Intraoperative Cardiac Arest

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SUDDEN INTRAOPERATIVE CARDIAC ARREST

• Dr.Asit Vaishnav
• Consultant Anaesthesiologist
• Rajkot

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Intraoperative Cardiac Arrest

• This is only a recapitulation of what we have
  learned and forgotten over the period of time in
  routine running schedules and then faced suddenly
  like a jolt.

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Intraoperative Cardiac Arrest

• Unfortunate Accident on table occurs unexpected,
• When you are
• overconfident
• Unaware of situation

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Intraoperative Cardiac Arrest

• known to the learned audience that
• Cardiac Arrest occurs because of
• Cessation of supply of oxygenated blood to
  myocardium Hypoxia,
• Hypotension, Hypovolaemia.
• Myocardial Depression- Drugs
• Electrolyte Imbalance and Arrhythmia

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• Cardiac Arrest/near arrest
• Most common Causes
• Failure of ventilation leading to Hypoxia
• Profound hypotension and progressive
  bradycardia

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These maybe Anaesthesia Related, Surgery
Related Pt. Related
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A. Anaesthesia Related

• A. Airway- Ventilation Related
• B. Cardiovascular Related
• C. Drugs Related

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Airway and ventilation Related

• Failure to secure the airway and ventilate
• Loosing the airway later on.
• Unexpected difficult intubation- Can not intubate
  and Can not ventilate situation.
• Unrecognized oesophageal intubation
• Displaced ETT after successful intubation during
  positioning the pt.

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Airway and ventilation Related..

• Regurgitation/vomiting leading to aspiration on
  mask ventilation - before intubation or
  unintubated patient.
• Airway blocked with blood, flooding with
  secretion/pleural fluid or FB during surgery
  (thoracic, airway surgery )
• Lost pack after extubation -Tonsillectomy, cleft
  palate.

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• Hypoventilation due to drugs
• high spinal,
• High spinal anaesthesia combined with
  oversedation
  -a deadly prescription of Unrecognised
  Hypoventilation and hypotension leading to
  cardiac arrest on table.

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Airway and Ventilation Related.

• Tension Pneumothorax.
• Equipment related
• O2 Failure
  
• Ventilator disconnection
• Suction not ready

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• So,
• Hypoventilation
• or
• failure to ventilate and subsequent
• Hypoxia and hypercarbia
• is the most common cause

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preventable if recognised in time. Pulse
oxymeter and capnopgraph combined, are most
essential monitor for this purpose. Pulse
oxymeter alone may recognise it but very late.
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b. Cardiovascular Related

• Myocardial depression /or peripheral
  vasodilatation leading to profound hypotension
  and arrest.
• Vulnerable are extremes of age, hypovolaemic,
  Poor LV function, I.H.D, DM, Ht., Severely
  anemic, debilitated

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Cardiovascular causes..

• Arrhythmias VT/VF
• hypercarbia/hypoxia,
• halothane,
• used up soda lime,
• Hypo/hyperkalemia

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c. Drugs Related

• Frank or relative over dose of a drug
• Cumulative effect of drugs,
• Almost all drugs used in perioperative period are
  Cardio-respiratory depressant and add to
  depressant effects of each others, local
  anaesthetics, antihypertensives, even drugs used
  preoperatively.

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Drug Related Cont.

• Accidental over dose calculation or dilution
  mistake or relying on others for drug
  preparation.
• Fast rapid injection / induction
• Both intravenous and inhalational agents
• Again, extremes of age, dehydrated,
  hypovolaemic and poor LV function are
  vulnerables.

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Drug Related..

• Accidental injection of other drugs, not intended
  for the pt.
• Anaphylaxis
• Effect of other drugs Adrenaline, Glysine,
  Haemolysis, Haemodilution, Hyponatremia,
  Hyperkelaemia- Succinyl choline.

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• SUDDEN INCREASE IN CONCENTRATION OF VOLATILE
  ANAESTHETIC AGENTS

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• Most vulnerable are Paediatric patients.
• Forgetting high dial concentration after
  induction and intubation and ventilating 3-4
  vigorous puffs of ventilation before fixing ETT
  is a typical incident.

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• One more dangerous and most common situation .
• Increasing dial concentration and
  hyperventilation on signs of light anaesthesia,
  particularly, during abdominal closure, to avoid
  a dose of relaxant for early resumption of
  spontaneous ventilation .

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Remembering words of Dr. P. N. Thota WATCH
YOUR VAPOURISER
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• WATCH YOUR VAPOURISER
• During induction, or sudden deepening of
  anaesthesia.
• Do not forget to decrease concentration after
  induction and intubation.

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WATCH YOUR VAPOURISER

• Keep one hand on vapouriser dial while inducing
  with volatile agents, by over pressure technique,
  and make it 0 when you lift mask from the face
  and proceed for intubation.

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B. Surgery Related Causes

• Intraoperative Blood loss - observed loss or
  concealed loss
• Cardiac tamponade
• Tn. Pneumothorax
• Airway injury
• Vasovagal, TrigeminoCardiac, Occulocardiac,
  anal/perianal stretch

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B. Surgery Related Causes..

• Pulmonary embolism Venous air embolism - Head
  and nack Surgery, ERCP, Neurosurgery, Fat
  embolism, Amniotic fluid embolism.
• Electrocution-Classical or leaking currants, or
  cautery current passing from heart gt V.FIB.

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C. Patient Related causes

• Not following NBM Order,
• or
• Hiding violation of it
• or
• Failure on our part to elicit it.

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Hiding or not reviling certain medical history or
failure to elicit it.
--Medical Colleges- different team for
assessment and anaesthesia. Language barriers -
Interstate residents and patients. --District
hospitals/Solo practice inadequate time for
assessment.
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Pt. With Poor Reserves, Extremes of age,
Debilitated, LVF, IHD, DM, Silent myo. ischemia,
Ketoacidosis, Long Q-T interval
Syndrome Precipitation of M.I. due to
hypotension, hypertension, tachycardia.
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Trauma Hypovolaemia Unrecognised blood
loss-Unrecognised spleen or liver injury in
patients posted for emergency Orthopaedic or
Neurosurgery .
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D. Other predisposing Causes

• Tired team, not an excuse , but definitely an
  hazard.
• Working at odd hours, in odd situations, camps,
  taking things casually, not prepared for
  situation.
• OVERCONFIDENCE

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• So, Most common Causes of arrest
• Inadequate ventilation leading to Hypoxia -
  easily picked up by pulse oxymeter and
  capnograph.
• Profound hypotension and progressive bradycardia
  or arrhythmia- can be picked up by NIBP and
  Cardiac Moniter.
• Precordial or oesophageal stethoscope still
  useful.

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It is never a sudden arrest. Always preceeded
by Bradycardia, Multiple Extrasystoles,
Hypotension, low spo2 . If you can not listen to
the cry of it, you have it.
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• Like any other Accident
• is
• preventable,
• By,

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• Pre operative
• Proper assessment
• Optimizing pt. condition
• Planning and discussion with surgical team.

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Availability and checkup of Anaesthesia machine,
Oxygen Ready and working Suction, Airway
management tools working laryngoscopes, ETTs,
stylets , bougie, LMA, Life Saving Drugs,
moniters, DEFIBRILATOR
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• Intraoperative
• Watchful monitoring
• ECG, SpO2 NIBP, EtCO2
• Paediatric patients - Stethoscope-
  Precordial/Oesophageal

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• DEFBRILATOR
• Remember Golden Period of
• 3 mins.
• Must be available,
• charged,
• ready to use and
• trained personal,
• knowing how to use it.

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• Knowledge of shokable
• or
• non shokable rhythm?
• AED is better alternate.

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IT WILL SAVE YOU ONCE Medically, legally,
socially AND
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ONCE IS ENOUGH