Possible causes of Intraoperative

cardiac arrest and management

Asaye T.(BSc, Anesthesia)

Outline
Introduction
Defining CA
Risk factors for CA
Causes of CA
Prevention, pre-cardiac arrest issues and
general principles of management
Adult BLS and ALS algorithm
Conclusion
References

Introduction
Cardiac arrest of patients during anesthesia has
been the driving force behind the development of
this specialty.
Safer procedures, new anesthetics, and technical
improvements such as monitoring devices and
ventilators
have
successfully
reduced
intraoperative mortality.
Initially, cardiac arrest seemed to be only related
to the use of general anesthesia.

Introduction..

Increased use of regional anesthesia, fatal outcome

was also connected with physiological causes as a
result of
loss of sympathetic reflexes
drug toxicity
convulsions
early or delayed hypoxia

Introduction..
The incidence of CA and death attributable to
anesthesia is very low.
Management of CA is governed by clear evidence
based guidelines.
In the past our efforts to limit the # of fatal events
have focused on drugs, equipment, monitoring and
anesthetics techniques
Nowadays organizational and human factors are
known to play a major role.

Defining CA
CA also known as CPR arrest or circulatory arrest
cessation of functional circulation of the blood due
to failure of the heart to contract effectively
different from congestive heart failure, where
circulation is substandard, but the heart is still
pumping sufficient blood to sustain life

Risk factors for CA

male
2 more likely to experience CA

Age
the incidence of CA increases with age, especially after
age 45 for men and age 55 for women

A personal or family Hx of other forms of heart

disease, such as
heart rhythm disorders,
CHD , HF and
cardiomyopathy
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Risk factors
A previous heart attack
A family history of coronary artery disease
Smoking
High blood pressure
chronic obstructive lung disease,
renal failure,
cancer and major surgery

Causes of CA in the OR

mainly divided into four categories;

1. preoperative complications (65%)
2. surgical procedures (24%)
3. intraoperative pathological events (9%)
4. those attributed to anesthetic Mgt (2%) Half of the anesthetic managementrelated events were
caused by airway or ventilator problems followed by
medication accidents and infusion

Causes .
There are various circumstances which can lead to
acute cardiac arrest:
Reflex arrest due to vagovagal stimulation:
surgical
trauma in the region of the aorta, the
hilus of the lung, the carotid sinus or the vagus
nerves.

Direct trauma to the heart: during operation in

pericardium or heart or may be caused by
inadvertent retractions on heart or aorta

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Causes .

Over doses of anesthetic agents: depress the

circulation, either by direct effect on the
heart or by vasodilation.
by altering the conduction mechanism
by direct depression of myocardium
Ventricular fibrillation :The heart sensitized by certain
anesthetic agents, may react by ventricular fibrillation if
subjected to an over dose of epinephrine

11

Causes .

The majority of cardiac arrests in the

operating room are multifactorial in origin
and may be ascribed to :
the patients pre-existing condition
an inadequate risk estimate
a failure in monitoring
inappropriate patient management or human error

12

Causes..

A review of the causes of intraoperative

cardiac arrest:
blood loss

cardiac
complications
(cardiac
events
(myocardial infarction)
drug- or hypoxia-inducing factors brought on
by airway loss or ventilation failure
end-stage organ failure
thromboembolic events
sepsis
13

Reversible causes of CA

Hs
Hypovolemia- A lack of blood volume
Hypoxia- A lack of oxygen
Hydrogen ions (Acidosis) - An abnormal pH in the
body
Hyperkalemia or Hypokalemia- Both excess and
inadequate potassium can be life-threatening.
Hypothermia- A low core body temperature
Hypoglycemia or Hyperglycemia- Low or high
blood glucose
14

Reversible causes.

Ts
Tablets or Toxins
Cardiac Tamponed- Fluid building around the
heart
Tension pneumothorax - A collapsed lung
Thrombosis(Myocardial infarction) - Heart
attack
Thromboembolism(Pulmonary embolism) - A
blood clot in the lung
Traumatic cardiac arrest
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Signs of cardiac arrest

Absence of pulsation
Absence of blood pressure
Respiratory arrest
Pallor or cynosis quickliy follows cardiac arrest
cardiac sounds cannot be heard over the
pericardium
Absence of bleeding in the wound
Direct observation of the heart
Dilation of pupils
The capillary refill time(>2sec)
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Prevention, pre-cardiac arrest issues

and general principles of Mgt
Patients in the operating room are monitored
extensively and, as a consequence, there should be
no delay in diagnosing a CA
A high-risk patient will often receive invasive blood
pressure monitoring, which is invaluable in the
event of a cardiac arrest.

If there is a strong possibility of a CA, it may be

advisable to apply self-adhesive defibrillation
patches before the induction of anesthesia
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Prevention..
Asystole and VF should be detected in the OR
immediately.
The onset of PEA might not be so obvious and
capnography, pulse oximetry and pulse check or
arterial line analysis may be required to establish a
diagnosis
A patient can deteriorate within minutes or hours
in the intraoperative setting
Effective monitoring and correction of physiological
Variables is the key to intraoperative prevention
and treatment

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Prevention..

To prevent a cardiac arrest an anesthetist

needs to control all the factors that affect :
cardiac output, including preload, after load

and contractility
ventilation, avoiding auto-PEEP and gas
trapping in patients with obstructive lung
diseases

19

Cardiopulmonary resuscitation

The major components of resuscitation from

cardiac arrest are :ABCDE
Airway
Breathing
Circulation
Drugs
Electrical therapy
CPR is a critical part of the management of cardiac
arrest
It should be started as soon as possible and interrupted
as little as possible
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CPR..

Traditionally, these have been divided into

Basic life support (BLS)

performed without additional equipment basic
airway management, rescue breathing, and
manual chest compressions

Advanced cardiac life support (ACLS)

encompassing, all the cognitive and technical
skills necessary for resuscitation.

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Adult Basic Life Support(BLS)

BLS is the foundation for saving lives following
cardiac arrest.
Survival to hospital discharge presently
approximately 5-10%
Early resuscitation and prompt defibrillation
(within 1-2 minutes) can result in >60%survival

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Chain of survival

23

BLS algorithm

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Adult BLS sequence

Ensure personal safety

Check patient for response
If response; use ABCDE approach
If no response ... Shout for help
Turn patient on back
Checking sign of life (10 seconds)
Breath check
Gasps
Apnea
Pulse check
No pulse

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BLS ...
If the patient has no pulse or sign of life (gasps or
inadequate breath)
Call for resuscitation team
Start CPR & get
resuscitation equipment 30 : 2 Ratio
Role of CPR
Create blood
flow by increasing intrathoracic
pressure and directly compressing the heart.
Generates blood flow and oxygen delivery to the
myocardium and brain whilst the cause of cardiac
arrest is treated.

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BLS ..

High quality CPR

1. .Rate of at least 100 compressions per minute (FAST)

2. Compression depth of at least 2 inches in

adults (HARD)
3. Allowing complete chest recoil after each
compression
4. Switching compressors every 2 minute
5. Minimizing interruptions in compressions
6. Avoiding excessive ventilations
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BLS ..

During CPR, cardiac output is 25% to 33% of normal

So O2 uptake from the lungs and CO2 delivery to the
lungs are also reduced.
As a result, a low minute ventilation (reduced TV & RR)
can maintain effective oxygenation and ventilation

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Automated external
defibrillator (AED)

Attach pads to casualtys bare chest

Analysing rhythm do not touch
victim
SHOCK INDICATED
Stand clear
Deliver shock

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Adult Advanced cardiac life support (ACLS)

ACLS interventions build on BLS foundation of
chain of survival.
Arrhythmias associated with cardiac arrest are
divided into 2 groups:

Shockable rhythms (VF/VT) and

Non-shockable rhythms (Asystole and PEA).

The principle difference in management is the

need for attempted defibrillation in patients with
VF/VT.
Subsequent actions are common to both.

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Normal sinus rhythm

Coarse ventricular fibrillation

Fine ventricular fibrillation

Ventricular fibrillation is shockable

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ACLS..

Ventricular tachycardia
Ventricular Tachycardia is shockable
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Shockable rhythms (VF/VT)

Pulseless VT or VF
it is the arrhythmia that yields the greatest
likelihood of immediate and long-term survival
when CA is witnessed and a monitor reveals
the mechanism to be pulseless VT or VF,
defibrillation should be performed immediately
The chances for survival decline 710% for
every minute without defibrillation
Shock should be delivered within 3 min ( 1
min) of arrest.
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Shockable rhythms (VF/VT)

Pulseless VT or VF
Apply monophasic and biphasic defibrillation

(360 and150j respectively)

If the rescuer is unfamiliar with the waveform
used, 200 J should be used as a default energy.
If VF recurs, either the same or an escalating
dose of energy can be used.
If at any time VF recurs after successful
conversion, defibrillation should be repeated at
the most recent successful energy level.
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Shockable rhythms (VF/VT)

Pulseless VT or VF
If return of spontaneous circulation has not
occurred after an initial attempt at defibrillation,
5 cycles CPR (30:2)
then a second defibrillatory shock, pharmacologic
interventions(epinephrine $ vasopressin)
Two minutes of CPR should be performed after
drug administration and before defibrillation is
attempted.

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Shockable rhythms (VF/VT)

Pulseless VT or VF
If VF persists thereafter, mediations with
antifibrillatory effects should be chosen(
Amiodarone and lidocaine )
Amiodarone( intial dose 300 mg) is the
preferred anti arrhythmic agent in the presence
of persistent VF.
Amiodarone produces prolongation of action
potentials and refractoriness in all cardiac
tissue
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Shockable rhythms (VF/VT)

Pulseless VT or VF
Sodium bicarbonate can be considered if specific
conditions ( severe metabolic acidosis , overdoses of
tricyclic antidepressants, and hyperkalemia)
Clinically, if this drug is used, an initial dose of
1mEq/kg can be given

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Nonshockable rhythms (Asystole and

PEA)

PEA
characterized by pulselessness in the presence of
some type of electrical activity other than VT or
VF.
High priority must be given to identification of a
possibly correctable cause of any form of PEA.
hypovolemia, cardiac tamponade, and tension
pneumothorax with hypoxemia are possible
causes
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Nonshockable rhythms (Asystole

and PEA)
Asystole
Complete and sustained absence of electrical
activity
most often an irreversible and therefore
terminal event caused by derangements such
as
uncorrected persistent hypoxia,
severe hyperkalemia,
massive drug overdose,
myocardial infarction, or
hypothermia
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Nonshockable rhythms.

Asystole..
In specific instances such as hyperkalemia, known
metabolic acidosis, or tricyclic antidepressant
overdose, sodium bicarbonate should be
administered early in the effort
Neither defibrillation nor pacing is indicated for
the treatment of asystolic cardiac arrest

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ACLS

Asystole Non-shockable

Pulseless electrical activity Non-shockable

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Safety Rules during Defibrillation

Defibrillation must NOT risk safety of
resuscitation team
Do NOT defibrillate in wet surroundings or
clothing
NO part of any person should make direct or
indirect contact with the patient
The operator must NOT touch any part of the
electrode surface

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Safety Rules

REMOVE any oxygen source from the patient

before defibrillation
There is a risk sparking from defibrillator paddles
causing fire

Paddles should NEVER be charged anywhere

other than on the patients chest
It is the OPERATORs responsibility to ensure
everyone is clear of the patient before a shock is
delivered

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Sequence for defibrillation

1. Confirm cardiac arrest
2. Confirm VF / VT with cardiac monitor
3. Place defibrillator gel pads on patients chest
4. Place defibrillator paddles firmly on patients chest
5. Select 360J/ 150J (Mono & bi respectively)
6. Remove oxygen from defibrillation zone
7. Warn everyone to stand clear and verbalise
charging

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Sequence for defibrillation..

8. Charge paddles
9. Reconfirm and check everyone is clear
10. Deliver the shock (time between stopping CPR
and shock delivery should be < 10 seconds)
11. Replace paddles immediately
12. Resume CPR for 2 minutes
13. Re-check rhythm

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Sequence for defibrillation..

14. If patient remains in VF / VT give 2nd shock
15. If patient remains in VF / VT give 1mg adrenaline
IV then give 3rdshock
16. If patient remains in VF / VT consider
amiodarone 300 mg IV or if unavailable lidocaine
100mg then give 4thshock
17. If patient remains in VF / VT repeat shock cycles
and administer 1mg IV adrenaline on alternate
cycles

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Sequence for defibrillation..

18. If organised electrical activity is seen with
the rhythm check -feel for a pulse
If no pulse i.e. PEA continue CPR nonshockable side of algorithm
If pulse start post-resuscitation care

19. If asystole is seen continue CPR nonshockable side of algorithm

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Summary of reversible causes Mx

Hypovolaemia
Volume IVF, PRBCs

Hypoxia
Oxygenate/Ventilate

Hyper-/ Hypokalemia
Sodium bicarbonate
Insulin/glucose
Calcium

Hypothermia
Warm --invasive
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Summary

Toxins

Check levels
Charcoal
Antidotes

Tamponade

Pericardiocentesis

Tension pneumothorax
Needle decompression
Tube thoracostomy

Thrombosis (coronary or pulmonary)

Thrombolytics

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Conclusion
Safer procedures, new anesthetics, and technical
improvements such as monitoring devices and
ventilators
have
successfully
reduced
intraoperative cardiac arrest.
CPR is not harmful, Inaction is harmful and CPR
can be lifesaving.
However, the quality of CPR is critical.
Push hard & fast, complete recoil & minimize
interruptions.

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References

1.Eisenberg MS, Mengert TJ (April 2001).

"Cardiac resuscitation". N. Engl. J. Med.344
(17): 130413
2.Millers Anesthesia ,7th edition, vol.2
:2971-2989
3.Clinical anesthesia ,Paul.G.Barsh
6thedition:1532-1546
4. Safar P (December 1986). "Cerebral
resuscitation after cardiac arrest: a
review". Circulation74 (6 Pt 2): IV13853
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THANK YOU!

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