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■Case Report■ Anesth Pain Med 2013; 8: 249-253 Cardiac arrest due to coronary spasms in a patient in a lateral decubitus position and contralateral thoracotomy state during Ivor Lewis esophagogastrectomy -A case reportDepartment of Anesthesiology and Pain Medicine, Konyang University Hospital, Daejeon, *Konkuk University Hospital, Seoul, Korea Dong-Ho Park, Jae-jung Kim, Chung-Sik Oh*, Tae-Yun Sung, Choon-kyu Cho, Hee-Uk Kwon, and Po-Soon Kang A coronary artery spasm (CAS) during noncardiac surgery is rare, but it can lead to catastrophic consequences. Furthermore, cardiac arrest caused by CAS, while a patient is in a lateral decubitus position and under contralateral thoracotomy conditions, represents a major challenge to both the anesthesiologist and the surgeon. We present a case of cardiac arrest due to CAS in a 69-year-old man undergoing Ivor Lewis esophagogastrectomy surgery for esophageal cancer in the left lateral decubitus position and the right thoracotomy state. The patient was successfully resuscitated with conventional cardiopulmonary resuscitation after repositioning him to a supine position. (Anesth Pain Med 2013; 8: 249-253) CASE REPORT A 69-year-old man (161 cm, 66 kg) was scheduled for elective Ivor Lewis esophagogastrectomy for esophageal cancer. The patient had a history of hypertension with medication, including a calcium channel blocker, beta-blocker, and hydrochlorothiazide for the past 4 years. His preoperative laboratory data were within normal limits. A preoperative electrocardiogram (ECG) revealed sinus bradycardia but no evidence of Key Words: Cardiac arrest, Cardiopulmonary resuscitation, ischemic change. Coronary artery spasm, Thoracotomy. On patient arrival at the operating room, the patient was monitored with an ECG (lead II), pulse oximetry (SpO2), A coronary artery spasm (CAS) during surgery is rare but non-invasive blood pressure (BP) monitoring, and bispectral can lead to catastrophic consequences, including malignant index (BIS). Preanesthetic vital signs showed blood pressure of dysrhythmias, cardiac arrest, and death [1-3]. Furthermore, if 143/81 mmHg, a heart rate of 65 beats/min, and a respiratory cardiac arrest caused by CAS occurs while the patient is in a rate of 20 breaths/min. Anesthesia was induced with propofol left lateral decubitus position and under right thoracotomy (1.5 mg/kg) and maintained with a target controlled infusion of conditions, both the anesthesiologist and surgeon are placed in remifentanil (target concentration, 2–10 μg/ml) and 2–4 vol% a difficult situation. Here, we report a case of sudden cardiac desflurane. Trachea was intubated with a left-sided double- arrest caused by CAS in a patient undergoing Ivor Lewis lumen tube (DLT). Fiber-optic bronchoscopy confirmed correct esophagogastrectomy surgery in the left lateral decubitus positioning of the DLT. Invasive monitoring included radial position and during a right thoracotomy. The patient was arterial BP and central venous pressure (CVP). The operation was started with the patient in the supine successfully resuscitated. We obtained the patient’s written position for abdominal mobilization of the stomach. The informed consent prior to preparing this report. patient’s position was changed 3-hr later to the left lateral Received: August 29, 2012. Revised: 1st, September 21, 2012; 2nd, November 6, 2012. Accepted: November 9, 2012. Corresponding author: Tae-Yun Sung, M.D., Department of Anesthesiology and Pain Medicine, Konyang University Hospital, 685, Gasuwon-dong, Seo-gu, Daejeon 302-718, Korea. Tel: 82-42-600-9316, Fax: 82-42-5452132, E-mail: [email protected] decubitus position. A right posterolateral thoracotomy incision was made in the fifth intercostal space for resection and reconstruction of the esophagus, and one lung ventilation was started. During one lung ventilation, SpO2 was decreased to below 95% periodically. Thus, to avoid hypoxemia, 100% 249 250 Anesth Pain Med Vol. 8, No. 4, 2013 inspired oxygen, and intermittent inflation of the collapsed lung the rib spreader, but this was ineffective. The operator was used. Ninety min after the right thoracotomy, systolic BP proceeded with a right ventricular massage using his palm dropped to 70–80 mmHg. Nasopharyngeal temperature was through the right thoracotomy incision. Although arterial BP checked 35.2oC. Up to that time, patient was infused 180 reached 40/25 mmHg using this method, we judged that this ml/hr of crystalloid, 100 ml/hr of colloid and CVP was was insufficient to meet cerebral perfusion pressure. In maintained 6–8 mmHg. A continuous dopamine infusion (5 μg/ addition, correct placement of a paddle on the left apex of the kg/min) was started and was increased to 10 μg/kg/min. Then, heart for defibrillation was also inaccessible in this position. boli of 8–12 mg ephedrine and/or 100–200 μg phenylephrine Therefore, were administered when systolic BP dropped to < 90 mmHg. administered, and the patient was turned back to the supine Three hours after the right thoracotomy incision and within 5 position for external precordial compressions and effective minutes after vagal denervation, the ECG showed tall and defibrillation after covering the thoracotomy with an Iovan broad-base T waves, HR was increased to 80–90 beats/min drape. Maintaining external chest compressions in supine from 60–65 and it became difficult to maintain the systolic BP position, > 90 mmHg despite loading administration of hydroxyethyl maintained. Fifteen minutes after initiating cardiac compression, starch (500 ml) and phenylephrine 200 μg with continuous administration of a 200 J shock restored sinus rhythm. dopamine infusion (5 μg/kg/min). Bolus epinephrine 10 and Mechanical ventilation was decreased to 8 from 14 breaths/min a bolus arterial BP infusion of reached 1 above mg epinephrine 60/31 mmHg was and 20 μg was administered two times intermittently when during the external chest compressions to avoid excessive systolic BP dropped to 60–65 mmHg because the bolus ventilation. Ice packs were placed around the patient’s head, ephedrine and phenylephrine were ineffective. We conducted an and the operating room was cooled to protect the brain. arterial blood gas analysis (ABGA) to rule out hyperkalemia. Nasopharyngeal temperature reached 34.0oC using this method. The results of ABGA were a [K+] of 3.3 mEq/L and pH, Three bolus infusions of 1 mg epinephrine every 3 min, 40 PaCO2, PO2, HCO3-, and SaO2 of 7.334, 44.8 mmHg, 492 units of vasopressin, and 0.5 mg of atropine were administered mmHg, 22.6 mEq/L and 99.0%, respectively. The vital signs during cardiopulmonary resuscitation (CPR). Immediately after showed BP of 86/52 mmHg, a heart rate of 87 beats/min, and restoration of sinus rhythm, the arterial BP and heart rate were nasopharyngeal temperature of 34.6°C. Ventricular tachycardia 83/63 mmHg and 115 beats/min, respectively. The results of began within 20 min after vagal denervation, and a bolus the ABGA were a pH, PaCO2, PO2, HCO3-, and SaO2 of infusion of 1 mg/kg lidocaine was administered. Also, to rule 7.105, 76.8 mmHg, 80 mmHg, 18.9 mM/L and 93.0%, out the hypovolemia, hydroxyethyl starch (400–500 ml) was respectively. Sixty ml of 8.4% sodium bicarbonate was infused rapidly administered. However, VT was sustained about 10 slowly and respiratory rate was adjusted 15 from 8 breaths/min minute and ventricular fibrillation (VF) (Fig. 1) occurred to correct metabolic and respiratory acidosis. After consulting suddenly about 30 min after vagal denervation. Immediately, with the surgeon, the operation was delayed until restoration of open-chest cardiac massage was attempted by the surgeon stable vital signs. Then, transthoracic echocardiography (TTE) through a right thoracotomy incision, which was already spread was performed in the operating room to evaluate the cause of for the operation. We simultaneously prepared an external the defibrillator and applied a 200 J biphasic shock after removing abnormalities except basal and mid anterolateral hypokinetic cardiac arrest. TTE did not reveal any specific wall motion. At that time, epinephrine was infused at 0.1 μg/ kg/min. The patient was moved to the intensive care unit (ICU) while being intubated with a DLT and continuous epinephrine infusion (0.1 μg/kg/min). A 12-lead ECG was performed after arrival at the ICU, which showed ST segment elevation in leads V2–V6 (Fig. 2). The cardiac physician decided to perform emergent coronary angiography (CAG). Eighty minutes after the onset of cardiac arrest, CAG revealed Fig. 1. Electrocardiographic (ECG) waveform recordings from lead II during cardiopulmonary resuscitation. The ECG shows ventricular fibrillation. The patient suddenly developed ventricular fibrillation 15 min after the onset of tall and broad-base T waves. diffuse spasms in the left anterior descending (LAD) and left circumflex coronary (LCX) arteries, and the diffuse spasms disappeared with thrombolysis in myocardial infarction 3 flow Dong-Ho Park, et al:Cardiac arrest in the lateral position 251 after an intracoronary injection of 100 μg isosorbide dinitrate (Fig. 3). Therefore, continuous infusion of 1 μg/kg/min DISCUSSION isosorbide dinitrate was started, and the epinephrine infusion was stopped. A dopamine infusion (5–10 μg/kg/min) was added Profound hypotension or cardiac arrest during esophago- and adjusted to maintain BP. The patient regained cons- gastrectomy might be caused in a patient who has history of ciousness the next day, though intubation and mechanical decompensated heart failure or unstable coronary syndromes ventilation were maintained. An elective reoperation was and by several factors, including surgeon’s hand interferes with performed 3 days after ICU admission to complete the cardiac filling, hypovolemia, and massive surgical bleeding. esophagogastrostomy. Self-adhesive electrodes for defibrillation However, the patient has not prior history of heart disease were placed on the anterior-apex electrode position, and a except hypertension. When hypotension was sustained despite 5-lead ECG (lead II and V5) was applied instead of a 3-lead all effort to increase BP, authors identified that was neither ECG before induction of anesthesia. A continuous infusion of interference of cardiac filling by surgeon’s hand nor vessels 0.5 μg/kg/min isosorbide dinitrate was maintained during injuries which can lead to massive bleeding. In addition, surgery. The reoperation ended without any events. The patient authors administered large amount of fluids intravenously to was transferred to ICU after surgery. rule out hypovolemia. Nine days after readmission to the ICU, the patient was hemodynamically Factors related to the etiology of CAS are endotracheal stable and showed no neurological sequelae, so he was intubation, inadequate depth of anesthesia, aspiration of the transferred to the general ward. tracheobronchial tree, hyperventilation and hypercapnia, administration of exogenous catecholamines, low body temperature, and altered sympathovagal balance [1-6]. All of these factors commonly occur during general anesthesia. Although we applied fluid warmer device since the induction of anesthesia, it was not sufficient to prevent hypothermia. CAS can occur even in the mild therapeutic hypothermia at the beginning of the cooling [6]. In particular, a Ivor Lewis esophagogastrectomy requires one lung ventilation using a DLT, which can Fig. 2. Electrocardiogram recorded in the intensive care unit. Marked elevation of the ST segment in leads V2–6. lead to hypercapnia, and aspiration of the tracheobronchial tree can occur when the bronchial cuff is deflated. Moreover, the Fig. 3. Coronary angiogram of the left anterior descending and left circumflex coronary arteries. (A) Coronary angiography showed diffuse narrowing with nearly complete obliteration in the left anterior descending and left circumflex coronary arteries. (B) Intracoronary injection of isosorbide dinitrate recovered the diffuse spasms in the left anterior descending and left circumflex coronary arteries with thrombolysis in myocardial infarction 3 flow. 252 Anesth Pain Med Vol. 8, No. 4, 2013 vagal nerve trunks are inevitably cut, which can lead to patient alterations we undergoing decompression surgery for trigeminal neuralgia [13]. administered large dose of catecholamines and α-agonist to External cardiac compressions were performed by two rescuers maintain the BP and the VF caused by the CAS that occurred in the lateral position; each rescuer pushed the chest and the within 30 minutes after vagal denervation. Therefore, we back, simultaneously. These authors concluded that chest strongly factors, compressions in the lateral position by two rescuers is an including intermittent hyperventilation with 100% inspired efficient resuscitation maneuver. However, their chest compre- oxygen, hypercapnia during single lung ventilation, low body ssions duration was relatively short duration, five minutes, in in sympathovagal suspect that the balance. In combination of this case, these in the left lateral decubitus position who was temperature, α-adrenergic stimulation and alteration of sympa- comparison to our case with fifteen minutes and the patient thovagal balance due to phenylephrine, dopamine, epinephrine was not in a thoracotomy condition. In addition, despite administration and vagal denervation, may have induced the conventional CPR, the patient eventually required extracorporeal CAS in our patient. cardiopulmonary resuscitation because they could not apply a A CAG demonstration of reversible coronary constriction is the definitive diagnosis for CAS [5]. An ECG shows ST defibrillator in the lateral position for more than 5 min after cardiac arrest. segment depression as a result of subendocardial ischemia as Open-cardiac massage through a left anterolateral thoraco- well as ST segment elevation [7]. In this case, diffuse LAD tomy approach or midline sternotomy should be considered if and LCX arterial spasms were detected during emergent CAG the patient is positioned supine. However, these approaches are before the spasm provocation test and were reversed by an not available for patients in the left decubitus position. To isosorbide dinitrate injection. However, in our patient, ischemic perform the effective open-cardiac massage, pericardium is ST changes on the ECG were not detected until VF occurred, opened and rescuer’s both hands are used to holding the left and only tall and broad-base T waves were shown. This can and right ventricle [14]. In the present case, patient’s pericar- be explained by the presence of collateral flow from the right dium was not opened, so, our surgeon could not hold both coronary artery [8], and we were only able to monitor lead II ventricle with his both hands, surgeon could just compress the intraoperatively. As shown in the present case, tall and right ventricle using the palm of his right hand. This was less broad-base T waves, so-called hyperacute T waves, may be the efficient compare to external chest compressions in supine earliest and only ECG signs of an acute myocardial infarction position. Since the right thoracotomy site was not closed, [9], and may also be seen in variant angina attacks [10]. inadequate chest recoil might have occurred, which may have Intraoperative CPR in the lateral position is rare; few cases decreased the changes in intrathoracic pressure that lead to have been reported [11-13]. Beltran and Mashour [11] reported blood flow. Nevertheless, external chest compressions signi- two cases of CPR during neurosurgery with the patient in the ficantly improved arterial BP to > 60/30 mmHg from 40/25 left mmHg when compared to cardiac massage through a right lateral decubitus position. However, the CPR was unsuccessful due to inaccessible and brisk surgical site thoracotomy in the left lateral decubitus position. bleeding after repositioning the patient to the supine. However, Defibrillation is another challenge if VF occurs in lateral our patient had little bleeding from the operative sites because decubitus position and thoracotomy state. In the present case, the cardiac arrest occurred after the gastroesophageal junction we initially applied external defibrillator paddles in lateral was divided with an endostapler. Abraham et al. [12] reported position, but this was ineffective because it may be that we a case of CPR that occurred in a 6-year-old boy in the left could not correctly place the paddle on apex of heart and lateral surgical could not deliver the firm paddle force to lower the decompression of a brain tumor. External cardiac compressions transthoracic impedance in left lateral decubitus position due to were performed by one rescuer using the two thumb-encircling fears of patient fall down a operating table. In such situation, hand technique in the lateral position, which was successful. internal defibrillation using ‘surgical’ paddle electrodes or However, the right chest of our patient was opened, and he self-adhesive external was defibrillation using decubitus not a child position with who a was small undergoing body size, thus two pads may be ‘sugical’ paddle considered. electrodes is Internal usually thumb-encircling hand technique by only one rescuer may not performed during open heart/chest procedures. However, as produce the sufficient force which lead to blood flow. In present case, if pericardium was not opened and heart another case report, CPR was administered to a 61-year-old mobilization to place the internal defibrillator paddles on the Dong-Ho Park, et al:Cardiac arrest in the lateral position 253 myocardium was technically not easy, automated external defibrillation using self-adhesive external pads may provide effective defibrillation [15]. 6. 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