Successful but prolonged resuscitation after local anesthetic-induced cardiac arrest: is clonidine effective?

Local anesthetics when injected intravascularly result in serious cardiac complications including therapy-resistant cardiac arrest. We report a case of cardiac arrest after lumbar plexus block using a combination of 0.5% bupivacaine and 2% lidocaine with epinephrine (1:200.000). Resuscitation was performed by a combination of chest compression, repeated external countershocks and i.v.epinephrine. Clonidine had poor effect. The whole resuscitation required 90 minutes. The patient was discharged four days later without any sequelae. Blood sampling at 10 minutes showed a concentration of 2.02 mg/l lidocaine and 0.87 mg/l bupivacaine. Prolonged resuscitation is necessary in local anesthetic-induced cardiac arrest.     

Donor cardiac arrest and cardiopulmonary resuscitation: impact on outcomes after simultaneous pancreas–kidney transplantation – a retrospective study

Donor cardiac arrest and cardiopulmonary resuscitation (CACPR) has been considered critically because of concerns over hypoperfusion and mechanical trauma to the donor organs. We retrospectively analyzed 371 first simultaneous pancreas–kidney transplants performed at the Medical University of Innsbruck between 1997 and 2017. We evaluated short- and long-term outcomes from recipients of organs from donors with and without a history of CACPR. A total of 63 recipients received a pancreas and kidney graft from a CACPR donor. At 1, and 5-years, patient survival was similar with 98.3%, and 96.5% in the CACPR and 97.0%, and 90.2% in the non-CACPR group (log rank P = 0.652). Death-censored pancreas graft survival was superior in the CACPR group with 98.3%, and 91.4% compared to 86.3%, and 77.4% (log rank P = 0.028) in the non-CACPR group, which remained statistically significant even after adjustment [aHR 0.49 (95% CI 0.24–0.98), P = 0.044]. Similar relative risks for postoperative complications Clavien Dindo > 3a, pancreatitis, abscess, immunologic complications, delayed pancreas graft function, and relative length of stay were observed for both groups. Donors with a history of CACPR are, in the current practice, safe for transplantation. Stringent donor selection and short CPR durations may allow for outcomes surpassing those of donors without CACPR.     

Transport with ongoing cardiopulmonary resuscitation - when does is it make sense?

The currently valid guidelines for resuscitation of the European Resuscitation Council (ERC) do not give any unambiguous recommendations for "transport with ongoing cardiopulmonary resuscitation". Furthermore, up to now there are no generally accepted criteria for terminating cardiopulmonary resuscitation, apart from certain signs of death. In spite of the generally poor outcome of patients being transported with ongoing cardiopulmonary resuscitation, there are a number of positive case reports and undisputable indications (e.g., in cases with a potentially reversible cause of cardiac arrest). The increase observed over the past few years in the number of patients being transported under cardiopulmonary resuscitation has as yet not been reflected in an improved prognosis for these patients. The use of mechanical chest compression devices with a better quality of chest compression, also under transport conditions, may have an influence on the number transports but this has not yet been evaluated sufficiently with regard to patient outcome. However, the decision to transport a patient resides with the responsible emergency physician who has to evaluate the prognosis for the patient on an individual basis.     

Extracorporeal cardiopulmonary resuscitation (EC-CPR) for hypothermic arrest in children: Is meaningful survival a reasonable expectation?

Purpose

We have previously reported the use of EC-CPR for the treatment of hypothermic cardiac arrest with an overall survival of 50%. As we have continued this protocol for an additional 5 years, we sought to update this information.

Methods

We reviewed all of the activations for hypothermic cardiac arrest from 2005 to 2011. Results are presented as means with minimum and maximum values. The 95% confidence interval for the point estimate of survival was calculated using a binomial distribution.

Results

Nine children were placed on EC-CPR for hypothermic cardiac arrest. Two patients survived to discharge and were neurologically normal. The other seven patients were adequately supported with veno-arterial EC-CPR but met brain death criteria after rewarming prompting withdrawal of support. Four of these went on to multiple organ donation. The overall survival in the series was 22% with a 95% confidence interval from 4% to 58%.

Conclusion

Cold water drowning and avalanche suffocations cause dramatic hypothermic cardiac arrests in previously robust children. A protocolized rapid response with EC-CPR can save some of these children despite prolonged periods of cardiac arrest prior to initiation of bypass. The overall survival rate is likely less than our prior more optimistic report suggested.     

Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether adrenaline might be a useful addition to a protocol for the management of cardiac arrests for patients shortly after cardiac surgery. Altogether 889 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that the European Resuscitation Council and the American Heart Association both recommend 1 mg of adrenaline as soon as pulseless electrical activity or asystole is identified or after the second failed shock if the rhythm is VF/pulseless VT. However, they acknowledge that the evidence behind this recommendation is lacking and based entirely on animal studies which have as yet not been successfully replicated in human studies to show a benefit of survival to hospital discharge. They acknowledge that the current evidence is insufficient to support or refute the use of adrenaline in arrests and the International Liaison Committee on Resuscitation grade the recommendation to give adrenaline in cardiac arrests as 'indeterminate'. Thus, in the particular situation of a patient who arrests shortly after cardiac surgery where the chance of restoring sinus rhythm either by defibrillation or by an emergency re-sternotomy is high, and where adrenaline could in this situation be highly dangerous once sinus rhythm is restored, we recommend that 1 mg of adrenaline forms no part of the resuscitation protocol for patients who arrest after cardiac surgery.     

Primary cardiac tumours: when is surgery necessary?

OBJECTIVE: Primary cardiac tumours are rare. The literature predominantly contains series on myxomas in adults and only a few long-term series that involve the very different primary cardiac tumours in early childhood. As foetal ultrasonography has continued to improve, cardiac tumours are increasingly detected early before significant symptoms develop. It is a challenge for paediatric cardiologists and surgeons to ascertain which patients need surgery and which will benefit from conservative follow-up. METHODS: A retrospective review of a 10-year period revealed 51 tumours in 26 children (median age: 1 month). Analysis was by presentation, location, associated findings, interventions, histological findings, and clinical course. RESULTS: The most common tumours were rhabdomyomas (29), fibromas (nine), teratomas (two), and haemangiomas (two). The tumour location was the right ventricle in 24 and the left ventricle in 22 patients. The symptoms varied between abnormal heart murmur (20), arrhythmia and conduction abnormalities (ten), obstruction of the outflow tract >30 mmHg (nine), severe cyanosis (three) and congestive heart failure (two). Fourteen children with haemodynamic compromises underwent surgery. There was one post-operative death and one heart transplantation after bridging with an assist device. There was no tumour recurrence even when resection was incomplete. Nine of 13 children with rhabdomyomas had spontaneous tumour regression without intervention. CONCLUSIONS: Most of the cardiac tumours in children are benign. Spontaneous regression is possible not only in rhabdomyoma. Surgical intervention is only required for children who develop relevant clinical symptoms. Total resection of the tumour is not the only therapeutic aim; more important is the restoration of the best possible heart function.     

Unrecognized drug-drug interactions: a cause of intraoperative cardiac arrest?

Many physicians overlook, or are unaware of, most drug-drug interactions. In our patient, the local anesthetic used for an axillary block may have been the precipitating drug in a cascade of drug-drug interactions that resulted in a cardiac arrest. The combination of multiple preoperative drug-drug interactions prevented the return of a stable native cardiac rhythm for almost 24 h. The mechanisms of interactions of these frequently used drugs are described, and the reader is guided to sources that identify and simplify the understanding of potentially dangerous drug-drug interactions.     

Neurological consequences of cardiac arrest: Where do we stand?

With increasing public education in basic life support and with the widespread use of automated defibrillators, post-cardiac arrest comatose patients represent a growing part of ICU admissions. However the prognosis remains very poor and only a very low proportion of these resuscitated patients will recover and will leave the hospital without major neurological impairments. Neurological dysfunction predominantly includes disorders of consciousness, and may also include other manifestations such as seizures, myoclonus status epilepticus and other forms of movement disorders including post-anoxic myoclonus. In the most severe cases, coma may be irreversible or evolve towards a minimally conscious state, a vegetative state or even brain death. These severe conditions represent by far the leading cause of mortality and disability in such patients. Currently, early use of mild therapeutic hypothermia is the only treatment that demonstrated its ability to decrease neurological consequences and to improve the prognosis. Prognostication outcome is still mainly based on a rigorous clinical evaluation coupled with neuro-physiological investigations, but brain functional imaging could become a valuable tool in the near future. Clinical research focusing on survivors should be strongly encouraged in order to assess the mid- and long-terms outcome of survivors and to evaluate the impact of new treatments or strategies.     

Why do I intubate cardiac arrest victims?

Pre-hospital airway management of cardiac arrest patients is an area of great controversy. In this opinion piece, we explore the reasons behind our belief that all patients suffering an out-of-hospital cardiac arrest should undergo endotracheal intubation. A review of current practice and guidelines suggests that endotracheal intubation should be performed by appropriately trained practitioners working within a specialised team that is adequately resourced and governed. The potential benefits of intubation, along with suggestions of how it should be delivered and by whom are described.     

Is internal massage superior to external massage for patients suffering a cardiac arrest after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether open chest cardiac massage is superior to closed chest compressions in patients suffering cardiac arrest following cardiac surgery. Using the reported search, 527 papers were identified. Fifteen papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that over 18 good quality animal studies have consistently demonstrated the superiority of open chest cardiac massage, with the cardiac index and coronary perfusion pressures often more than doubling. There are fewer human studies but they have shown that closed chest massage generates a cardiac index of around 0.6 l/min/m(2) which rises to 1.3 l/min/m(2) or more with open-chest-CPR, accompanied by even bigger improvements in coronary perfusion pressure. ILCOR recommends prompt conversion to open-chest-cardiac massage in patient's shortly post-cardiac surgery, and we would support this intervention if simple resuscitative efforts such as defibrillation, pacing or atropine fail, in order to significantly improve the quality of cardiopulmonary resuscitation.     

If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage. Altogether 550 papers were found in Medline and 990 in Embase using the reported search, of which 22 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that current resuscitation guidelines state that there is no evidence to support or refute external cardiac massage prior to defibrillation in-hospital, although a benefit has been shown for patients out-of-hospital if the response time is over 4-5 min. In addition, four large studies including the AHA National Registry of Cardiopulmonary Resuscitation, who reported the findings of 6789 in-hospital arrests, emphasise the importance of early defibrillation within 1-2 min. More concerning in patients post-cardiac surgery are four case reports after cardiothoracic surgery and five in the non-surgical literature where significant harm has been caused from external cardiac massage, although equally we found cohort studies of cardiac surgical patients who had external cardiac massage followed by re-sternotomy and found no trauma due to external cardiac massage. We recommend that guidelines for immediate external massage should be adhered to currently as the evidence that these guidelines may do harm is not yet strong enough to recommend a change in practice. However, we acknowledge that there are no in-hospital data to support very short periods of external massage prior to defibrillation and there have been examples of damage to the myocardium due to external massage. This should be borne in mind when external massage is being performed on a patient after cardiac surgery.