper airway obstruction characterized by episodes of breathing cessation during sleep. It is the most prevalent of sleep disorders, seen in about one in four males and one in ten females. We reviewed current literature, collated expert opinion, and synthesized protocols from several institutions to present practical principles and functional algorithms to assist the anesthesiologist in the perioperative management of known and suspected OSA.

Principal findings

Patients with OSA may have an increase in postoperative adverse respiratory events, sustained arrhythmias, hypertension, and other cardiovascular events. The gold standard for the diagnosis of OSA is polysomnography. The Berlin questionnaire and the American Society of Anesthesiologists OSA checklist are useful screening tools, while the STOP and the STOP-Bang questionnaires are easy to use in adults. Patients scheduled for elective major surgery, who are at high risk of OSA with significant comorbidities, may be referred for preoperative polysomnography. Perioperative precautions, such as anticipation of a possible difficult airway, use of short-acting anesthetic agents, avoidance of opioids, and extubation in a non-supine position, should be undertaken for known or suspected high-risk OSA patients. Postoperative disposition of the OSA patient should be based on the severity of the sleep disorder, recurrent postanesthesia care unit respiratory events, and the need for opioid analgesia.

Conclusion

With adequate screening and vigilance in the preoperative period, risk stratification should be undertaken for known and suspected OSA patients, and care should be individualized. Practical algorithms based on current best evidence and expert opinion may be useful in the perioperative management.     

Karotisoperation in Lokoregionalanästhesie

Purpose.

Carotid artery surgery, when performed under local anesthesia, allows continuous neurologic monitoring of the patient during the procedure. The surgeon is in permanent contact with his patient and can clearly decide on the necessity of intraluminal shunt placement.

Methods and results.

From October 1992 to December 2001, 2014 carotid artery operations were performed, of which 1912 were under local anesthesia. All adverse reactions due to the local anesthetic were recorded in a separate datasheet. Three cases of bradycardia, two cases of cardiac arrest, and three epileptic episodes were observed.

Conclusion.

Patients benefit from a risk reduction due to local anesthesia and hence from short hospital stays. Furthermore, neuromonitoring of the patient during local anesthesia allows a much more selective shunt policy. Reduced overall costs are another favorable side effect of the technique.     

Management of simulated maternal cardiac arrest by residents: didactic teaching versus electronic learning

Purpose

Successful resuscitation of a pregnant woman undergoing cardiac arrest and survival of the fetus require prompt, high-quality cardiopulmonary resuscitation. The objective of this observational study was to assess management of maternal cardiac arrest by anesthesia residents using high-fidelity simulation and compare subsequent performance following either didactic teaching or electronic learning (e-learning).

Methods

Twenty anesthesia residents were randomized to receive either didactic teaching (Didactic group, n?=?10) or e-learning (Electronic group, n?=?10) on maternal cardiac arrest. Baseline management skills were tested using high-fidelity simulation, with repeat simulation testing one month after their teaching intervention. The time from cardiac arrest to start of perimortem Cesarean delivery (PMCD) was measured, and the technical and nontechnical skills scores between the two teaching groups were compared.

Results

The median [interquartile range] time to PMCD decreased after teaching, from 4.5?min [3.4 to 5.1?min] to 3.5?min [2.5 to 4.0?min] (P?=?0.03), although the change within each group was not statistically significant (Didactic group 4.9 to 3.8?min, P?=?0.2; Electronic group 3.9 to 2.5?min, P?=?0.07; Didactic group vs Electronic group, P?=?1.0). Even after teaching, only 65% of participants started PMCD within four minutes. Technical and nontechnical skills scores improved after teaching in both groups, and there were no differences between the groups.

Conclusion

There are gaps in the knowledge and implementation of resuscitation protocols and the recommended modifications for pregnancy among residents. Teaching can improve performance during management of maternal cardiac arrest. Electronic learning and didactic teaching offer similar benefits.     

Anesthetic management of a parturient with VACTERL association undergoing Cesarean delivery

Purpose

We present the anesthetic management of a parturient with VACTERL association undergoing combined regional and general anesthesia for Cesarean delivery. Defined as a syndrome, VACTERL association comprises at least three of the following abnormalities: vertebral, anal atresia, cardiac, tracheoesophageal, renal, and limb.

Clinical features

The patient’s anatomic abnormalities and comorbidities comprised severe cervicothoracic scoliosis, kyphoscoliosis, congenitally fused ribs, and severe restrictive lung disease. She had a Mallampati class 3 airway, a right laterally flexed neck, and reduced mandibular protrusion. We performed a lumbar spine ultrasound for epidural placement which was used to provide peri- and postoperative analgesia. Due to the anticipated difficult tracheal intubation, the patient underwent an awake fibreoptic intubation and subsequently received general anesthesia. The patient’s trachea was extubated on the first postoperative day, and she received adequate post-Cesarean epidural analgesia.

Conclusion

This case highlights the challenges that anesthesiologists face when managing parturients at extremely high risk for perioperative anesthetic morbidity due to the presence of severe pre-existing disease, anticipated difficult airway, and major spinal abnormalities complicating neuraxial anesthesia. We used a combined general and epidural anesthetic approach to control ventilation, provide effective postoperative analgesia, and reduce the risk of anesthetic-related perioperative morbidity. An individualized approach should be considered for the anesthetic management of high-risk pregnant patients with complex and multiple medical and surgical morbidities undergoing labour and delivery.     

Morbidity and Mortality in Elective Total Hip Arthroplasty Following Surgical Care Improvement Project Guidelines

Background

Following evidence questioning the safety and efficacy of perioperative beta-blocker therapy in noncardiac surgery, the Surgical Care Improvement Project (SCIP) guidelines were retired in 2015. However, perioperative myocardial infarctions and cardiac complications remain leading causes of mortality following noncardiac surgery. The impact of the SCIP guidelines on reducing cardiac complications in patients undergoing elective total hip arthroplasty (THA) has not been evaluated.

Cardiac arrest during removal of a pulmonary artery catheter

Purpose

This case report describes an asystolic cardiac arrest that occurred during removal of a pulmonary artery (PA) catheter.

Clinical features

A 70-yr-old man underwent elective hepatectomy because of hepatic carcinoma with a combination of thoracic epidural blockade and general anaesthesia. After the conclusion of the operation, the PA catheter was removed and immediately after, the patient developed profound sinus bradycardia and hypotension followed by asystolic cardiac arrest. Two minutes after the onset of asystole, cardiac rhythm was detected following the administration of epinephrine and atropine. He had no further episodes of bradycardia or neurological deficit.

Conclusion

Removal of a PA cathether has the potential of inducing asystole requiring cardiac resuscitation and availability of emergency drugs.     

Transdiaphragmatic Resuscitative Open Cardiac Massage: Description of the Technique and a First Case-Series of an Alternative Approach to the Heart

Background

The purpose of this paper is to describe the transdiaphragmatic approach to the heart for open CPR in patients that arrest at laparotomy and to present a first case series of patients that have undergone this procedure.

Methods

All patients who had undergone intraperitoneal transdiaphragmatic open CPR between January 1, 2002 and December 31, 2012 were retrieved from the operation registry at Bern University Hospital, Switzerland. Transdiaphragmatic access to the heart is initiated with a 10-cm-long anterocaudal incision in the central tendon of the diaphragm—approximately at 2 o’clock. Internal cardiac compression through the diaphragmatic incision can be performed from both sides of the patient. From the right side of the patient, cardiac massage is performed with the right hand and vice versa.

Results

A total of six patients were identified that suffered cardiac arrest during laparotomy with open CPR performed through the transdiaphragmatic approach. Four patients suffered cardiac arrest during orthotopic liver transplantation and two trauma patients suffered cardiac arrest during damage control laparotomy. In three patients, cardiac activity was never reestablished. However, three patients regained a perfusion heart rhythm and two of these survived to the ICU. One patient ultimately survived to discharge.

Conclusions

In patients suffering cardiac arrest during laparotomy, the transdiaphragmatic approach allows for a rapid, technically easy, and almost atraumatic access to the heart, with excellent CPR performance. After this potentially life-saving procedure, pulmonary or surgical site complications are expected to occur much less compared with the conventionally performed emergency department left-sided thoracotomy.     

Perfusion index as a possible predictor for postanesthetic shivering

Background

Postanesthetic shivering can be triggered by surgical stress and several aspects of anesthetic management and is frequently preceded by a decrease in peripheral blood flow due to thermoregulatory vasoconstriction. As perfusion index correlates with peripheral blood flow, we examined whether perioperative perfusion index, measured using pulse oximetry, might be correlated with postanesthetic shivering.

Methods

Twenty-eight patients presenting for elective abdominal surgery were enrolled. Core (esophagus) and peripheral (finger) temperatures and perfusion index were recorded in the perioperative periods. Correlations between perfusion index and peripheral temperature and core-to-peripheral temperature gradient were then explored. Plasma levels of epinephrine and norepinephrine were also measured. The extent of shivering was graded after emergence from anesthesia.

Results

Perfusion index declined before emergence from anesthesia in patients who then developed postanesthetic shivering. This coincided with the time at which the difference between core and peripheral temperature became dissociated and peripheral temperature declined. Perioperative perfusion index was correlated with peripheral temperature and peripheral-core temperature gradient. Perfusion index at closure of the peritoneum predicted postanesthetic shivering and was significantly correlated with the extent of shivering. Plasma levels of both epinephrine and norepinephrine were significantly elevated after shivering events.

Conclusions

Perfusion index was significantly lower in patients with postanesthetic shivering before emergence from anesthesia, indicating that measurement of perfusion index during and before the end of anesthesia might be a useful means of predicting postanesthetic shivering.     

Myocardial Infarction Risk in Arthroplasty vs Arthroscopy: How Much Does Procedure Type Matter?

Background

This study aimed at assessing short-term risk of serious cardiac events after elective total joint arthroplasty (TJA) as compared to a less-invasive procedure, knee arthroscopy (KA).

Case series: anesthetic management of patients with spinal and bulbar muscular atrophy (Kennedy’s disease)

Purpose

Kennedy’s disease (KD) is a rare, X-linked recessive, neurodegenerative disorder of lower motor neurons characterized by progressive proximal limb and bulbar muscular atrophy with spontaneous laryngospasm, which may present an anesthetic risk. We undertook a computerized search of the Mayo Clinic medical records database between January 1996 and May 2008 for patients with KD undergoing general anesthesia. Medical records were reviewed for anesthetic techniques and perioperative complications.

Clinical features

We identified six patients with KD, confirmed by DNA testing, who underwent 13 general anesthetics. Succinylcholine was used in two patients, and non-depolarizing neuromuscular blockers in seven cases, all without adverse effects. Although laryngospasm was not identified in any patient, one patient with advanced disease experienced postoperative glottic edema, worsening respiratory distress, bulbar dysfunction, requiring tracheostomy and prolonged ventilatory support. One patient experienced a pneumothorax.

Conclusion

The potential for bulbar dysfunction and muscle weakness in patients with KD places them at risk for perioperative complications from anesthesia. Anesthesia providers should be cognizant of the different potential anesthetic risk factors in these patients.     

Differences in Perioperative Care at Low- and High-Mortality Hospitals with Cancer Surgery

Objective

To evaluate adherence to perioperative processes of care associated with major cancer resections.

Background

Mortality rates associated with major cancer resections vary across hospitals. Because mechanisms underlying such variations are not well-established, we studied adherence to perioperative care processes.

Methods

There were 1,279 hospitals participating in the National Cancer DataBase (2005–2006) ranked on a composite measure of mortality for bladder, colon, esophagus, stomach, lung, and pancreas cancer operations. We sampled hospitals from among those with the lowest and highest mortality rates, with 19 low-mortality hospitals [(LMHs), risk-adjusted mortality rate of 2.84 %] and 30 high-mortality hospitals [(HMHs), risk-adjusted mortality rate of 7.37 %]. We then conducted onsite chart reviews. Using logistic regression, we examined differences in perioperative care, adjusting for patient and tumor characteristics.

Results

Compared to LMHs, HMHs were less likely to use prophylaxis against venous thromboembolism, either preoperative or postoperatively [adjusted relative risk (aRR) 0.74, 95 % CI 0.50–0.92 and aRR 0.80, 95 % CI 0.56–0.93, respectively]. The two hospital groups were indistinguishable with respect to processes aimed at preventing surgical site infections, such as the use of antibiotics prior to incision (aRR, 0.99, 95 % CI 0.90–1.04), and processes intended to prevent cardiac events, including the use of β-blockers (1.00, 95 % CI 0.81–1.14). HMHs were significantly less likely to use epidurals (aRR, 0.57, 95 % CI 0.32–0.93).

Conclusions

HMHs and LMHs differ in several aspects of perioperative care. These areas may represent opportunities for improving cancer surgery quality at hospitals with high mortality.     

Unrecognized tamponade diagnosed pre-induction by focused echocardiography

Purpose

We report a case of unrecognized cardiac tamponade diagnosed pre-induction by focused transthoracic echocardiography (TTE). The value of focused perioperative TTE, the anesthetic implications of Churg-Strauss syndrome, and the diagnosis of cardiac tamponade are discussed.

Clinical features

A 58-yr-old man with a history of severe asymptomatic aortic stenosis presented for elective endoscopic sinus surgery for intractable nasal polyps with recurrent sinusitis. His cardiologist and cardiac surgeon had recommended proceeding with surgery, as aortic valve replacement was not indicated because he was asymptomatic. Prior to induction, a focused TTE was performed by anesthesia in order to document the degree of aortic stenosis, baseline ventricular function, and baseline volume status. This provided a baseline for comparison in case the patient’s hemodynamic status should deteriorate intraoperatively. Unexpectedly, the TTE examination revealed cardiac tamponade. After confirmation of the diagnosis by cardiology, urgent pericardiocentesis was performed. A diagnosis of Churg-Strauss syndrome was ultimately made, and the patient was treated with high-dose prednisone therapy.

Conclusion

Focused TTE has significant clinical utility for the diagnosis and assessment of hemodynamically significant cardiac conditions, particularly in the complex patient where clinical examination is challenging and echocardiographic findings can have immediate management implications.     

Prospektive Datenerfassung und Qualitätskontrolle am Beispiel der Karotischirurgie

Purpose.

The main goal of this study was to demonstrate the importance of an internal quality control in carotid artery surgery. On the basis of a prospective datasheet, clinical, morphologic, or cerebral predispositions and intraoperative quality control with angiography were evaluated.

Methods and results.

From 1 January 1996 to 31 January 2002, 1426 operations of the internal carotid artery were performed on 1271 patients. The data of all patients regarding preoperative evaluation, risk profiles, comorbidity and perioperative course were documented prospectively on a specially designed datasheet. The incidence of perioperative neurologic events was 3.2% and the mortality rate 0.2%. The technical result of all reconstruction was evaluated by intraoperative angiography.

Conclusion.

The continuous quality control of the technical results and relative surgical risk of each patient led to a significant reduction in perioperative neurologic events. The permanent neurologic deficit of all stages of cerebral vascular disease decreased from 3% in 1996 to 0.8% in 2002 in our unit.     

Anesthetic considerations in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome: a case series

Purpose

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome (MELAS) is a rare inherited mitochondrial disorder associated with severe multiorgan pathology and stress-induced episodes of metabolic decompensation and lactic acidosis. The purpose of this case series is to review the medical records of patients with MELAS who underwent anesthetic care at the Mayo Clinic to observe their perioperative responses to anesthesia and to assess outcomes.

Principal findings

From September 1997 to October 2010, nine patients with MELAS were identified who underwent 20 general anesthetics, 12 prior to MELAS diagnosis. Debilitating neurologic symptoms involved eight patients, and three patients had substantial cardiac comorbidities. The patients tolerated commonly used anesthetics and muscle relaxants, including succinylcholine. Lactated Ringer’s solution was used frequently. One patient was noted to have elevated postoperative serum lactate, but his serum lactate was chronically elevated. Metabolic acidosis was not observed in any patient. Hyponatremia and hyperkalemia, sometimes profound, were observed in seven patients, but these abnormalities also occurred at times remote from surgery. Two patients developed renal dysfunction following cardiac surgery and abdominal surgery for severe sepsis.

Conclusion

The MELAS patients developed episodes of hyponatremia and hyperkalemia of variable severity unrelated to the timing of surgery, suggesting these patients are prone to major electrolyte disturbances. Given the propensity to develop acid-base disturbances and lactacidemia, it is prudent to review and normalize electrolyte abnormalities and to adjust the anesthetic plan accordingly. Fortunately, the limited data suggest that patients with MELAS tolerate commonly used anesthetic drugs well.     

Catastrophic outcomes are rare in outpatient plastic surgery: a multicenter analysis of 10,954 patients

Background

Catastrophic outcomes of outpatient plastic surgery such as septic shock, myocardial infarction, and death are rare. Few studies have provided robust data on risk factors associated with these events. This study utilizes an independent, multicenter database to investigate the incidence and predictive factors of catastrophic outcomes associated with outpatient plastic surgery.

Methods

Patients in the National Surgical Quality Improvement Program (NSQIP) participant use database who underwent outpatient plastic surgery between 2006 and 2010 were identified. Demographic information for patients and rates of catastrophic outcomes within 30 days of surgery (sepsis/septic shock, pulmonary embolism, stroke, myocardial infarction (MI), cardiac arrest, coma, and death) was determined.

Results

Over the 5-year study period, 10,954 patients underwent an outpatient plastic surgery procedure. Thirty-one patients presented with catastrophic outcomes (0.28 %). These patients had a total of 34 catastrophic outcomes: 20 sepsis/septic shock (58.8 %), 5 pulmonary embolism (14.7 %), 3 stroke (8.8 %), 2 cardiac arrest (5.9 %), and 4 death (11.7 %). No occurrences of MI or coma were reported.

Conclusions

Outpatient plastic surgery can be performed safely in accredited ambulatory facilities as demonstrated by the overall 0.28 % catastrophic outcome rate garnered from a 5-year review of the NSQIP database. Level of Evidence: Level III, prognostic/risk study.