Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist Part 1
Moitra, Vivek K.; Einav, Sharon; Thies, Karl-Christian; Nunnally, Mark E.; Gabrielli, Andrea; Maccioli, Gerald A.; Weinberg, Guy; Banerjee, Arna; Ruetzler, Kurt; Dobson, Gregory; McEvoy, Matthew D.; O’Connor, Michael F.
Anesthesia & Analgesia126(3):876-888, March 2018.
It seems like in today’s day and age, emergencies are occurring everywhere. From hurricanes to shooters to earthquakes and fires… I think it’s always important to know what to do. Here are some fabulous checklists I’ve found for getting through those emergencies. These are not substitutions for knowledge and training. Clinical judgement warranted.
Emergency Manual from Stanford — Printable PDF
Ariadne Labs OR Crisis Checklist
Ariadne Labs Safe Surgery Checklist Template
Ariadne Labs Ambulatory Safe Surgery Checklist Template
Newton-Wellesley’s L&D Checklists
Checklist for Trauma Anesthesia
ASRA checklist for Local Anesthetic Systemic Toxicity
Johns Hopkins Central Line Checklist
STS Adult Cardiac Surgery Checklist
Ariadne Labs Cardiac Surgery Checklist
STS General Thoracic Surgery Checklist
STS Congenital Heart Surgery Checklist
University of Kansas Daily ICU Quality Checklist
They say that anesthesiology is 95% comfy and relaxed and the other 5% is “oh shit”! It’s a great career choice — pretty flexible hours, great patient contact, broad spectrum medicine, crisis management, leadership role, etc.
There happened to be an interesting case in the OR — awake tracheostomy for a patient coming in from home.
The Difficult Airway in Head and Neck Tumor Surgery
Our patient had two prior tracheotomies all with successful decannulation. His most recent trach was about 2.5 months ago (which a fiberoptic intubation was used with a 6.0 ETT). He had a neck cancer with a rapidly growing tongue base tumor that seems to be less responsive to chemo than his shrinking neck tumor. Because of the enlarging size of the tongue base tumor, he is starting to notice worsening stridor without his trach. The ENT surgeon evaluated his airway just days before and deemed it unintubateable. Therefore, my plan was to have a pedi FO scope with 5.0 cuffed ETT (smallest available in our OR), glidescope, emergency cric supplies (14g angio cath, 3cc syringe with plunger removed and 7.0 ETT adapter hooked into the end of the syringe), jet ventilator and tubes, and ENT surgeon.
We decided to use a bit of midazolam as well as Precedex for the awake trach. The dosing on the package says 1 mcg/kg for 10 minutes then 0.7 mcg/kg/hr. We started with 0.5 mcg/kg for 10 minutes then 0.5 mcg/kg/hr. This regimen worked well as we started it in preop and monitored his SpO2 as he dozed off but was easily aroused to voice and gentle touch.
The Role of Dexmedetomidine for Awake Trach
Monitors were placed in the OR and we used a face mask running 10 L/min O2 with ETCO2 monitoring. Every now and then he would obstruct while lying supine, therefore, we placed a nasal trumpet to aid the obstruction. The surgeon localized the surgical area. See video for procedure.
The patient coughed once the trachea was perforated, but it was short lived as the surgeons were able to place the trach and hookup to our anesthesia circuit. After confirming ETCO2, we pushed propofol IV and the remainder of the case was performed under general anesthesia (direct laryngoscopy and biopsy by surgeon).
Key take home points
Now check out this amazing Case Report on a patient with a massive maxillofacial tumor!
These aren’t my own thought, however, I can easily agree with the list below. One of the things that was left off this list was pediatric hearts. I had the chance to do a one month pediatric cardiac anesthesia rotation at a very busy Children’s hospital and it was definitely an eye opening experience. Teeny tiny babies. Itty bity tubes and IVs. The heart plumbing/circuitry was anything but normal. I have the utmost respect for pediatric cardiac anesthesiologists — and that’s coming from an adult cardiac anesthesiologist.
Taken and shared from The Anesthesia Consultant Blog:
TOP 10 MOST STRESSFUL SITUATIONS IN AN ANESTHESIOLOGIST’S JOB
- Emergency general anesthesia in a morbidly obese patient. Picture a 350-pound man with a bellyful of beer and pizza, who needs an emergency general anesthetic. When a patient with a Body Mass Index (BMI) > 40 needs to be put to sleep urgently, it’s dangerous. Oxygen reserves are low in a morbidly obese patient, and if the anesthesiologist is unable to place an endotracheal tube safely, there’s a genuine risk of hypoxic brain damage or cardiac arrest within minutes.
- Liver transplantation. Picture a patient ill with cirrhosis and end-stage-liver-failure who needs a complex 10 to 20-hour-long abdominal surgery, a surgery whichfrequently demands massive transfusion equal to one blood volume (5 liters) or more. These cases are maximally stressful in both intensity and duration.
- An emergency Cesarean section under general anesthesia in the wee hours of the morning. Picture a 3 a.m. emergency general anesthetic on a pregnant woman whose fetus is having cardiac decelerations (a risky slow heart rate pattern). The anesthesiologist needs to get the woman to sleep within minutes so the baby can be delivered by the obstetrician. Pregnant women have full stomachs and can have difficult airway because of weight changes and body habitus changes of term pregnancy. If the anesthesiologist mismanages the airway during emergency induction of anesthesia, both the mother and the child’s life are in danger from lack of oxygen within minutes.
- Acute epiglottitis in a child. Picture an 11-month-old boy crowing for every strained breath because the infection of acute epiglottis has caused swelling of his upper airway passage. These children arrive at the Emergency Room lethargic, gasping for breath, and turning blue. Safe anesthetic management requires urgently anesthetizing the child with inhaled sevoflurane, inserting an intravenous line, and placing a tracheal breathing tube before the child’s airway shuts down. A head and neck surgeon must be present to perform an emergency tracheostomy should the airway management by the anesthesiologist fails.
- Any emergency surgery on a newborn baby. Picture a one-pound newborn premature infant with a congenital defect that is a threat to his or her life. This defect may be a diaphragmatic hernia (the child’s intestines are herniated into the chest), an omphalocele (the child’s intestines are protruding from the anterior abdominal wall, spina bifida (a sac connected to the child’s spinal cord canal is open the air through a defect in the back), or a severe congenital heart disorder such as a transposition of the great vessels (the major blood vessels: the aorta, the vena cavas and the pulmonary artery, are attached to the heart in the wrong locations). Anesthetizing a patient this small for surgeries this big requires the utmost in skill and nerve.
- Acute anaphylaxis. Picture a patient’s blood pressure suddenly dropping to near zero and their airway passages constricting in a severe acute asthmatic attack. Immediate diagnosis is paramount, because intravenous epinephrine therapy will reverse most anaphylactic insults, and no other treatment is likely to be effective.
- Malignant Hyperthermia. Picture an emergency where an anesthetized patient’s temperature unexpectedly rises to over 104 degrees Fahrenheit due to hypermetabolic acidotic chemical changes in the patient’s skeletal muscles. The disease requires rapid diagnosis and treatment with the antidote dantrolene, as well as acute medical measures to decrease temperature, acidosis, and high blood potassium levels which can otherwise be fatal.
- An intraoperative myocardial infarction (heart attack). Picture an anesthetized 60-year-old patient who develops a sudden drop in their blood pressure due to failed pumping of their heart. This can occur because of an occluded coronary artery or a severe abnormal rhythm of their heart. Otherwise known as cardiogenic shock, this syndrome can lead to cardiac arrest unless the heart is supported with the precise correct amount of medications to increase the pumping function or improve the arrhythmia.
- Any massive trauma patient with injuries both to their airway and to their major vessels. Picture a motorcycle accident victim with a bloodied, smashed-in face and a blood pressure of near zero due to hemorrhage. The placement of an airway tube can be extremely difficult because of the altered anatomy of the head and neck, and the management of the circulation is urgent because of the empty heart and great vessels secondary to acute bleeding.
- The syndrome of “can’t intubate, can’t ventilate.” You’re the anesthesiologist. Picture any patient to whom you’ve just induced anesthesia, and your attempt to insert the tracheal breathing tube is impossible due to the patient’s anatomy. Next you attempt to ventilate oxygen into the patient’s lungs via a mask and bag, and you discover that you are unable to ventilate any adequate amount of oxygen. The beep-beep-beep of the oxygen saturation monitor is registering progressively lower notes, and the oximeter alarms as the patient’s oxygen saturation drops below 90%. If repeated attempts at intubation and ventilation fail and the patient’s oxygen saturation drops below 85-90% and remains low, the patient will incur hypoxic brain damage within 3 – 5 minutes. This situation is the worst-case scenario that every anesthesia professional must avoid if possible. If it does occur, the anesthesia professional or a surgical colleague must be ready and prepared to insert a surgical airway (cricothyroidotomy or tracheostomy) into the neck before enough time passes to cause irreversible brain damage.
Anesthesia is a pretty social field in medicine. Even though you can be stuck in a room with no windows for hours on end, one can typically have good conversation with the people in the room (nurses, scrub techs, surgeons, assists, reps, etc.). Typically, it’s a jovial atmosphere. Well, while checking-in with our schedule runner (the czar) a call came through that someone needed to be intubated upstairs.
Luckily, I was in between cases and decided to run upstairs to assess the situation. I see a rather obese gentleman appearing a bit mottled in color. The vitals monitor said SpO2 90%. The patient was on a bipap machine. His belly was heaving up and down with each breath…making it appear that he was using a lot of effort for each breath. I called for the intubation supplies. Sadly, this gentleman had suffered from a cerebellar stroke a week ago and they had attempted an extubation a couple of hours prior to my arrival. Needless to say, his respiratory effort was wearing me out…and I had already huffed and puffed my way up several floors of stairs (my preferred method of solo transport). Once the supplies were ready, it was go time. Labs checked out ok. He seemed to be moving all extremities appropriately, despite his stroke. All systems go. After the drugs were pushed through his central line, I took a look and quickly suctioned his posterior oropharynx — there was mucus covering his glottic opening. Once it was cleared, I skillfully maneuvered the endotracheal tube through the vocal cords and secured his airway. The end tidal CO2 detector changed color appropriately and bilateral breath sounds were established. For those crucial few minutes, everything around me seemed to halt. I consciously let out a sigh of relief and thanked the RT and nurses who were present in the room for their help. The beauty of my job is that it’s ever changing. One must be flexible enough to adapt to different types of cases as well as challenging anatomy and situations. Plus, I get to meet all types of people from all walks of life. Therein lies the reason why I love my job.
Anesthesia is a pretty social field in medicine. Even though you can be stuck in a room with no windows for hours on end, one can typically have good conversation with the people in the room (nurses, scrub techs, surgeons, assists, reps, etc.). Typically, it’s a jovial atmosphere. Well, while checking-in with our schedule runner (the czar) a call came through that someone needed to be intubated upstairs.
Luckily, I was in between cases and decided to run upstairs to assess the situation. I see a rather obese gentleman appearing a bit mottled in color. The vitals monitor said SpO2 90%. The patient was on a bipap machine. His belly was heaving up and down with each breath…making it appear that he was using a lot of effort for each breath. I called for the intubation supplies. Sadly, this gentleman had suffered from a cerebellar stroke a week ago and they had attempted an extubation a couple of hours prior to my arrival. Needless to say, his respiratory effort was wearing me out…and I had already huffed and puffed my way up several floors of stairs (my preferred method of solo transport). Once the supplies were ready, it was go time. Labs checked out ok. He seemed to be moving all extremities appropriately, despite his stroke. All systems go. After the drugs were pushed through his central line, I took a look and quickly suctioned his posterior oropharynx — there was mucus covering his glottic opening. Once it was cleared, I skillfully maneuvered the endotracheal tube through the vocal cords and secured his airway. The end tidal CO2 detector changed color appropriately and bilateral breath sounds were established. For those crucial few minutes, everything around me seemed to halt. I consciously let out a sigh of relief and thanked the RT and nurses who were present in the room for their help. The beauty of my job is that it’s ever changing. One must be flexible enough to adapt to different types of cases as well as challenging anatomy and situations. Plus, I get to meet all types of people from all walks of life. Therein lies the reason why I love my job.
My 1st true difficult airway…. something I hope to never see again, but who am I kidding? It’s my job to be an airway expert… therefore, that only means I will be challenging my skills and will someday encounter that dreaded unintubateable airway.
The patient was a friendly, easy-going gal who was an anesthesiologist’s nightmare. She was coming in for a 3 vessel CABG… she was a known difficult IV access (yes, she came from the floor with an infiltrated 22g IV). She stood proud at 5’3″, 255lb, short chin, small mouth opening, and thick neck. She had had her cath done a couple days prior to her surgery — and yes, the radial artery was used. In addition to her already challenging anatomy, the surgeon requested that her other radial artery be spared for grafting.
I go to meet her in the holding area. She was so nice…friendly… had a positive attitude. These are the patients I love to care for. After updating her H&P and checking her consent, I apprehensively started searching for venous access. 3 PIV sticks..with flash but no luck. 2 attempts with U/S…no luck. Luckily, my a-line went in without any trouble. The attending tried several times for a PIV as well with U/S.. no luck.
We wheeled her back to the OR. She had a rather unchallenging R IJ MAC introducer placement (thank goodness!). Now to go to sleep!
We had a glidescope and bougie handy… knowing this intubation could be difficult. (In retrospect, I would’ve had the fiberoptic cart and an LMA within reach). We pre-oxygenated in reverse T-burg for what seemed like forever. Go time: Prop, sux,… glidescope…. barely saw arytenoids…even with a glidescope!! Small mouth opening kept us from truly getting the styletted tube in her mouth. I took a look for what felt like maybe 5 seconds and could eerily hear the sat probe dwindle down… 100….98……95……92….87….84…. time to mask ventilate!! We 2-hand mask her… a very difficult mask! Oral airway in…still difficult. Reposition, jaw lift,…sats 64…52….39… “Call for help” exclaimed my attending! I called out for an LMA and a bougie and told the surgeons to be on standby for an emergency airway.
Fortunately, we were able to place an LMA #4 and slowly ventilate her back up to 100% sat. By now, there were 3 other anesthesiologists and an anesthesia tech who came to help.
We had an airway, but couldn’t proceed with the surgery with just an LMA…we needed to secure her airway. We switched over to a Fast trach LMA#5…one that would accomodate a 7.0 ETT. We used a fiberoptic scope to look down the LMA. It was difficult to discern the structures. She had a pretty small glottic opening…and after several attempts, we were able to guide the fiberoptic scope down into the trachea and secure a breathing tube for ventilation.
Once the tube was secured… I took a step back and realized this could have been a disaster. However, we initiated all the right things in the difficult airway algorithm and saved this woman’s life. It was incredible.
After her surgery, we delivered her to the SICU, intubated. She was extubated the next morning under the supervision of an anesthesiologist. Everything went well. She recovered well from her CABG and was informed to have “difficult airway” written all over her medical record.
Key points:
-Call for help early
-Always have backup airway devices ready
-Even as a resident, don’t depend on your attendings to bail you out of trouble….b/c someday, that “attending” will be you.
-Reflect at the end of a challenging case
April 11, 2010 (CA-3)
My 1st true difficult airway…. something I hope to never see again, but who am I kidding? It’s my job to be an airway expert… therefore, that only means I will be challenging my skills and will someday encounter that dreaded unintubateable airway.
The patient was a friendly, easy-going gal who was an anesthesiologist’s nightmare. She was coming in for a 3 vessel CABG… she was a known difficult IV access (yes, she came from the floor with an infiltrated 22g IV). She stood proud at 5’3″, 255lb, short chin, small mouth opening, and thick neck. She had had her cath done a couple days prior to her surgery — and yes, the radial artery was used. In addition to her already challenging anatomy, the surgeon requested that her other radial artery be spared for grafting.
I go to meet her in the holding area. She was so nice…friendly… had a positive attitude. These are the patients I love to care for. After updating her H&P and checking her consent, I apprehensively started searching for venous access. 3 PIV sticks..with flash but no luck. 2 attempts with U/S…no luck. Luckily, my a-line went in without any trouble. The attending tried several times for a PIV as well with U/S.. no luck.
We wheeled her back to the OR. She had a rather unchallenging R IJ MAC introducer placement (thank goodness!). Now to go to sleep!
We had a glidescope and bougie handy… knowing this intubation could be difficult. (In retrospect, I would’ve had the fiberoptic cart and an LMA within reach). We pre-oxygenated in reverse T-burg for what seemed like forever. Go time: Prop, sux,… glidescope…. barely saw arytenoids…even with a glidescope!! Small mouth opening kept us from truly getting the styletted tube in her mouth. I took a look for what felt like maybe 5 seconds and could eerily hear the sat probe dwindle down… 100….98……95……92….87….84…. time to mask ventilate!! We 2-hand mask her… a very difficult mask! Oral airway in…still difficult. Reposition, jaw lift,…sats 64…52….39… “Call for help” exclaimed my attending! I called out for an LMA and a bougie and told the surgeons to be on standby for an emergency airway.
Fortunately, we were able to place an LMA #4 and slowly ventilate her back up to 100% sat. By now, there were 3 other anesthesiologists and an anesthesia tech who came to help.
We had an airway, but couldn’t proceed with the surgery with just an LMA…we needed to secure her airway. We switched over to a Fast trach LMA#5…one that would accomodate a 7.0 ETT. We used a fiberoptic scope to look down the LMA. It was difficult to discern the structures. She had a pretty small glottic opening…and after several attempts, we were able to guide the fiberoptic scope down into the trachea and secure a breathing tube for ventilation.
Once the tube was secured… I took a step back and realized this could have been a disaster. However, we initiated all the right things in the difficult airway algorithm and saved this woman’s life. It was incredible.
After her surgery, we delivered her to the SICU, intubated. She was extubated the next morning under the supervision of an anesthesiologist. Everything went well. She recovered well from her CABG and was informed to have “difficult airway” written all over her medical record.
Key points:
-Call for help early
-Always have backup airway devices ready
-Even as a resident, don’t depend on your attendings to bail you out of trouble….b/c someday, that “attending” will be you.
-Reflect at the end of a challenging case
Sleepy Time 