Case Report, Analg Resusc Curr Res Vol: 8 Issue: 2
Cardiac Resuscitation in the Lateral Position and the Potential Role of Intraoperative Simulation: A Case Repor
*Corresponding Author: Yasutaka Konishi
Department of Anesthesia, Teikyo University
School of Medicine, 2-11-1 kaga
itabashi-ku, Tokyo, Japan
Tel: +(813) 3964 1211 E-mail: [email protected]
Received: December 11, 2018 Accepted: December 21, 2018 Published:December 12, 2019
Citation: Konishi Y, Bertram V (2019) Cardiac Resuscitation in the Lateral Position and the Potential Role of Intraoperative Simulation: A Case Report. Analg Resusc: Curr Res 8:1.
Intraoperative resuscitation of patients in positions other than supine is inherently difficult. Rapidly returning patients supine requires a coordinated effort and is seldom rehearsed by theatre teams.
A 77-year-old female with severe pulmonary hypertension was scheduled to undergo a hemiarthroplasty repair for a fractured neck of femur. Under general anesthesia in the left lateral decubitus position, a massive embolus provoked during cement pressurization of the femur caused cardiovascular collapse and irretrievable right heart failure. Cardiac compressions were performed in the lateral position for approximately 8 minutes before the patient was turned supine. Intraoperative death was declared after 25 minutes of ACLS.
We suggest there is a role for developing an in situ intraoperative simulation program inclusive of all operating room team members that focuses on the resuscitation of patients positioned other than supine.
Keywords: BCIS; ACLS; Intraoperative
Unanticipated intraoperative cardiac arrest (ICA) is a rare but life threatening event, with incidence previously reported at 7.22 per 10,000 non-cardiac surgeries, with a 30-day mortality rate of 63% . Ideally cardiac resuscitation is performed with the patient in the supine position, however in a recent report examining three month mortality following cardiac arrest in adults, Hur et al found that 16% of intraoperative cardiac arrests occurred in positions other than supine, including but not limited to the lateral decubitus position, sitting or “beach-chair position”, lithotomy and prone positions . Complicating resuscitation in these scenarios is that the surgical procedure is often incomplete, with the same study finding 74% of intraoperative cardiac arrests occurred during operating. In these instances, patients require a rapid temporary closure and repositioning. We report a case of intraoperative resuscitation initiated in the lateral decubitus position after cardiac arrest due to severe pulmonary embolism during hemi-arthroplasty of a fractured neck of femur, and suggest the potential role for multidisciplinary rehearsal of intraoperative resuscitation.
The patient was a frail 77-year-old female who fractured her right neck of femur after suffering a mechanical fall at home. She was scheduled to undergo a hemiarthroplasty repair several days later as an inpatient. Her past medical history included moderate to severe pulmonary hypertension (right ventricular systolic pressure 62 mmHg) of unclear origin, hypertension, aortic sclerosis, chronic hyponatremia, psoriatic arthritis, chronic anemia, a large parastomal hernia (resulting from repair of a perforated colon), depression, and a previous left total hip replacement 6 years ago. Her medications included amlodipine, atenolol, olmesartan, pantoprazole, folic acid, methotrexate, meloxicam, domperidone, nitrazepam, and a prophylactic dose of clexane for inpatient thromboprophylaxis. Her exercise tolerance was less than 4 metabolic equivalents.
Pre-operative blood tests showed her hemoglobin to be 133 g/ dL with a normal platelet count and normal renal function and electrolytes. A pre-operative arterial blood gas was remarkable for a reduced PaO2 74 mmHg (room air) and mildly raised PaCO2 49 mmHg. Chest X-ray revealed no abnormal findings. A left lower leg ultrasound was performed 2 months prior for investigation of new onset pain and edema but found no evidence of deep vein thrombosis. Transthoracic echocardiography (TTE) performed 6 months prior estimated her right ventricular systolic pressures to be 62 mmHg (upper end of moderate severity on the clinical laboratory’s scale) with a mildly dilated but normally functioning right ventricle. She had a normal sized and functioning left ventricle (ejection fraction 66%) with no significant valve pathology.
She was reviewed and medically optimized prior to surgery by the Peri-operative Medical Unit.
Pre-anesthetic assessment revealed stable hemodynamic vital signs with a non-invasive blood pressure of 152/88 mmHg and a heart rate of 68bpm. Oxygen saturation was 94% (with 3L nasal prong O2 supply). She was alert with a GCS 15. Physical exam revealed a soft systolic murmur in keeping with her TTE findings, and decreased air entry at both bases. There were no anticipated airway difficulties and she weighed 52 kg at 158 cm tall.
The plan was for general anesthesia with an endotracheal tube, large gauge intra venous access, and arterial line monitoring. The risk of perioperative morbidity and mortality was discussed between the orthopedic and anesthesia teams.
Anesthesia was induced with 100 mcg of fentanyl, 100 mg of propofol and 50 mg of atracurium. The patient was intubated with a size 7.0 mm endotracheal tube uneventfully. Maintenance was achieved with 2% sevoflurane and blood pressure supported with a phenylephrine infusion to within 20% of her baseline blood pressure. The patient was positioned in the left lateral decubitus position.
Cardiovascular collapse occurred during cement pressurization of the femur. Figure 1 demonstrates the dramatic drop in blood pressure during this time. The surgical team was informed and cardiac compressions were commenced in the lateral position. A total of 1 mg of phenylephrine and 100 mcg of adrenaline were unsuccessful in rescuing a cardiac output. Advanced Cardiac Life Support (ACLS) in the supine position was delayed approximately 8 minutes while the surgical wound was rapidly closed, and technicians and staff attempted to access and remove the supporting bolsters to allow the patient to be turned supine. ACLS continued for 25 minutes with 6 biphasic shocks (200 J), adrenaline boluses and amiodarone to manage an initial rhythm of ventricular fibrillation, which then degenerated into asystole. A transesophageal echo (TOE) probe was inserted and identified a massive right atrial mass, presumed to be a cement embolus (Figure 2). In addition, there was severe right ventricular dysfunction and severely reduced left ventricular volume. Based on the TOE findings of massive embolus and irretrievable right heart failure, multiple comorbidities and prolonged resuscitation, the decision was made to cease and death was declared.
Figure 1: The figure shows the trend of systolic blood pressure and SpO2 after the cement implantation with ACLS actions including administration of vasopressors, electrocardiogram, cardiopulmonary resuscitation, and rotation of the patient’s posture. CPR was commenced in the lateral position with anteroposterior two hands approach, continued with normal chest compression in the supine position after rotation.
Intraoperative cardiac resuscitation requires a coordinated and multidisciplinary approach. Doctors learn standardized algorithms for cardiac resuscitation with chest compressions most effective in the supine position. However, intraoperative cardiac arrest is often complicated by patients being in positions other than supine. This adds a layer of complexity to an already time critical and stressful scenario, as surgeons attempt to close the surgical site and efforts are made to re-position patients.
The patient’s death in this case is likely to have been due to Bone Cement Implantation Syndrome (BCIS). On the spectrum of physiological insults caused by BCIS, cardiac arrest is the most severe. The risk factors for BCIS are high ASA grade, chronic obstructive pulmonary disease (COPD), medication with diuretics and receiving warfarin therapy. Although all teams had communicated the high risk nature of the case, plans for intraoperative resuscitation were not specifically discussed [3-5].
In order to increase survival following cardiac arrest, constant and adequate maintenance of cardiac output is important. Song et al reported the effectiveness of chest compressions in lateral tilted and semirecumbent positions [6,7], and Bengali et al also reported the successful resuscitation in the lateral position during intraoperative cardiac arrest . We attempted as best as possible to maintain the blood pressure with lateral chest compressions until the orthopedic surgeons closed the wound and theatre technicians rotated the patient supine. As Figure 1 shows, the supine chest compressions started approximately eight minutes after the sudden loss of blood pressure.
There are a number of reasons why resuscitation may have been inadequate in this position. Firstly, there is a loss of mechanical advantage and without a firm surface behind the patient, it is difficult to apply the required axial force to the sternum during compressions. The majority of doctors are not specifically trained in how to best perform compressions in this position. In addition, it is unlikely but not impossible that moving the patient from a lateral to supine position relieved obstruction to the pulmonary artery allowing for more effective blood flow chest compressions.
From that perspective, we believe there is a potential role for simulation training amongst all theatre staff to improve the knowledge and efficiency of intraoperative resuscitation. It is costly and often not practical to recruit all multidisciplinary participants into simulation center training . On the other hand, in-situ or in operating room simulations can identify latent safety threats in medication, equipment, or systems and improve the teamwork for cardiac resuscitation . Building on this theme, the Society of Thoracic Surgeons have recently released a consensus guideline for patients who arrest post cardiac surgery, recognizing that this group of patients have specific needs and considerations and recommend all care providers and units caring for cardiac surgery patients practice the resuscitation protocol on a regular basis and document competencies.
Overall, intraoperative cardiac arrest is a rare event. Anesthetists are required to learn and rehearse Advanced Cardiac Life Support (ACLS) throughout their training and as part of their ongoing education. ACLS is performed in the supine position to achieve efficient chest compressions. However, as our case highlights, anesthetists and the whole theatre team are faced with the challenge of resuscitating patients in a variety of positions. We suggest that there is therefore a place for developing an “Intraoperative” Advanced Cardiac Life Support which simulates resuscitation in situations such as this. Furthermore running these simulations with nursing, anesthesia and surgical staff and theatre technicians would assist in coordinating and managing these scenarios in real life.
- Goswami S, Brady JE, Jordan DA, Li G( 2012) Intraoperative cardiac arrests in adults undergoing noncardiac surgeryincidence, risk factors, and survival outcome. Anesthesiol 117: 1018-1026.
- Hur M, Lee HC, Lee KH, Kim JT, Jung CW, et al. (2017) The incidence and characteristics of 3-month mortality after intraoperative cardiac arrest in adults. Acta Anaesthesiol Scand 61: 1095–1104.
- Rutter PD, Panesar SS, Darzi A, Donaldson LJ (2014) What is the risk of death or severe harm due to bone cement implantation syndrome among patients undergoing hip hemiarthroplasty for fractured neck of femur? A patient safety surveillance study. BMJ Open 4: e004853.
- Olsen F, Kotyra M, Houltz E, Ricksten SE (2014) Bone cement implantation syndrome in cemented hemiarthroplasty for femoral neck fracture: Incidence, risk factors, and effect on outcome. Br J Anaesth 113: 800-806.
- Bhatnagar V, Jinjil K, Dwivedi D, Verma R, Tandon U (2018) Cardiopulmonary resuscitation: Unusual techniques for unusual situations. J Emerg Trauma Shock. 11: 31-37.
- Song Y, Oh J, Chee Y, Cho Y, Lee S, et al. (2015) Effectiveness of chest compression feedback during cardiopulmonary resuscitation in lateral tilted and semirecumbent positions: A randomised controlled simulation study. Anaesthesia 70: 1235-1241.
- Hyun SH, Han JH, Ryew CC (2018) Effect of knee positions on cardiac compression variables in cardiopulmonary resuscitation of rescuer; Manikin study. J Exerc Rehabil 14: 530-535.
- Bengali R, Janik LS, Kurtz M, McGovern F, Jiang Y (2014) Successful cardiopulmonary resuscitation in the lateral position during intraoperative cardiac arrest. Anesthesiol 120: 1046–1049.
- Weinstock PH, Kappus LJ, Kleinman ME, Grenier B, Hickey P, et al. (2005) Toward a new paradigm in hospital-based pediatric education: The development of an onsite simulator program. Pediatr Crit Care Med 6: 635-641.
- Wheeler DS, Geis G, Mack EH, LeMaster T, Patterson MD (2013) Highreliability emergency response teams in the hospital: Improving quality and safety using in situ simulation training. BMJ Qual Saf 22: 507-514.