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)
 1st 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

5. 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

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

11. Possible diagnosis
 Diabetic neuropathy
 Nerve compression
 Cardiac arrest
 Hypoglycemic attack

12. Intraoperative Cardiac Arrest(ICA)

13. 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

14.  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

15. 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

16. 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

17. 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

18.  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

19. 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

20.  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

21.  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

22.  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

23. 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

24. Management of ICA

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

26. 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

28. 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.

29.  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.

30.  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).

31. 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.

32.  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.

33.  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
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-
(one in the left mid-axillary line, the other over the right scapula) or bi-axillary
axillary positions.

34.  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.

35. Performing CPR on a patient with an open wound
 Any patient with an open wound, who requires CPR, with or without the
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.

36. 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
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.

37.  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

38.  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
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 etCO2 monitors are checked.
 Use etCO2 and/or arterial waveform to ensure quality of chest compressions and detect signs of ROSC.

39.  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
required.

40. Thank You