Download Cardiac arrest due to coronary spasms in a patient in a lateral

￭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
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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
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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
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myocardium was technically not easy, automated external
defibrillation using self-adhesive external pads may provide
effective defibrillation [15].
6.
In summary, we described a case of cardiac arrest with the
patient in the left lateral decubitus position and in a right
7.
thoracotomy state during Ivor Lewis esophagogastrectomy
surgery. We conclude that if a cardiac arrest occurs while the
8.
patient in the left lateral decubitus position and in a
contralateral thoracotomy state, prompt repositioning to a
supine position might be more effective for CPR than that in
9.
the lateral position. However, further studies are needed to
determine the efficacy of this technique.
10.
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