SUMMER 8-WEEK SESSION June 15 - August 8

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Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
This document has been developed by the ASA Committee on Critical Care Medicine, and has not been reviewed or approved as a
practice parameter or policy statement by the ASA House of Delegates.
Anesthesia Advanced Circulatory Life Support:
Andrea Gabrielli, MD, FCCM
Michael F. O’Connor, MD
Gerald A. Maccioli, MD, FCCM
Introduction:
Advanced Cardiac Life Support (ACLS) was originally developed as an extension of
Basic Life Support (BLS), and thus focused on the resuscitation of individuals found
unresponsive in the field. It was subsequently expanded to encompass their immediate
care in the emergency department, and has been exported to patients found
unresponsive anywhere else in the hospital. The initiation of ACLS is predicated upon
the discovery of an unresponsive patient who does not have a pulse. ACLS is rhythm
oriented and specific to sudden manifestations of cardiac disease during everyday life; it
presumes that effective electrical and pharmacological management of a pulseless
electrical rhythm will result in the return of spontaneous circulation (ROSC).
Cardiac arrest during anesthesia is distinct from cardiac arrest in other settings in that it
is usually witnessed, and frequently anticipated. In comparison to other settings, the
response is both more timely and focused. In many instances, the prognosis is improved
by both a detailed knowledge of the patient and the enormous resources, which can be
mobilized in a short time.
In the perioperative setting, patients typically deteriorate into a pulseless arrest over a
period of minutes or hours, under circumstances wholly dissimilar to other in-hospital or
out-of-hospital scenarios. Consequently, aggressive measures taken to support their
physiology can avert, avoid, or forestall the need for ACLS. Additionally, patients in the
perioperative period have a different milieu of pathophysiology. For example,
hypovolemia is far more common than transmural infarction from plaque rupture and
intraoperative myocardial ischemia from O2 delivery consumption imbalance rarely
evolves to full pump failure or ventricular fibrillation in the operating room. The result is a
different spectrum of dysrhythmias and desirable interventions in the operating room
than in the Emergency Department. The most common cardiac dysrrythmia during
general and neuraxial anesthesia is bradycardia followed by asystole (45%). The other
life threatening cardiac rhythms are severe tachydysrrhythmias including ventricular
tachycardia,ventricular fibrillation (14%), and pulseless electrical activity (7%).
Remarkably, in 33% of the cases the heart rhythm is not fully assessed or documented.
While the cause of circulatory arrest is usually unknown in patients found down in the
field, there is a relatively short list of probable causes in patients who have circulatory
collapse in the perioperative period. This certainty produces more focused and etiologybased resuscitation efforts, which frequently do not comply with the more generic
algorithms of the ACLS guidelines. While some construe this as sub-standard care,
most experts in resuscitation in the operating room regard it as entirely appropriate. In
fact it provides care tailored to the patient’s unique and specific clinical situation.
Monograph as of February 2008
1
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
When ACLS was first introduced, it was the consensus product of a small
multidisciplinary group with a common interest in ACLS. There was little clinical science
to guide and shape the guidelines they authored. Fortunately, the scenarios they took
an interest in were sufficiently common that they permitted systematic study, which has
facilitated subsequent revisions of ACLS guidelines. The current guidelines have their
foundation in a large number of directly applicable studies. Unfortunately, these studies
have focused upon the issues and circumstances outside the perioperative, thus the
guidelines generated translate less well into the perioperative setting. While cardiac
arrest in the community remains a common problem, cardiac arrest in the perioperative
period is relatively rare. This makes it difficult or impossible to perform large
epidemiological studies, and frustrates the generation of evidence-based guidelines. In
spite of this, there is a wealth of expertise and experience among anesthesiologists in
managing both circulatory crisis and cardiac arrest in perioperative patients.
We offer these guidelines as a consensus statement from a group of experts, hoping
that they will inspire the systematic study of how to manage these rare events.
1. Pre-arrest/ Avoiding arrest: Rescue
Failure to rescue is a commonly misidentified ‘cause’ of cardiac arrest. It is rare that the
practitioners caring for a patient fail to realize that they are in crisis. Regrettably, in most
instances the problem is not a ‘failure’ to rescue but rather an inability to rescue: the
patients’ underlying process was so severe that disaster would have been inevitable in
spite of the timely institution of maximal support.
Rescue requires two separate and very distinct components: comprehension that the
patient is in crisis and effective action to manage it. In practice, recognizing that a
patient is in crisis is far more difficult than effectively responding. Patients can have poor
outcomes in spite of both timely recognition of crisis and the institution of effective
therapies. Hindsight bias affords reviewers a clear view of the evolution of a crisis, along
with the luxuries of time and access to infinite resources thus making confident
proclamations that it might have been averted. Below are some ideas about how to
recognize and manage patients in crisis.
Cardiac arrest in perioperative patients typically occurs as a consequence of either
hypoxemia or the progression of a circulatory process. Avoiding cardiac arrest requires
successfully managing acute anemia, hypoxemia, and all contributing factors to cardiac
output: preload, contractility, and afterload. Anesthesiologists as a group are masters of
recognizing and treating hypoxemia, and consequently the focus of the remainder of this
document will be on the management of cardiopulmonary interactions and the circulation
in the rapidly decompensating patient.
.
Avoiding Cardiac Arrest
- afterload
- contractility
____ - preload_________
ACLS/ACLS rhythms
Monograph as of February 2008
2
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Auto-PEEP: When the lungs choke the circulation
Auto-PEEP, also known as intrinsic PEEP and gas trapping, is a phenomenon that
occurs almost exclusively in patients with obstructive lung disease, both asthma and
COPD (emphysema). In these patients, patterns of ventilation which do not allow
sufficient time for complete exhalation produce a gradual increase in the end-expiratory
volume and pressure in the lung. This pressure is transmitted to the great veins in the
thorax and depresses both venous return and cardiac output. As the auto-PEEP
increases, the venous return declines. Auto-PEEP is well described as a cause of
circulatory collapse, and a very difficult to recognize cause of PEA/EMD (pulseless
electrical activity/Electromechanical Disassociation).
Practitioners as a group may be concerned that hypoventilation will have deleterious
effects. This has been the conventional wisdom in anesthesia and medicine for the past
50 years, but has been overturned by a variety of clinical observations and studies in the
past 20 years. Although none of these studies were of perioperative patients, there are
a large number of case series and studies from the past 15 years, all of which suggest a
survival benefit to moderate hypoventilation and respiratory acidosis. Hypoventilation is
clearly and reproducibly associated with a lower incidence of barotrauma in patients with
ARDS or COPD. Furthermore patients who experience cardiac arrest during the
perioperative period almost uniformly are receiving some form of supplemental oxygen
therapy and as such are less prone to experience ‘hypoventilation hypoxemia’.
Capnography is misleading in obstructive lung disease and the more severe the
obstructive lung disease, the more misleading the capnography data. Most experts
agree upon two things: 1. patients with severe lung disease tolerate hypercarbia and
respiratory acidosis very well, and 2. that these patients should be ventilated with high
inspiratory flows (and their associated high peak airway pressures) and respiratory rates
no higher than 12 breaths a minute. If auto-PEEP is suspected as a cause of circulatory
crisis, disconnecting a patient’s tracheal tube from the ventilator for a brief time (10-20
seconds) can produce a dramatic improvement in the circulation. Patients who
demonstrate dramatic improvement in response to this maneuver will benefit from
maximal therapy for obstruction/bronchospasm, and will likely fare best with lower
minute ventilations and ventilator rates.
Detecting and decreasing auto-PEEP is a straightforward way to support a sagging
circulation. It should be among the first assessments performed in a susceptible patient
with an unstable circulation, as the most effective response to the presence of a large
amount of auto-PEEP is to decrease it.
Monograph as of February 2008
3
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
DEC 14 2000
60
WAVEFORM MONITORING
PATIENT ID 0000000000000
Paw
cmH2
O
-20
60
.
V
Lm
a 60
2
4
6
8
10
2
4
6
8
10
In the above figures, the failure of the expiratory waveforms to return to the zero
baseline before the next inspiration is indicative of the presence of auto-PEEP.
Importantly, animal models of circulatory crisis and of CPR demonstrate that
hyperventilation is almost invariably associated with worsened survival. Ventilation at 20
breaths a minute is associated with significantly lower survival than ventilation at 12
breaths a minute. As a whole, these studies emphasize the principle : in a low flow state
the duration of increased intrathoracic pressure is proportional to the ventilation rate and
inversely proportional to blood pressure, coronary and cerebral perfusion.
This is why more recent versions of the ACLS guidelines have recommended much
lower levels of ventilatory support, and is the rationale driving the development of
technologies to ventilate patients using negative pressure. It is also the genesis of one
the recommendations in these guidelines:
Patients with an unstable circulation should receive sufficient support to
adequately oxygenate their blood, but should otherwise be ventilated with the
smallest tidal volumes and the lowest rate that their care givers feel is safe.
Monograph as of February 2008
4
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Escalating Care:
If, as a practitioner, you feel the urge to consult this outline or initiate therapies outlined
in the guidelines and algorithms below, it is also appropriate to give serious
consideration to escalating the level of monitoring in parallel with the level of supportive
care. The timely insertion of both an arterial line and a central venous line will likely be
very helpful in the serial evaluation of patients as outlined below. Insertion of invasive
monitors should not take precedence over supportive measures. The decision to
escalate the level of monitoring, like the decision to escalate therapies , is ultimately a
clinical decision that accounts for a large number of factors, beyond the scope of these
guidelines.
Hypovolemia and Systolic Pressure Variation
The most common cause of hypotension in the perioperative period is hypovolemia, and
the most reliable indicator of hypovolemia is systolic and pulse pressure variation. The
cause of hypovolemia is usually, but not always self-evident in the perioperative patient.
The greater the fluctuation of the systolic pressure and pulse pressure with respiration,
the more likely the patient will respond to volume infusion (SPV figure).
The corollary is also true: minimal or absent systolic and pulse pressure variation with
respiration strongly suggest that interventions other than the infusion of volume will be
required to support the circulation (add positive inotropes, eliminated negative
inotropes). Importantly, large tidal volumes ( >8 ml/Kg) , higher lung compliance (
emphysema) and lower chest wall compliance ( 3rd degree chest burn) will also cause
an increase in systolic pressure variation, requiring practitioners to incrementally adjust
their criteria for assessing the need for volume infusion.
Monograph as of February 2008
5
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Does my patient need an increase in SV or CO?
(clinical examination, SV, CO or SvO
2
measurements, lactate level, renal failure
…)
Yes
Is the arterial pressure tracing accurate?
(fast -flush test)
Yes
Does my patient make significant respiratory efforts?
(clinical examination, airway pressure curve)
No
Is the tidal volume
" 8 mL/kg ?
Yes
Is the cardiac rhythm regular?
Yes
< 10%
How is !PP?
No Fluid
(intropes , vasodilators …)
> 15%
Fluid
(or less aggressive ventilation
V T or / and PEEP reduction)
Figure 2 above provides a simple algorithm for choosing between volume infusion and
other measures to support the circulation.
How much volume is too much? This debate continues unabated in the modern era. In
the absence of consensus and when presented with a patient in crisis, it is reasonable
for practitioners to volume resuscitate as long as there is both clinical evidence the
patient might respond and they are not obviously in high pressure pulmonary edema.
Pump Shock
The management of LV failure is substantially different than the management of RV
failure. In both settings, an adequate circulating volume is essential for ventricular filling
and forward flow. The failing LV is best supported with afterload reduction when
possible, followed by positive inotropes. Mechanical assist devices are available in
some settings to support the patient with LV failure, but escalation of therapy to that
level may not always be possible or clinically appropriate.
The failing RV is best managed with some combination of pulmonary vasodilators and
positive inotropes. Unlike the setting of LV failure, the use of systemic arterial
vasoconstrictors in this setting is usually associated with improved end organ perfusion
and cardiac output. At present, mechanical devices are not part of the management of
the vast majority of patients with failing RVs. With the exception of patients with
infarction of the right ventricle, the most common causes of an RV limited circulation
share the pathophysiology of elevated pulmonary vascular resistance.
Monograph as of February 2008
6
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Causes of an
!
!
!
!
!
!
RV limited Circulation
Primary Pulmonary Hypertension
Massive pulmonary embolism
Recurrent thromboembolism
Severe Obstructive Lung Disease, including COPD & Chronic Bronchitis
Obstructive Sleep Apnea/Sleep Disordered Breathing
Morbid Obesity
Monograph as of February 2008
7
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
RV Shock
Hypotensive?
Hypotensive?
Give
Give O2
O2
Y
pRBC
pRBC
CVP
Hct
CVP << 12?
12? (16
(16 -20)
-20)
Hct << 32?
32?
Does
Does SPV
SPV work?
work?
N
Vasopressin
Vasopressin 20
20 -40
-40 (or
(or Phenylephrine)
Phenylephrine)
Dobutamine
Dobutamine
Improved?
Improved?
N
albumin
albumin
Norepi
Norepi
Epi
Epi
Milrinone
Milrinone
Consider
Consider iNO
iNO
Rising
Rising CVP?
CVP?
Falling
Falling BP?
BP?
Sinking
Sinking SVO2?
SVO2?
R/O
R/O tPTX
tPTX and
and
Tamponade
Tamponade !!
Crisis
Some patients will continue to deteriorate in spite of escalating support.
Anesthesiologists typically administer small boluses of ‘CODE’ drugs in such instances,
a practice which is entirely appropriate. Other measures, which might be helpful in this
setting, include:
- evaluation of the surgical procedure
- rapid trouble shooting of the anesthesia machine & circuit
- review of medications recently administered
- stat portable chest X-ray to R/O tension PTX
- stat echocardiogram to evaluate ventricular filling, ventricular function,
valvular function, and exclude tamponade
- empiric therapy with an H1 and H2 blocker
- empiric therapy with replacement or stress doses of steroid.
In patients who have not been previously treated with steroids, 50mg of hydrocortisone
IV and 50 micrograms of fludrocortisone po/ng is an appropriate dose.
- If therapy with catecholamines seems to make things worse instead of better,
the possibility that the patient might have previously undiagnosed carcinoid
should be entertained, and the circulation supported exclusively with volume and
vasopressin.
- Small boluses of vasopressin (0.5 to 2 u IV) may work where catecholamines
fail.
Monograph as of February 2008
8
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
2. Arrest
Common Situations Associated with Peri-op Circulatory Crisis are listed below:
Anesthetic
o Intravenous anesthetic overdose
o Inhalation anesthetic overdose
o Neuraxial block with high level sympathectomy
o Local anesthetic systemic toxicity
o Malignant hyperthermia
o Drug administration errors
Respiratory
o Hypoxemia
o Auto PEEP
o Acute Bronchospasm
Cardiovascular
o Vasovagal reflex
o Hypovolemic and/or hemorrhagic shock
o Tension Pneumothorax
o Anaphylactic Reaction
o Transfusion Reaction
o Acute Electrolyte Imbalance (high K)
o Severe Pulmonary Hypertension
o Increased intraabdominal pressure
o Pacemaker failure
o Prolonged Q-T syndrome
o Acute Coronary Syndrome
o Pulmonary Embolism
o Gas embolism
o Oculocardiac reflexes
o Electroconvulsive therapy
Anaphylaxis
Anaphylaxis is a rare but important cause of circulatory collapse in the perioperative
period. While there is a wide range of minor allergic reactions, hypotension, tachycardia
and bronchospasm can be more easily followed by vasogenic shock when the offending
agent is administered as a rapid intravenous bolus, the most common route of drug
administration during anesthesia. The preponderance of anaphylaxis in perioperative
patients is caused by a small number of drugs.
Anaphylactic shock has been identified as a coexisting or major indeterminate factor for
dysrhythmic cardiac arrest during anesthesia occurring in 2.2 to 22.4 per 10,000
anesthetics with 3% to 4% of them being life threatening.
Common Causes:
- IV contrast
- Beta lactam antibiotics
- Latex
- Non-depolarizing neuromuscular blockers
Monograph as of February 2008
9
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
The management of the patient with anaphylaxis consists of measures to interrupt the
reaction and support the patient. Surgery should be interrupted when feasible and the
patient should be immediately supported with IV fluid and vasopressors. It is imperative
to remember that the Epinephrine administered to patients with anaphylaxis is intended
to interrupt the reaction, and not support the circulation. Thus it should always be given
and at the full recommended dose (0.01 mg/kg or approx 1mg in most adults).
Treatment
- Stop or remove the inciting agent or drug (e.g. IV contrast or latex)
- If feasible, stop surgery
- Oxygen at FIo2 of 1.0
- Chest compression if no pulse detected for 10 seconds
- 1 mg Epinephrine IV
- + 2 u Vasopressin IV
- IV fluids/large bore access
- H1 blocker (50 mg diphenhydramine IV)
- H2 blocker (20 mg famotidine IV)
- + steroid (e.g. 50-150 mg hydrocortisone IV)
- a tryptase level in the blood can be used to confirm the diagnosis
Gas Embolism
Gas embolism remains an important cause of circulatory crisis and cardiac arrest in
perioperative patients, and is likely to increase in frequency as greater numbers of
procedures are performed utilizing minimally invasive techniques incorporating gas
insufflation. While it is difficult to conduct systematic prospective human studies of this
problem, there is a growing consensus among the experts reviewing these cases that
resuscitative efforts should focus more on supporting a failing right heart, with less
emphasis on attempts to remove the offending gas.
Causes
Laparoscopy
Endobronchial Laser procedures
Central Venous Catheterization
Hysteroscopy
Pressurized Wound Irrigation
Prone Spinal Surgery
Posterior Fossa Surgery
Pressurized Fluid Infusion
Presentation
• Bradyarrhythmias/Bradycardia
• Cardiovascular Collapse
• Loss of end-tidal carbon dioxide
Treatment
1. Administer 100% oxygen and intubate for significant respiratory distress or
refractory hypoxemia. Oxygen may reduce bubble size by increasing the gradient for
nitrogen to move out.
2. Promptly place patient in Trendelenburg (head down) position and rotate toward
the left lateral decubitus position. This maneuver helps trap air in the apex of the
ventricle, prevents its ejection into the pulmonary arterial system, and maintains right
ventricular output.
Monograph as of February 2008
10
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
3. Maintain systemic arterial pressure with fluid resuscitation and
vasopressors/beta-adrenergic agents if necessary. See the algorithm on pg.8 for RV
failure.
4. Consider transfer to a hyperbaric chamber. Potential benefits of this therapy
include (1) compression of existing air bubbles, (2) establishment of a high diffusion
gradient to speed dissolution of existing bubbles, (3) improved oxygenation of ischemic
tissues and (4) lowered intracranial pressure.
5.
Circulatory collapse should be addressed with CPR and consideration of more
invasive procedures as described above.
Hyperkalemia
Hyperkalemia can be an elusive but important cause of cardiac arrest in perioperative
patients. Patients at greatest risk are those with end-stage renal disease or renal
insufficiency requiring the transfusion of red cells, and any patient suffering massive
hemorrhage. The management of unexpected cardiac arrest in these patients and in
these settings should include treatment for hyperkalemia, with at the very least
intravenous administration of calcium and bicarbonate.
It is important for practitioners to appreciate that the majority of patients who sustain a
cardiac arrest do not seem to undergo the orderly deterioration of their cardiac rhythm
as has been widely taught. Cardiac arrest from hyperkalemia can present as
bradycardia, asystole, ventricular tachycardia, ventricular fibrillation, and PEA.
Complications of Central Venous Access
Pneumothorax is a well described and relatively rare complication of central line
placement in perioperative patients. Most practitioners astutely suspect this
complication in patients who become unstable after undergoing central venous
cannulation. More recent analysis from the closed-claims database suggests that both
hemo-pneumothorax and tamponade may be important and sometimes unrecognized
fatal complications of patients who undergo attempts at central venous cannulation. In
those instances where a patient deteriorates following central line placement,
echocardiography should be considered in addition to chest radiography.
Anesthetic Techniques and Cardiac Arrest:
Local Anesthetics
Risk of local anesthetic toxicity is difficult to predict. In general, local anesthetics
depress the heart in a dose dependent fashion. Amongst the local anesthetics in
widespread clinical use, bupivicaine is the most potent myocardial depressant and most
often associated with cardiac arrest. Fortunately, most awake patients who are
developing systemic toxicity manifest CNS symptoms that alert their caregivers to the
possibility of local anesthetic toxicity. In some unfortunate patients, these changes
presage cardiac arrest.
Monograph as of February 2008
11
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Manifestations of local anesthetic toxicity
- ringing in the ears or buzzing in the ears
- metallic taste or peri-oral tingling
- dysphasia
- orthostasis
- confusion
- PVCs
- wide QRS complex EKG which can subsequently deteriorate into EMD/PEA or
asystole (bupivicaine)
- bradycardia or atrioventricular block (lidocaine and etidocaine)
Treatment
- Stop the administration of local anesthetic
- CPR as indicated (pulseless for >10 sec)
- Epinephrine 1 mg IV (some experts recommend higher doses)
- Tracheal intubation and ventilation with 100% oxygen
- 20% intralipid, 1.5ml/kg IV load, then 0.25ml/kg/hr IV
- Sodium Bicarbonate to maintain a pH greater than 7.25 in patients who do not
respond quickly
- Consider therapy with H1 and H2 blockers
- Consider transcutaneous or intravenous pacemakers for all bradycardic
rhythms.
- Most importantly, continue CPR for at least 60 minutes, as very good
neurologic recovery has been reported in patients after very prolonged cardiac
arrests from local anesthetic overdoses.
Neuroaxial Anesthesia
Cardiac arrest in association with neuraxial (spinal or subarachnoid block) anesthesia
remains the most mysterious cause of morbidity and mortality in the perioperative
period. Its existence would be controversial, except that is has been well documented
as an occurrence in younger, otherwise healthy patients undergoing a variety of clinical
procedures. Its pathophysiology remains a mystery. Clinically, the only unifying feature
of this syndrome is the degree of surprise among the caregivers of these patients.
Various hypotheses have been put forward over the years, invoking unrecognized
respiratory depression, excessive sedation concurrent with high block, under
appreciation of both the direct and indirect circulatory consequences of a high spinal
anesthetic, and ‘failure to rescue’ with airway management and drugs. Hypoxemia from
hypoventilation does not appear to be the cause, as there are case reports documenting
adequate saturation in these patients. Thus there is a substantial amount of basic
science and clinical interest in the effects of high spinal anesthesia on the sympathetic
innervation of the heart and the circulation.
The most recent North American review of the epidemiology of cardiac arrest during
neuraxial anesthesia indicates the prevalence of cardiac arrest at 1.8 per 10,000
patients, with more arrests occurring in patients with spinal anesthesia vs. all the other
techniques (2.9 vs. 0.9 per 10,000 ; P = 0.041). In almost 50% of the cases cardiac
arrest was associated with recurrent specific surgical events (cementing of joint
components, spermatic cord manipulation, manipulation of a broken femur, and rupture
of amniotic membranes.
Monograph as of February 2008
12
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
The choice of vasopressors during neuraxial anesthesia is still being debated.
Treatment of Cardiac Arrest Associated with Neuraxial Anesthesia
- Discontinue anesthetic or sedation infusion
- Ventilate with 100% Oxygen, intubate trachea
- Begin CPR if patient has significant bradycardia or is pulseless >10sec
- Treat bradycardia with 1mg Atropine
- Treat with at least 1 mg epinephrine IV (up to 0.1mg/kg)
- Consider concurrent treatment with 40 u vasopressin
Monograph as of February 2008
13
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Sequence Rescue Approach for Cardiac Arrest in the OR.
A treatment guideline based on BLS and ACLS sequence approach is offered
below ( Fig 5)
Sequence Rescue Approach for Cardiac Arrest in the OR
Based on the 2005 AHA guidelines (modified)
BLS
Recognition of a true crisis*
and differential diagnosis
Oxygen / BMV
Hold Surgery and Anesthetic
Call for Help
EKG Rhythm
interpretation
Check pulse 10 sec
ACLS
Advanced Airway/ Capnography
Continue effective CPR,
rate 100 min
Continue appropriate ventilation,
Check IV
rate 8 -10 min
Access,
Inspiratory threshold device
IV Fluids
Drug Rx
wide open,
Electrical Rx / Pacing
instruct for
CVL
Effective CPR, rate 100 min, C:V = 30:2
Appropriate
Ventilation
Defibrillation
Attempt CVL/Invasive Monitoring
Differential diagnosis
ROSC
Surgical / Anesthetic
plan change
Organize transport to
ICU
Fig 5: Sequence rescue approach for cardiac arrest in the OR based on the 2005 AHA
Guidelines (modified)
Monograph as of February 2008
14
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Recognizing cardiac arrest in the OR
- EKG with pulseless rhythm (V-tach, V-fib)
- loss of pulse X 10 seconds
- loss of end-tidal CO2
- loss of plethysmograph
BLS/ACLS in the OR
- CPR for patients undergoing general anesthesia need not be preceded by
“Annie!! Annie!! Are you Okay?”
- Instruct appropriate personnel to start effective CPR.
- Discontinue the anesthetic and surgery
- Call for help, defibrillator
- Bag mask ventilation if ETT not in place followed by immediate endotracheal
intubation if feasible FiO2 = 1.0
- Don't stop CPR unnecessarily. Capnography is a more reliable indicator of
ROSC than carotid or femoral arterial pulse palpation.
- Capnograph to confirm advance airway positioning and effective CPR
- Hand ventilate rate 8 -10, VT to chest rise, TI one second with 100% oxygen –
assess for obstruction, if none, institute mechanical ventilation. If obstruction,
suctioning, fiberoptic bronchoscopy, consider exchanging the airway
- Open all IVs to wide open
- Blow in capnograph to confirm function
Initiating ACLS Protocols in the OR: Special Considerations
Recognizing that it is time to commence ACLS in the OR is more difficult than it might
seem to outsiders for a variety of reasons.
First, false alarms vastly outnumber real events with OR monitors and monitor
failure is more common than cardiac arrest in most operating rooms. By far, the most
likely cause of ‘asystole’ on an EKG monitor in the OR is an electrode failure or lead
disconnect. The operating room is a brutal environment, and the devices we use to
monitor patients can fail from heavy use. It is likely that monitor failure is more common
than cardiac arrest in most operating rooms.
Second, hypotension and bradycardia are relatively common occurrences in the
OR, and most patients recover to an adequate hemodynamic status with minimal
intervention.
Third, it can be difficult or impossible to obtain satisfactory monitoring in many
patients (vasculopaths, hypothermic, morbidly obese).
Monograph as of February 2008
15
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Ventilation
The growing appreciation of the deleterious effects of excessive positive
pressure ventilation has led to the overall single most important change in the
resuscitation guidelines for cardiac arrest: the change of the compression-toventilation ratio (C:V) to a universal 30:2 for single rescuers for victims of all ages
(except newborns) and two-rescuer CPR for adult victims until an advanced
airway device (ETT, LMA or esophageal airway) is inserted; and the
recommendation to maintain a respiratory rate of no more than 10
breaths/minute with an inspiratory time of one second and a tidal volume limited
to “chest rise” (approximately 500 ml in the adult) for intubated patients. The
concern that a higher percentage of infants and children frequently develop
cardiac arrest secondary to asphyxia has resulted in a more conservative
approach to ventilation in that population, with a recommended C:V of 15:2
when two rescuers are available.
PRE-ARREST OR ALGORITHMS
A schematic overview of unstable pre-arrest dysrhythmias is illustrated below (Fig 6)
Pre-arrest Outline of ACLS in Perioperative Patients
Bradycardia
Pre-Arrest
Tachycardia
Atrial fib/flutter
Cardiac Arrest
Respiratory Arrest
V-Fib
Non-Respiratory Arrest
Pulseless VT
PEA
Asystole
Fig. 6
Monograph as of February 2008
16
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Bradycardia
A comprehensive algorithm approach is offered below. (Fig 7)
BRADYCARDIA
BRADYCARDIA
Heart
Heartrate
rate<< 60
60 bpm
bpm or
or
inadequate
inadequatefor
for clinical
clinicalcondition
condition
••
••
••
••
••
Check
Checksurgical
surgicalfield
field//anesthetic
anesthetic
Maintain
patent
Maintain patent airway
airway ;;assist
assist breathing
breathing as
asneeded
needed
Give
Give Oxygen
Oxygen
Monitor
oxymetry
Monitor EGC
EGC(identify
(identifyrhythm),
rhythm),blood
bloodpressure,
pressure,
oxymetry
Establish
EstablishIV
IVaccess
access
Signs or sym ptom s of poor perfusion caused by the bradycardia?
(eg, acute altered mental status, ongoing chest pain, hypotension o
Observe
Observe//Monitor
Monitor
Adequate
Perfusion
Poor
Perfusion
Check!
Hypoxia
Hypoxia
Hypovolemia
Hypovolemia
Hyper
Hyper -/Hypokalemia
-/Hypokalemia
Hydrogen
Hydrogenion
ion
(Acidemia
(Acidemia ))
Hypothermia
Hypothermia
Hypoglycemia
Hypoglycemia
mH
mH
Hypervagal
Hypervagal
Toxins
Toxins(anaphylaxis
(anaphylaxis//Anesthesia)
Anesthesia)
Tension
Tension pneumothorax
pneumothorax
Thrombosis/Embolus,
Thrombosis/Embolus,pulmonary
pulmonary
Thrombosis,
Thrombosis,coronary
coronary
Tamponade
Tamponade
Trauma
Trauma(Hemorrhagic
(Hemorrhagicshock,
shock,CV
CVinjury
injury
qT
qTprolongation
prolongation
Pulmonary
Pulmonary hyper
hyper Tension
Tension
r other signs of shock)
•• Prepare
Preparefor
for transcutaneous
transcutaneous pacing:
pacing:
use
usewithout
withoutdelay
delayfor
for high
high -degree
-degreeblock
block
(type
(typeIIIIsecond
second -degree
-degreeblock
blockor
or third
third -degree
degreeAV
AVblock)
block)
•• Consider
Consider atropine
atropine 0.5
0.5mg
mgIV
IV while
while
awaiting
awaitingpacer.
pacer.May
Mayrepeat
repeatto
toaatotal
total
dose
doseof
of33mg.
mg.IfIfineffective,
ineffective,begin
beginpacing
pacing
•• Consider
Consider epinephrine
epinephrine (2
(2to
to10
10 _g/min
_g/min
to
to11mg)
mg) or
or dopamine
dopamine(2
(2to
to10
10 _g/kg
_g/kgper
per
minute)
minute) infusion
infusionwhile
whileawaiting
awaitingpacer
pacer or
or
ififpacing
pacingineffective
ineffective
•• Consider
Consider CVL
CVL
•• Prepare
Preparefor
for Transvenous
Transvenous pacing
pacing
•• Treat
Treatcontributing
contributingcauses
causes
•• Consider
Consider expert
expertconsultation
consultation
Fig 7: A comprehensive algorithm for treatment of perioperative bradycardia
The different spectrum of causes of bradycardia in the perioperative period makes it
more reasonable to attempt pacing in this patient population than in most other settings.
Monograph as of February 2008
17
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Perioperative Bradycardia: Special Considerations
• Ensure adequate oxygenation via pulse oximetry if possible
• IV fluids wide open
• Initiate CPR for severe bradycardia, as meds will otherwise not reach the heart in a
timely fashion.
• Atropine 0.5 mg IV, then Epi 1 mg IV (repeat q 1 minute)
• Call for transthoracic pacemaker and transvenous pacemaker immediately
• Esophageal pacing is a reasonable alternative to transvenous pacing
• Pacing, atropine, and Epi fail: Pace at maximal output (to ensure capture),
asynchronous, and at 100 bpm
• Check ETCO2 and plethysmograph tracing for adequate pacing
• Invasive blood pressure monitoring is appropriate in instances where palpation of the
pulse is difficult
Indications for Emergency Pacing
• Hemodynamically symptomatic bradycardia unresponsive to positive chronotropic
agents
• Pharmacologically unresponsive bradycardia with escape rhythms, drug overdose,
acidosis or electrolyte abnormalities
• Standby for symptomatic sinus node dysfunction, Mobitz type II 2nd degree, 3rd
degree, alternating BBB or bi-fascicular block
• Overdrive pacing of supraventricular or ventricular tachycardia refractory to Rx or
electrical cardioversion
Monograph as of February 2008
18
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Tachycardia
TACHYCARDIA
TACHYCARDIA
With
With Puls
Pulses
es
••
••
••
••
AAsssses
esss and
and ssupport
upportAABCs
BCs as
as needed
needed
Giv
Givee ox
oxyygen
gen
Monit
or
ECG
(ident
if
y
rhy
thm),
Monit or ECG (ident if y rhy thm),blood
blood pres
presssure,
ure, EE
Identif
Identifyy and
and treat
treatrev
revers
ersible
ible ccaus
auses
es
CO
CO2 ,2 ,plat
plathy
hyssmograph
mograph
TT
Sym ptom s Persist
••
••
••
Chec
Checkk IV
IV ac
accces
esss
Obtain
Obtain 12
12 -lead
-lead ECG
ECG
(w
hen
av
ailable)
(w hen av ailable)
or
orrhy
rhythm
thmsstrip
trip
QRS
QRS narrow
narrow (<0.12
(<0.12 ssec
ec)?
)?
IsIspat
patient
ientsstable?
table?
Uns
Unstable
tablessigns
ignsinc
include
ludealtered
altered
Mental
s
tatus
,
ongoing
Mental s tatus , ongoing cches
hesttpain
pain
Hy
Hypotens
potension
ion or
or other
other ssigns
igns of
of low
low global
global DO
DO
Stable
Unstable
2
Perform
cardioversion
Performim
immmediate
ediatesynchronized
synchronized
cardioversion
••
Es
Establis
tablishh IV
IV ac
accces
esss and
and giv
givee ssedation
edation ifif pat
patient
ient
is
is ccons
onsccious
ious;;do
do not
not delay
delay ccardiov
ardiovers
ersion
ion
••
Cons
Consider
ider ex
expert
pertccons
onsult
ultation
ation
••
IfIf pulseless
pulseless arrest
arrestdevelops,
develops,see
see
pulselessness
Arrest
Algorithm
pulselessness Arrest Algorithm
2
Wide (> 0.12 sec)
Narrow
Regular
Regular QRS:
QRS:
IsIs Rhy
Rhythm
thmRegular?
Regular?
Regular
••
••
Irregular
Irregular Narrow -Com plex Tachycardia
Probable atrial fibrillation or pos s ible atrial
flutter or M AT (mult if oc al atrial tac hy c ardia)
•
Cons ider ex pert c ons ult ation
•
Control rate ( eg . Diltiaz em , _-bloc kers ) us e
(_-bloc kers w ith c aution in pulmonary
dis eas e or CHF)
AAttempt
ttempt vvagal
agal maneuv
maneuvers
ers
Giv
Givee adenos
adenosine
ine 66 mg
mg rapid
rapid IV
IV pus
push.
h. IfIf no
no
cconv
ers
ion,
giv
e
12
mg
onv ers ion, giv e 12 mg rapid
rapid IV
IV pus
push;
h; may
may
repeat
repeat12
12 mg
mg dos
dosee onc
oncee
Does
Does rhy
rhythm
thmcconv
onvert?
ert?
Not
Note:e:Cons
Consider
iderex
expert
pertccons
onsultation
ultation
Converts
Does not convert
If rhythm converts, probable
reentry SV T (reentry
supraventricular tachycardia):
•
Obs erv e f or rec urrenc e
•
Treat rec urrenc e w ith adenosine
or longer ac t ing A V nodal
bloc king agents ( eg, diltiaz em ,
_-blockers)
If rhythm does NOT convert,
atrial flutter,
ectopic atrial tachycardia, or junctional
tachycardia:
•
Control rate ( eg, dilt iaz em , _-bloc kers :
us e _-bloc k ers w ith c aution in pulmonary
dis eas e or CHF)
•
Treat underly ing c aus e
Hy
Hypox
poxiaia
Hy
Hypov
povolemia
olemia
Hy
Hyper-/Hy
per-/Hypokalemia
pokalemia
Hy
Hydrogen
drogenion
ion( ( AAccidemia)
idemia)
Hy
pothermia
Hy pothermia
Hy
pogly
c
emia
Hy pogly c emia
mmHH
Hy
Hyperv
pervagal
agal
Wide
WideQRS:
QRS:
Is
Is Rhy
Rhythm
thm Regular?
Regular?
Ex
pert
c
ons
ultat
Ex pert c ons ultation
ion adv
advisised
ed
Regular
If ventricular tachycardia
or uncertain rhythm
•
Am iodarone
150 mg IV ov er 10 min
Repeat as needed to
max imum dos e of 2.2
g/24 hours
•
Prepare f or elec tiv e
synchronized
cardioversion
If SV T w ith aberrancy
•
Giv e adenosine
Irregular
If atrial fibrillation w ith aberrancy
•
See irregular Narrow -Complex
Tac hy c ardia (Box 11)
If pre -excited atrial fibrillation (A F +
WPW)
•
Ex pert c ons ultat ion adv is ed
•
A v oid A V nodal bloc king agents
(eg, adenosine, digoxin ,
diltiaz em , verapam il )
•
Cons ider ant iarrhy thmia (eg,
am iodarone 150 mg IV ov er 10
min)
If recurrent polym orphic V T
, s eek
ex pert c ons ultation
If torsade de pointes , giv e
m agnesium (load w ith 1 -2 g ov er 5 60 min, then inf us ion)
Tox
Toxins
ins(anaphy
(anaphylax
laxisis/ A
/ Anes
nesthes
thesia)
ia)
Tens
Tension
ion pneumothorax
pneumothorax
TThrombos
hrombosisis/ /Embolus
Embolus, ,pulmonary
pulmonary
TThrombos
hrombosisis, ,ccoronary
oronary
Tamponade
Tamponade
Trauma
(Hemorrhagic
Trauma (Hemorrhagicsshoc
hock,k,CV
CVinjury
injury
qT
qTprolongat
prolongation
ion
Pulmonary
hy
perTens
ion
Pulmonary hy perTens ion
Fig 8: A comprehensive algorithm for treatment of perioperative tachycardia
Monograph as of February 2008
19
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Perioperative Tachycardia: General Principles
• Attempt to diagnose the underlying rhythm
• Amiodarone is not always the best drug but it is rarely the wrong drug if the patient
has a stable arrhythmia unless it is torsades
• Antiarrhythmics can act as proarrhythmic. So after 1 or 2 antiarrhythmics...
Cardiovert. Patients with compromised heart function should not receive multiple
antiarrhythmics and should be cardioverted early.
• Biphasic cardioversion is preferable to monophasic cardioversion.
• WPW? Use Amiodarone. Avoid Rx that blocks the AV node: adenosine calcium
blockers, beta blockers, digoxin.
• Atrial fibrillation of unknown duration or which is greater than 48 hours old should not
be cardioverted.
• Wide Complex Supraventricular Tachycardia is VT unless proven otherwise use
amiodarone or procainamide
SVT:
• Narrow complex and irregular? Likely Afib: Amiodarone, cardiovert if unstable
• Narrow Complex and regular? Carotid sinus massage in appropriate patients, then
adenosine 12mg IVP. If adenosine fails consider PSVT due to reentry (cardioversion
responsive) or an automatic rhythm e.g. ectopic atrial tachycardia, multifocal atrial
tachycardia, junctional tachycardia (cardioversion non-responsive, ventricular
dysfunction)
Cardioversion: Special Considerations
• Immediate cardioversion is indicated for a patient with serious signs & symptoms
related to the tachycardia or if ventricular rate is > 150 bpm ( Table 2)
• Always be prepared to externally pace patients who are being cardioverted, as some
will convert into a very bradycardic rhythm.
Rhythm
PSVT
Energy Sequence Monophasic
50 J, 100 J, 200 J, 300 J, 360 J
Energy Sequence Biphasic
100 j
A Flutter
50 J, 100 J
50 J
Atrial Fibrillation
200 J, 300 J, 360 J
50 J, 100 J
Table 2. Cardioversion energy sequence of unstable tachycardias
Monograph as of February 2008
20
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
ARREST OR ALGORITHMS
A schematic overview of cardiac arrest pathophysiology is illustrated below (Fig 9)
Bradycardia
Pre-Arrest
Tachycardia
Atrial fib/flutter
Cardiac Arrest
Respiratory Arrest
V-Fib
Non-Respiratory Arrest
Pulseless VT
PEA
Asystole
Fig 9 A schematic overview of cardiac arrest pathophysiology in the OR
Monograph as of February 2008
21
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Cardiac Arrest in the OR
A comprehensive algorithm approach is offered below (Fig 10), including a
differential diagnosis of asystole and PEA in the OR (Table 3, 4, 5)
Check
CheckEKG
EKGLeads
LeadsCheck
CheckETCO2
ETCO2Check
CheckPulse
Pulse Ox
Ox
Hold
HoldSurgery
Surgery//Anesthetic
AnestheticCheck
CheckAnesthesia
AnesthesiaMachine
Machine
Check
CheckAirway
AirwayEffective
EffectiveCPR
CPRAppropriate
AppropriateVentilation
Ventilation
Call
Callfor
forHelp
HelpThink!
Think!Differential
DifferentialDiagnosis
Diagnosis
Shockable
Check
Checkrhythm
rhythm
Shockable
Shockablerhythm?
rhythm?
VF/VT
VF/VT
1
Give
Give11shock
shock
••
Manual
Manual biphasic:
biphasic:device
device specific
specific
(typically
(typically12C
12Cto
to200
200J)
J)
••
Monophasic
Monophasic 360
360JJ
Resume
ResumeCPR
CPRimmediately
immediately
Continue
ContinueCPR
CPRwhile
whiledefibrillator
defibrillatorisischarging
charging
Give
Give11shock
shock
••
Manual
Manualbiphasic:
biphasic:device
devicespecific
specific
Same
Sameas
asfirst
firstshock
shockor
or higher
higher dose)
dose)
Note:
if
unknown,
use
200
Note: if unknown, use 200JJ
••
Monophasic
360
J
Monophasic 360 J
Resum
ResumeeCPR
CPRimm
immediately
ediatelyafter
afterthe
theshock
shock
Epinephrine
Epinephrine 11mg
mgIV/IO
IV/IO
Repeat
Repeatevery
every33to
to55m
mininor
or
••
May
Maygive
give11dose
doseof
of vasopressin
vasopressin 40
40UUIV/IO
IV/IOtotoreplace
replace
first
firstor
or second
seconddose
doseof
of epinephrine
epinephrine
Asystole
AsystolePEA
PEA
Resume
ResumeCPR
CPRImmediately
Immediatelyfor
for55cycles
cycles
••
Epinephrine
Epinephrine 11mg
mgIV/IO
IV/IO
••
Repeat
Repeat every
every33to
to 55min
min or
or
••
May
Maygive
give11dose
dose of
of vasopressin
vasopressin 40
40UUIV/IO
IV/IOto
to
replace
epinephrine
replacefirst
firstor
or second
seconddose
doseof
of
epinephrine
••
Atropine
Atropine 11mg
mgIV/IO
IV/IOfor
forasystole
asystoleor
orslow
slowPEA
PEA
rate
rate Repeat
Repeatevery
every33 to
to 55min
min(up
(upto
to 33doses)
doses)
2
Give 5 cycles of CPR
Check
Checkrhythm
rhythm
Shockable
Shockable rhythm?
rhythm?
Not Shockable
No
Attempt
Attempttransthoracic
transthoracic or
ortransvenous
transvenouspacer
pacer
Asynchronous,
Asynchronous,max
maxMA
MAoutput,
output,rate
rate 100
100check
check
Pulse
Pulseor
orarterial
arterialline
line ififpresent
presentfor
forcapturing
capturing
•• IfIfasystole,
asystole,go
gototoBox
Box
22ififelectrical
electricalactivity.
activity.
Check
Checkpulse,
pulse,ififno
no
pulse
pulsego
gototoBox
Box22
•• IfIfpulse
pulsepresent,
present,
begin
beginpost
post
resuscitation
resuscitationcare
care
Give 5 cycles of CPR
Check
Checkrhythm
rhythm
Shockable
Shockablerhythm?
rhythm?
Not
Shockable
Shockable
Go
Goto
toBox
Box11
Give 5 cycles of CPR
Check
Checkrhythm
rhythm
Shockable
Shockablerhythm?
rhythm?
Shockable
Continue
ContinueCPR
CPRwhile
whiledefibrillator
defibrillator isischarging
charging
Give
Give11shock
shock
••
Manual
biphasic:
device
specific
Manual biphasic: device specific
Same
Sameas
asfirst
firstshock
shockororhigher
higherdose)
dose)
Note:
Note:ififunknown,
unknown,use
use200
200JJ
••
Monophasic
Monophasic360
360JJ
Resum
ResumeeCPR
CPRimm
immediately
ediately after
afterthe
theshock
shock
Consider
Consider antirrhythm
antirrhythmics
ics ,,give
giveduring
duringCPR
CPR
(before
(beforeor
orafter
afterthe
theshock)
shock) am
amiodarone
iodarone
(300
(300m
mggIV/IO
IV/IOonce)
once)or
or lidocaine
lidocaine (1
(1to
to1.5
1.5
mg/kg
mg/kgfirst
firstdose,
dose,then
then0.5
0.5to
to0.75
0.75m
mg/kg
g/kg
IV/IO,
IV/IO,maxim
maximum
um33doses
dosesor
or33mg/kg)
mg/kg)
Consider
Considermagnesium,
magnesium,loading
loadingdose
dose22ggIV/IO
IV/IO
for
torsade
de
pointes
for torsade de pointes
No
During CPR
•
•
•
•
•
•
•
Push hard and fast (100/min)
Ensure full chest recoil
Minimize interruptions in
chest compressions
One cycle of CPR: 30
compressions then 2 breaths;
5 cycles = 2 min
Avoid hyperventilation
Secure airway and confirm
placement
After an advanced airway is
placed, rescuers no longer
deliver “cycles ” of CPR. Give
continuous chest
compressions without pause
for breaths. Give 8 to 10
breaths/minute. Check
rhythm every 2 minutes
•
•
8H
and
8T
Fig 10: Cardiac arrest in the OR. A comprehensive algorithm fro the 2005 AHA
guidelines (modified)
Monograph as of February 2008
Rotate compressors every 2
minutes with rhythm checks
Search for and treat possible
contributing factors:
22
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Cardiac Arrest in the OR: Special Considerations
• Wide open IV crystalloid without glucose unless hypoglycemia suspected.
•
Ventilate by hand or anesthesia machine 10 min VT 5-7 ml/kg confirmed by
spirometry or chest rise asynchronous with chest compressions
•
Surgeon stand-by for possible open chest cardiac massage
Differential Diagnosis for perioperative PEA or Asystole: 8H & 8T
Hypoxia
Trauma/hypovolemia
Hypovolemia
Tension Pneumothorax
Hyper-vagal
Thrombosis of Coronary
Hydrogen Ion
Tamponade
Hyperkalemia
Thrombus in Pulmonary Artery
Malignant Hyperthermia
Long QT syndrome
Hypothermia
Toxins (anaphylaxis)
Hypoglycemia
Pulmonary HTN
Table 3. Differential Diagnosis for perioperative PEA or Asystole
Causes of PEA arrest and the EKG rhythm that most often precedes them
Cause of PEA
Pre Arrest Rhythm
Hypovolemia
Narrow complex tachycardia or bradycardia
Hypoxia
Bradycardia
Auto-PEEP
Narrow complex Tachycardia that devolves into bradycardia
Vaso-Vagal
Bradycardia, sometimes associated with peaked T waves
Anaphylaxis
Tachycardia
Tension Pneumothorax
Narrow complex tachycardia, then bradycardia
Tamponade
Narrow complex tachycardia
RV arrest
Narrow complex tachycardia which devolves into bradycardia
PA HTN
RBBB, RV strain
Coronary Syndrome/LV arrest Q waves, ST depression followed by ST elevation, VT, Vfib
Hyperkalemia
peaked T waves, widened QRS, sine wave wide complex PEA
Hypoglycemia
Narrow complex tachycardia
Hypothermia
J or Osborne Waves
Long QT syndrome
Bradycardia
Hypokalemia
Flattened T waves, prominent U waves, widened QRS,
prolonged QT, wide complex tachycardia
Table 4. Causes of PEA arrest and the EKG rhythm that most often precedes them
Monograph as of February 2008
23
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
EKG Ventricular Complex Size and the PEA associated with it
Narrow Complex
Wide Complex
Non-Cardiac Causes
Cardiac Causes
e.g. hypovolemia, vasodilation
e.g. drugs and toxins
Table 5. EKG Ventricular Complex Size and the PEA associated with it
Monograph as of February 2008
24
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Ventricular Tachycardia and Torsades-de-Pointes
Monomorphic vs Polymorphic VT
Monomorphic VT:
- Normal LV function: amiodarone, lidocaine or procainamide
- Impaired LV function: amiodarone, lidocaine
Polymorphic VT:
- Usually self limiting but if recurrent then Mg 2 gm IV,
- Defibrillate if unstable
- Rx usually after spontaneous termination and is directed at preventing the
recurrence. If ongoing and unstable go to pulseless VT/VF algorithm
- Prolonged QT? then Mg 2 gm IV
- Not prolonged? See monomorphic VT
- Torsade de pointes: Mg 2 gm, defibrillate if unstable
Ventricular Fibrillation
Defibrillation for Adult and Pediatric Patients
Biphasic Defibrillators are supplanting Monophasic defibrillators in most
instances as they are likely more effective, and utilize lower energies in every clinical
instance.
Clinical Situation
Biphasic Energy
Monophasic Energy
Ventricular Tachycardia
150 Joules, synchronized
300-360 joules, synchronized
Ventricular Fibrillation
150-200 joules
Monograph as of February 2008
300-360 joules
25
Anesthesiology / Perioperative ACLS by
The American Society of Critical Care Anesthesiologists &
The American Society of Anesthesiologists, Committee on Critical Care Medicine
Patients who fail to respond to their first round of attempts at cardioversion or
defibrillation may respond to the following medications:
Rhythm
Ventricular Tachycardia
Ventricular Fibrillation
Torsades
1st line
Amiodarone
Amiodarone
Magnesium
2nd line
Lidocaine
3rd line
Procainamide
Usage:
Amiodarone: 300 mg IV push, then 150 mg IV push, repeat q 5 minutes up to
1.5 grams total.
Infusion rate: 1 mg/min
Lidocaine: Load1.0-1.5 mg/kg push. Repeat 0.5 to 0.75 mg/kg 3- 5 min later.
Max dose 3 mg/kg
Infusion range: 1-4 mg/min
Magnesium Sulfate:2 grams IV for Torsades, Hypo Mg or K. May repeat x3.
Procainamide: 20-50 mg/min IV. Max: 17mg/kg.
Infusion rate: 1-4 mg/min
VT, VFib and TdP: Additional Considerations
- Do NOT use adenosine, calcium channel blockers, beta blockers or digoxin
- Consider atropine (1mg IV), epinephrine (1mg IV) and vasopressin (40 U IV) for
patients with cardiac arrest associated with neuraxial anesthesia. Repeat q 1
minute x 3 FAST. Do Not Wait for 5 CV cycles.
- Hyperkalemia is a frequently unsuspected cause of a wide complex
tachycardia. Consider treating at risk patients with:
- 1 gram CaCl IV push (typically 10 cc of 100mg/ml)
- 100 meq NaHcO3 (2 x 50 cc ampules)
- 10 units of regular insulin IV and 25 grams of dextrose IV (1- 50cc
ampule of D50%w).
- Consider empiric treatment for tension pneumothorax and sub-xiphoid
pericardiocentesis in patients at risk for these complications
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Acknowledgement
The authors would like to extend their deepest gratitude to those
practitioners who read and provided useful feedback to various drafts of
these guidelines:
Avery Tung, MD
Karen Domino, MD
Mark Nunnally, MD
Heidi Kummer, MD
Steven Robicsek, PhD, MD
Eugene Y. Cheng, MD
Daniel Brown, MD PhD
Sheila E. Cohen MB, Ch.B., F.R.C.A.
Patricia A. Dailey M.D.
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Appendix 1: Recommended Infusions
Infusion
Dobutamine
Infusion range
1-20 mcg/kg/min
Mixed as
1g/250ml
mid-range rate(ml/hr for 80 kg pt)
12
(10 mcg/kg/min)
Norepinephrine
0.05 – 0.5 mcg/kg/min
16mg/250ml
7.5
(0.1mcg/kg/min)
Epinephrine
0.05-0.2 mg/kg/min
16mg/250ml
7.5
(0.1mcg/kg/min)
Dopamine
1-20 mcg/kg/min
400mg/250ml
30
(10 mcg/kg/min)
Vasopressin
(AVP – Pitressin)
5-80 milliunits/min
20Unit/100ml
12
(40 milliUnits/min)
Phenylephrine
0.1-3 mcg/kg/min
20mg/250ml
60
(1 mcg/kg/min)
Nitroprusside
0.3-10 mcg/kg/min
50mg/250ml
24
(1mcg/kg/min)
Fenoldopam
0.05-0.3 mcg/kg/min
4mg/100ml
12
(0.1 mcg/kg/min)
Amiodarone
1 mg/minx 6 hr, then 0.5 mg/min 720mg/500ml
20.8
(0.5 mg/min)
Lidocaine
1 mg/min
2g/250ml
7.5
Milrinone
Load: 50 mcg/kg over 10 min
Then 0.375 -0.75 mcg/kg/min
20mg/100ml
12
Monograph as of February 2008
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Appendix 2: CODE drugs
Drug
Formulation
Dose/adminstration
Epinephrine
varies: 1/1000 and 1/10,000
1 mg IV push repeat q 3 min
Vasopressin (Pitressin)
20u/1ml
40 units
Atropine
varies (typically 0.4mg/ml)
1 mg
Adenosine
varies
6mg IVP & 20cc NS
may then Rx with
12 mg IVP & 20cc NS qmin x 2
Amiodarone
300 mg in 20-30 ml D5
300 mg IV push,
repeat w/ 150 mg IV push in 3 min
Digoxin
0.25mg/ml or
0.1mg/ml in 1 or 2 ml ampule
load 10-15 mcg/kg IBW
Esmolol
varies
0.5 mg/kg over 1 minute then
50 mcg/kg/min for 4 minutes
May repeat bolus x1 and increase
rate to 100 mcg/kg/min
Lidocaine
varies (typically 100mg in 5cc)
1-1.5 mg/kg – 100 mg IVP
Magnesium sulfate
varies
1-2 grams IV over 5 minutes
Calcium chloride
100mg/ml in 10 ml
500-2000 mg IV push
Bicarbonate Sodium
50 milliequivalents in 50 ml
50 meq IV push
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Appendix 3: Resuscitation of the Pregnant Woman in Cardiac Arrest
Sheila E. Cohen MB, Ch.B., F.R.C.A.
Patricia A. Dailey M.D.
There are two potential patients when a pregnant woman arrests, the mother and the
fetus. The best hope of fetal survival is maternal survival. The most common
pregnancy-related causes of maternal deaths are hemorrhage (hypovolemia), embolism
(venous or amniotic fluid), preeclampsia/eclampsia, cardiomyopathy, and
cerebrovascular accident. Morbidity and mortality also result from deterioration of
medical conditions during pregnancy (e.g., cardiac disease, lupus, diabetes, asthma),
coincidental medical conditions (e.g., malignancies, morbid obesity), and automobile
accidents, suicide and homicide. The anesthesia team may be called to resuscitate
pregnant women in any of these circumstances.
When performing BLS/ACLS, rescuers must understand the anatomic, mechanical and
physiologic changes caused by pregnancy. Multiple gestations are associated with
greater changes and correspondingly less reserve when crises occur. Hypoxia,
hypercapnia and acidosis develop extremely rapidly during pregnancy because of
decreased FRC, increased O2 demand/CO2 production and decreased buffering
capacity. Difficult intubation and pulmonary aspiration often complicate resuscitation
efforts because of suboptimal positioning, airway edema, gastroesophageal reflux and
lack of the usual prophylactic measures. Most important, after 20 weeks of gestation
the pregnant uterus compresses the inferior vena cava and aorta when the mother
is supine, markedly decreasing venous return and cardiac output. This can cause
prearrest hypotension or shock and in the critically ill patient may precipitate arrest.
During cardiac arrest, aortocaval compression can impede venous return and cardiac
output such that cardiac compressions are ineffective. Displacing the uterus 15-30° by
tilting the patient or displacing the uterus laterally may alleviate obstruction in the
prearrest situation. During cardiac arrest, resuscitation may prove impossible until
the fetus is delivered.
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BLS/ACLS for the Pregnant Woman
The recommendations in the Anesthesia Advanced Circulatory Life Support with respect
to intubation and ventilation, medications (including epinephrine, vasopressin and
dopamine) and defibrillation doses apply equally to the pregnant patient. In addition, the
following modifications to BLS and ACLS are appropriate:
•
•
•
•
•
•
•
•
•
Displace the uterus 15-30° by placing the mother on her left side, placing a
wedge under her right hip or by manually moving the uterus laterally.
Secure the airway early using a smaller than usual endotracheal tube and cricoid
pressure (if possible).
Perform chest compressions slightly above the center of the sternum to adjust for
the elevation of the diaphragm
Defibrillate using standard ACLS doses but remove fetal or uterine monitors
before shocking.
Do not use the femoral vein for administration of medications, as there may be
no effective flow until the fetus is delivered.
At gestational age <20 weeks, urgent Caesarean delivery need not be
considered, because a gravid uterus of this size is unlikely to significantly
compromise maternal cardiac output.
At gestational age approximately 20—23 weeks, initiate emergency hysterotomy
to enable successful resuscitation of the mother, not survival of the delivered
infant, which is unlikely at this gestational age.
After 20-24 weeks gestation, perform immediate hysterotomy (cesarean delivery)
within 5 min of cardiac arrest if no response to BLS and ACLS to enable
successful resuscitation of the mother and fetus .
For cardiac arrest secondary to hemorrhagic shock (ectopic pregnancy, placental
abruption, placenta praevia and uterine rupture) consider the following additions
to the resuscitation protocol:
a.
b.
c.
d.
e.
oxytocin and prostaglandins to correct uterine atony
uterine compression sutures
radiological embolization of uterine blood supply
hysterectomy
aortic cross-clamping
Providers should try to identify reversible pregnancy-specific and incidental causes of
cardiac arrest when deciding whether to proceed to cesarean delivery. For example,
spinal hypotension is often treatable with oxygenation, ventilation and aggressive use of
vasopressors, including epinephrine or vasopressin (see neuraxial anesthesia section
above), eclamptic seizures may be self-limiting, and magnesium overdose should
respond to one or repeated doses of calcium chloride, 1 gm iv. In contrast, the cardiac
failure after amniotic fluid embolism (also called anaphylactoid syndrome of pregnancy)
rarely resolves over the course of several minutes. Inotropic support is often required
and patients who survive the first minutes typically have uterine atony and a
consumptive coagulopathy.
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Emergency Hysterotomy (Perimortem Cesarean Delivery)
Aortocaval compression from the gravid uterus may result in no venous return and
therefore no response to BLS/ACLS. In this situation, immediate delivery (within 4-5
min) may prove life saving to the mother. Beneficial changes after delivery include
immediate relief of aortocaval compression with consequent improved venous return and
cardiac output, improved pulmonary mechanics, and decreased oxygen demand. Also,
the fetus of !24 weeks gestational age has the best chance of intact survival when
delivery occurs less than 5 min after maternal cardiac arrest. The American Heart
Association’s 2005 guidelines state that when maternal cardiac arrest is not immediately
reversed by BLS and ACLS: “The resuscitation leader should consider the need for
an emergency hysterotomy (cesarean delivery) protocol as soon as a pregnant
woman develops cardiac arrest.” They further emphasize: “… you will lose both
mother and infant if you cannot restore blood flow to the mother’s heart. Note
that 4 to 5 minutes is the maximum time rescuers will have to determine if the
arrest can be reversed by BLS interventions. The rescue team is not required to
wait for this time to elapse before initiating emergency hysterotomy.” When
uterine size corresponds to < 20 weeks gestational size, immediate delivery may not be
indicated. Between 20 and 23 weeks (before fetal viability) it is likely to benefit only the
mother; after 24 weeks it may benefit both mother and fetus. Even when delivery cannot
be accomplished within 5 minutes, performing it as soon as possible usually will confer
maternal benefit. In a 20-year review of maternal cardiac arrests by Katz et al., maternal
pulse and blood pressure returned after CD in 12 out of 18 cases in which hemodynamic
status was reported; in no case was there deterioration of maternal condition.
To optimize the chance of maternal survival with good neurologic outcome, advance
preparations designed to facilitate urgent CD in non-operating room locations are
necessary. Transferring a patient to an operating room during BLS/ACLS (rather than
performing CD on-site) is logistically challenging and time-consuming, will almost
certainly result in interruption of chest compressions and monitoring, and overall
probably will decrease maternal and fetal survival. Plans for performing emergency CD
should be made in collaboration with obstetric, anesthesia, neonatal, and nursing
personnel to determine what is feasible in that particular institution.
Appendix 4: Pediatrics - forthcoming
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Appendix 5: Epidemiology and Pathophysiology of ACLS in the perioperative
period.
The epidemiology of cardiac arrest in the anesthesia world is unique and special.
In fact hypoxemic or dysrhythmic cardiac arrest is rarely observed when
sedation, regional or general anesthetics are provided. There are also intuitive
differences in a patient’s chance of survival when the health care provider has
prior knowledge of a his medical history, is instantly aware of cardiovascular
and respiratory vital sign changes, can immediately recognize the probable
cause of arrest and begins medical management within seconds.
Cardiac arrest during anesthesia has been labeled a rare event. In fact, the
development of better monitoring, safer medications, adoption of clinical
standards, and advances in knowledge and training have all had a significant
impact on patient safety. Despite this, cardiac arrest during anesthesia still
occurs but with prompt recognition, diagnosis, and treatment can be successfully
managed.
The most recent data of cardiac arrest during anesthesia comes from the Mayo
Clinic in Rochester. Cardiac arrest was defined as the requirement for
resuscitation with either closed chest compression or open cardiac message,
after the onset of anesthesia. Cardiac arrests after transport to the ICU were not
included. The two outcome variables were survival of at least one hour after
initial resuscitation and survival to discharge from the hospital. All probable
causes of cardiac arrest were grouped into three categories: 1) intraoperative
hemorrhage, 2) permanent cardiac cause and 3) hypoxia, both at intubation or
extubation. Overall 24 cardiac arrests were determined to be attributed to
anesthesia (0.5/10,000 anesthetics).
If one extrapolates this number to the 20 million anesthetics performed annually
in the United States, it translates to at least 1000 patients/year, or about three
patients a day going from "sleep" to cardiac arrest!
This number is probably a gross underestimation since the many prestigious
academic institutions in the US and abroad that report their experiences do not
necessarily reflect the incidence of this problem in the “real world,” i.e. outside
academic boundaries or abroad.
The impact on favorable outcome of having an anesthesiologist present or
immediately available during a surgical procedure is clear. In a large
retrospective review, the adjusted alteration for death and failure to rescue were
greater when care was not directed by a physician anesthesiologist (alteration for
death = 1.08, p< 0.04; alteration for failure to rescue = 1.10, P < 0.01),
suggesting that anesthesiologist-directed anesthesia care has a significant
positive effect on the outcome for cardiac arrest, and long term mortality.
Appropriate vigilance and monitoring is often the key to recognition and timely
response to such a crisis. For example, in the late 80s the ASA closed claimed
study reported that 57% of hypoxia related deaths could have probably been
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avoided simply by a better awareness life threatening respiratory complications
during anesthesia and the use of pulse oximetry and capnography.
Asphyxial Cardiac Arrest
Respiratory complications and their variations have been described as an important
cause of cardiac arrest and death during anesthesia, but the information became
widespread only when, at the end of the 1980s, new confidentiality agreements
between scientist and government institutions allowed the development of a massive
database on anesthetic deaths.
For all anesthesiologists, hypoxia as a main cause of cardiac arrest can be more
frequently seen within the context of a “cannot intubate – cannot ventilate” scenario.
Hypoxia during anesthesia occurs in airway management failure such as
misplacement of the endotracheal tube (esophageal or endobronchial; accidental
tracheal extubation) aspiration of gastric contents, laryngospasm mainly due to
mechanical irritation during inadequate depth of anesthesia, severe bronchospasm
because of anaphylactic or intrinsic reactions, and errors in providing oxygen
supply (hypoxic gas mixture).
Failure of adequate ventilation was observed in the 80s in about 35% of the cases of
cardiac arrest and has continued to increase in the 90s, when the American
Society of Anesthesiologists started recording nationwide insurance claims for
major anesthesia complications reported voluntarily. In spite of the limitations of
voluntary reports, the claims confirmed the unrecognized difficult airway as a major
cause of cardiac arrest in approximately 25% of the cases.
In the most recent review, airway and ventilation-related cardiac arrests, both at
intubation or extubation, amounted to approximately 45% of all cases. In this series
24 cardiac arrests were directly attributed to anesthesia management.
Irreversible hypoxic or ischemic brain damage is the clinical, most crucial
consequence when - at normothermia - the brain is not receiving adequate oxygen
delivery for more than five to seven minutes during cardiac arrest. Hypoxic brain
damage can be an unexpected finding following prolonged hypotension (low global
oxygen delivery) or inadvertent administration of an unrecognized hypoxic gas
mixture.
The electrophysiologic aspect of cardiac arrest during hypoxemia is unique. An initial
brief sympathetic stimulation aggravated by preexisting hypercarbia when present, is
followed by severe bradycardia. Increased serum potassium, acute metabolic
(lactic) and respiratory acidosis potentiates the cardiovascular depressant effect of
the anesthetic, if present at the time of the hypoxic event. The result of this cascade
if left uncorrected is asystole or more rarely PEA potentiated by vagal stimulation
and increased serum potassium. If this vicious cycle is recognized and hypoxia is
corrected in a timely manner, the process can be successfully reversed.
During the first few minutes of dysrhythmic adult cardiac arrest ventilation is not
fundamental to restore spontaneous circulation and has been somewhat deemphasized in the new AHA guidelines in favor of more effective chest
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compressions. The attention of the rescuer of a hypoxemic a cardiac arrest is now
focused on providing hemodynamic support while attempting to re-establish
oxygenation and normal ventilation. Since the most frequent evolution of severe
hypoxia is an unshockable rhythm, immediate pharmacological support with
epinephrine is fundamental while attempting to secure the airway.
Furthermore, when the patient is in full arrest and an ETT is in place resulting in an
unobstructed airway a small amount of tidal volume is exchanged, estimated to
about 50 ml for compression. At a frequency of 100 compressions per minute,
“involuntary” minute ventilation by simply compressing the chest would approximate
4.5 liters. Unfortunately, the effect of increased dead space ventilation on these
small and frequent volumes cannot be easily anticipated.
When asphyxia is clearly the cause of cardiac arrest, such as in a “witnessed no
ventilation no intubation scenario or in most of the pediatric population, oxygen
consumption has proceeded to near complete exhaustion, and carbon dioxide and
lactate have significantly accumulated just before cardiac arrest. In these cases,
oxygen content of the tissues is minimal and providing ventilation with an FiO2 of 1.0
is essential for survival.
Animal studies of asphyxial cardiac arrest (clamping of the endotracheal tube in an
anesthetized pig with preexisting good oxygenation) showed that the arterial partial
pressure of oxygen is maintained within the normal range for only approximately one
minute in a model of chest compressions without ventilation and more importantly
that return of spontaneous circulation was noted only when ventilation was added to
chest compression.
This is in contrast to ventricular fibrillation, in which hypoxemia and acidemia
become significant only several minutes after the onset of cardiac arrest.
However, positive pressure ventilation comes as a tradeoff of venous return during
low flow states, including cardiac arrest and ventilation needs to be “matched” to the
current lung perfusion.
When systemic blood flow decreases, lung perfusion decreases. In a low flow state,
with less venous CO2 delivered to the lungs, less is available for elimination via
exhalation and the concentration of CO2 in exhaled gas decreases. Because CO2
elimination is diminished, it accumulates in venous blood and in the tissues. Mixed
venous PCO2 thus reflects primarily systemic and pulmonary perfusion and is an
indicator of the tissue acid-base environment.
Positive pressure ventilation produces positive intrathoracic pressure during
inspiration, reducing venous return to the chest and, as a result, reducing cardiac
preload and subsequent cardiac output. For a given airway pressure, pleural
pressure transmission of positive pressure ventilation increases when the lung is
more compliant and when the chest wall is rigid. Furthermore, airway pressure
pleural transmission increases on a number of variables including inspiratory flow
rate and time, tidal volume, ventilation rate and degree of intrinsic positive endexpiratory pressure (auto-PEEP).
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During low flow conditions, arterial PCO2 and PO2 reflect primarily the adequacy of
alveolar ventilation. In these conditions, if alveolar ventilation is excessive, blood
flowing through the pulmonary capillary bed is over-ventilated resulting in a large
ventilation-perfusion mismatch. Adequate ventilation with an advanced airway in
place and an FiO2 of 1.0 include a respiratory rate of 8 -10/min, VT to chest rise
(usually 5-7 ml/Kg), TI of one second. The immediate consequence of unnecessary
hyperventilation during cardiac arrest is further decrease of preload, coronary and
cerebral perfusion without significant change of the acid base balance.
Local Anesthetic Toxicity
•
Local Anesthesia
Local anesthetic toxicity is often unpredictable since the administration of the drug
can result either in local constriction or systemic dilatation depending on the dose.
Systemic effect can also vary, but in general the principal toxic effect is the result of
cardiac depression or dysrhythmia. Local anesthetics affect either fast or slow
calcium channels. While this latter characteristic has been debated for years, a
study shows that in general all local anesthetics have a drug specific negative
inotropic effect. When local anesthetic toxicity is studied in animal myocardial
preparations, bupivacaine is associated with the most severe depression of cardiac
conduction suggesting an extensive block of cardiac sodium channels as principal
etiology of its cardio toxicity.
Bupivacaine exhibits a higher potency than the average anesthetic possibly by
inhibition of myocardial energy metabolism in several ways, including blockade of the
respiratory chain, inhibition of ATPases, uncoupling of oxidative phosphorylation and
inhibition of ATP-ADP translocation.
Clinically, systemic toxicity from local anesthetic overdose can be subtle and
nonspecific. Initial unexplained dysrhythmias such as uni or multifocal PVCs and mild
neurocognitive dysfunction and “auras” of tinnitus, metallic taste, or dysphasia, might
be followed by generalized seizure activity. The specific EKG rhythm feature of
bupivacaine is widening of the QRS complex preceding a malignant ventricular
dysrhythmia, typically electromechanical dissociation or asystole. Lidocaine and
etidocaine more often progress to severe bradycardia or atrioventricular block.
Rarely, local anesthetic toxicity leads to unidirectional block and re-entry, which in
turn can produce ventricular tachycardia and fibrillation.
• Neuraxial anesthesia
It has been said that more than 50% of episodes of cardiac arrest during regional
anesthesia could be avoided if inadequate ventilation were expeditiously recognized
and avoided.
A nationwide study of closed insurance claims for major anesthetic mishaps has
been retrieved from the database of the American Society of Anesthesiologists
closed claim study, a project of the American Society of Anesthesiologists committee
on professional liability.
Interesting clinical trends were revealed. In each single case, the event was
unexpected, the patient ASA status was low and the outcome was, in general, poor.
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In 30% of the 14 cases reviewed, a spinal anesthetic was chosen in an emergency
procedure. The use of tetracaine seemed to be the most commonly associated with
cardiac arrest. Most of the anesthesiologists involved in these cases were
reasonably experienced. Despite the obvious selection bias of these self reported
cases, the following were common features of patients suffering cardiac arrest: 1.The
use of intraoperative sedation to achieve deep, sleep-like sedation to a level the
patients would not vocalize; a combination of opioids, benzodiazepines and hypnotic
agents was commonly the drug cocktail of choice. 2. Cardiac arrest was detected on
a range of 5 to 25 minutes after the last administration of drug. 3. Often, cardiac
arrest was preceded by a few minutes of unexplained and under treated progressive
tachycardia and hypotension. 4. Cyanosis was noticed in a majority of the cases
inferring that a mechanism of respiratory depression was added to the sympathetic
blockade with the highest documented sensory level of T4 ± 1. When blood gases
were available during an arrest, hypoxemia was confirmed, although immediately
corrected by endotracheal intubation. 5. While immediate placement of an advanced
airway was achieved in most of the patients, CPR seemed to have been delayed
several minutes after the probable arrest. 6. Ephedrine was the most common first
choice of vasopressor used to allow recovery of heart rate and blood pressure,
mostly with minimal therapeutic success. 7. The administration of a more powerful
direct catecholamine such as epinephrine averaged five minutes after the initial
diagnosis of arrest.
To summarize the above observations, despite the presence of an anesthesiologist
immediately available and a clear relationship between the anesthetic management
and the cardiac arrest, the recognition of the crisis was in general late and the
treatment not very effective. The result was a surprisingly poor neurological recovery,
with only four patients regaining consciousness but with various degrees of cognitive
dysfunction. It can be easily speculated that hypoventilation induced by concurrent
use of opioids, benzodiazepines or hypnotics could have expedited a sympathetic
blockade produced by the high spinal anesthesia and that the anesthesiologist’s
level of awareness of this combination was low.
Since the introduction of pulse oximeters, a few episodes of cardiac arrest have been
documented with normal saturation readings and thus impossible to explain using
the hypoxia theory. Therefore, alternative mechanisms to the hypoxia/hypercarbia
theory should occasionally be considered. However, the lack of early recognition of
a high level of neuraxial block in a patient silent and sedated, combined with delayed
administration of direct acting catecholamines have been identified as typical
patterns in the development of cardiac arrest. The mechanisms behind circulatory
collapse during central neuraxial blockade or “total spinal anesthesia” have been
recently reviewed.
In spinal and epidural anesthesia preganglionic efferent sympathetic nerve fibers are
blocked. When the autonomic sympathetic fibers of the heart are denervated at the
T1-T4 level, the release of endogenous catecholamines is blunted by blockage of the
efferent sympathetic adrenal medulla fibers from T5-L2. This results in vasodilatation
of the venous and arterial side and uncompensated sympathetic blockade of the
adrenal medulla. Vagal influence on the heart becomes predominant. Overall the
major determinate of severe hypotension during central neuraxial blockade is the
decrease in venous return, with venous pooling occurring mostly in the splanchnic
circulation. Pre-existing low heart rate by virtue of a healthy physical status or the
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use of negative chronotropic agents may lead to severe bradycardia and asystole,
without clear correlation between the severity of bradycardia and the level of
blockade.
Several other factors may acutely decrease the heart rate. They include a
decreased stimulation of receptors located in the atria and the venoatrial junction (a
“reversed” Bainbridge phenomenon), direct stretching of the sinoatrial node from
atrial emptying and increased non-myelinated vagal nerve afferents firing. The left
ventricular wall stretch sensor is also reacting to decreased stretch, a phenomenon
still debated in originating severe bradycardia and known as Bezold-Jarisch reflex.
While all neuraxial anesthesia techniques have been described in the context of
cardiac arrest, spinal anesthesia has clearly the worst track record.
In animal studies, cardiac arrest induced by high spinal anesthesia seems to respond
best to a higher dose of epinephrine. Spinal anesthetic blunting of the
neuroendocrine response to catecholamines during cardiac arrest is believed to
contribute to the need for a high dose of epinephrine.
An initial intravenous administration of epinephrine of 1 mg can be supplemented by
escalating bolus doses up to a total of 0.1 mg/kg. The use of a higher dose than 1
mg of epinephrine, while anecdotally associated with good recovery, needs to be
carefully evaluated in view of its possible deleterious effect on the myocardium.
Animal studies have shown that epinephrine can increase myocardial oxygen
consumption, ventricular rhythm, ventilation profusion mismatch, and postmyocardial dysfunction, all undesirable adverse effects during resuscitation in
anesthetized patients.
Furthermore, in an animal model of epidural neuraxial anesthesia where V fib was
induced by electrocution, a single dose of vasopressin appeared immediately
comparable to mega dose epinephrine achieving better organ perfusion (heart and
brain) at five minutes. While this is an interesting observation, it cannot be easily
generalized to the common scenario described in humans, where cardiac arrest
under neuraxial block is typically a unshockable rhythm. Therefore, the potential
beneficial effect on a “high spinal” anesthetic has never been tested. The end tidal
CO2 can be used as a marker of successful resuscitation. An end tidal CO2 of less
than 10 mmHg, despite an appropriate dose of epinephrine during CPR, correlates
with poor outcome.
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2005 American Heart Association guidelines for cardiopulmonary resuscitation and
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Biboulet P, Aubas P, Dubourdieu J, Rubenovitch J, Capdevila X, d'Athis F. Fatal and
non-fatal cardiac arrests related to anesthesia. Can J Anesth 2001; 48:326-332 . Olsson
GL, Hallen B. Cardiac arrest during anaesthesia. A computer-aided study in 250,543
anaesthetics. Acta Anaesthesiol Scand 1988; 32:653-664
Newland MC, Ellis SJ, Lydiatt CA, Peters KR, Tinker JH, Romberger DJ, Ullrich FA,
Anderson JR. Anesthetic-related cardiac arrest and its mortality. A report covering
72,959 anesthetics over 10 years from a US teaching hospital. Anesthesiology 2002;
97(1):108-115
Runciman WB, Morris RW, Watterson LM et al. Crisis management during anaesthesia:
Cardiac arrest. Qual Saf Health Care 2005; 14:e14
Silber JH, Kennedy SK, Even-Shoshan O et al. Anesthesiologist direction and patient
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