Cardiac Arrest in the OR

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.


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Keep calm and page anesthesia!

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.

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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.

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Call for help

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

Call for help

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

Calm before the storm

People who have witnessed and/or survived crazy forces of Mother Nature often state that there’s a “calm before the storm”. I have experienced this with tornados growing up in west Texas.

But on OB?
Yep.

The OB anesthesia team was enjoying the fruits of the night team’s labor. All epidurals were in…. most of the ladies had delivered. Life was good! I even had time to prop my feet up and get some reading done. Not only that, we all enjoyed a rather relaxed lunch. It was WAY TOO CALM!!!

Anesthesia stat was called overhead/paged to our beepers/called to the anesthesia room….
What appeared to be a normal vaginal delivery… turned into any OB’s worst nightmare. The cause wasn’t clearly revealed. We started multiple large bore IVs and sent off blood and raced to the OR. EBL 3L. Once in the OR, complete assessment of the bleeding by the OBs rendered a necessary hysterectomy. The patient was pale white…never before had I seen a human being so pale, but alive and interacting with us. She didn’t flinch for a 14g PIV or the a-line. I wonder what she was thinking as she could probably feel her life fading away. Belmont, cardiac nurses, cell saver..dozens of people in an OB OR; all wanting to give this woman a chance to see her 5 kids.

PreOX, Cricoid, RSI–>GA. Quick prep. Intraop, a uterine rupture was noted. Hysterectomy completed. Still more bleeding!! Multiple uterine veins were found…just avulsed along the lateral walls of the abdomen. 2 more ob/gyn surgeons called stat for repair. Still no control of the bleeding. Partial aortic compression to help with hypotension. 2 vascular surgeons called. + Confirmation of control of bleeding. Belmont was running about 200ml/min x 120 min. Multiple blood product given (20-30U PRBC, 20-30U FFP, 24 plt, 10 cryo). pH 7.11–>7.38. UOP about 100ml/hr. At it’s lowest, Hb was 4.8 (the lowest I’ve ever seen!). Upon delivery to the unit, pH 7.38, Hb 10, Plt 127 (got as low as 84), PT/PTT slightly elevated, INR 1.2 (1.8 at its highest), fibrinogen 213 (65 at its lowest). She was mechanically ventilated based on the ARDSnet protocol (small tidal volumes, higher PEEP, fast frequency).

This is not something you see everyday…. much less something you see commonly on OB. The wonderful communication between the nurses, surgeons, staff, anesthesia…everyone truly made this a world-class effort. And because of this… a mother cheated death.

Lessons learned:
– Call for help early and clearly
– Practice effective communication
– Close the loop — verify if questions
– Don’t be afraid to get help — there’s many consultants at a hospital…
– Debrief — because you’ll never know when you’ll need to be prepared for another “storm”

Calm before the storm

March 5, 2010

People who have witnessed and/or survived crazy forces of Mother Nature often state that there’s a “calm before the storm”. I have experienced this with tornados growing up in west Texas.

But on OB?
Yep.

The OB anesthesia team was enjoying the fruits of the night team’s labor. All epidurals were in…. most of the ladies had delivered. Life was good! I even had time to prop my feet up and get some reading done. Not only that, we all enjoyed a rather relaxed lunch. It was WAY TOO CALM!!!

Anesthesia STAT was called overhead/paged to our beepers/called to the anesthesia room….

What appeared to be a normal vaginal delivery… turned into any OB’s worst nightmare. The cause wasn’t clearly revealed. We started multiple large bore IVs and sent off blood and raced to the OR. EBL 3L. Once in the OR, complete assessment of the bleeding by the OBs rendered a necessary hysterectomy. The patient was pale white.  Never before had I seen a human so pale, but alive and interacting with us. She didn’t flinch for a 14g PIV or the a-line. I wonder what she was thinking as she could probably feel her life fading away. Belmont, cardiac nurses, cell saver..dozens of people in an OB OR; all wanting to give this woman a chance to see her 5 kids.

PreOX, Cricoid, RSI–>GA. Quick prep. Intraop, a uterine rupture was noted. Hysterectomy completed. Still more bleeding!! Multiple uterine veins were found…just avulsed along the lateral walls of the abdomen. 2 more ob/gyn surgeons called stat for repair. Still no control of the bleeding. Partial aortic compression to help with hypotension. 2 vascular surgeons called. + Confirmation of control of bleeding. Belmont was running about 200ml/min x 120 min. Multiple blood product given (20-30U PRBC, 20-30U FFP, 24 plt, 10 cryo). pH 7.11–>7.38. UOP about 100ml/hr. At it’s lowest, Hb was 4.8 (the lowest I’ve ever seen!). Upon delivery to the unit, pH 7.38, Hb 10, Plt 127 (got as low as 84), PT/PTT slightly elevated, INR 1.2 (1.8 at its highest), fibrinogen 213 (65 at its lowest). She was mechanically ventilated based on the ARDSnet protocol (small tidal volumes, higher PEEP, fast frequency).

This is not something you see everyday…. much less something you see commonly on OB. The wonderful communication between the nurses, surgeons, staff, anesthesia…everyone truly made this a world-class effort. And because of this… a mother cheated death.

Lessons learned:
– Call for help early and clearly
– Practice effective communication
– Close the loop — verify if questions
– Don’t be afraid to get help — there’s many consultants at a hospital
– Debrief — because you’ll never know when you’ll need to be prepared for another “storm”