Elsevier

Resuscitation

Volume 50, Issue 2, August 2001, Pages 233-238
Resuscitation

Case report
Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic review

https://doi.org/10.1016/S0300-9572(01)00362-8Get rights and content

Abstract

We present a case report of successful resuscitation following cardiac arrest in a patient undergoing surgery in the prone position. A systematic review of the literature identified 22 further cases. Risk factors for intra-operative cardiac arrest in patients in the prone position include: cardiac abnormalities in patients undergoing major spinal surgery, hypovolaemia, air embolism, wound irrigation with hydrogen peroxide, poor positioning and occluded venous return. Cardiac arrest is also a risk in the increasing number of patients with acute respiratory distress syndrome ventilated in the prone position. Management of prone cardiac arrest may be improved by identification of high-risk patients, careful patient positioning, use of invasive monitoring and placement of self-adhesive defibrillator paddles. Suitable techniques for cardiopulmonary resuscitation including methods for chest compression, defibrillation and the management of air embolism are discussed.

Sumàrio

Apresentamos um caso clı́nico de uma reanimação com sucesso de um doente com paragem cardı́aca no decurso de cirurgia quando estava em decúbito ventral. Os factores de risco para paragem cardı́aca intra-operatória nos doentes em decúbito ventral incluem: cardiopatia em doentes submetidos a cirurgia major da coluna, hipovolemia, embolia gasosa, irrigação da ferida com peróxido de hidrogénio, mau posicionamento e obstrução do retorno venoso. A paragem cardı́aca é também um risco no número crescente de doentes com ARDS ventilados em decúbito ventral. A abordagem da paragem cardı́aca em pronação pode ser melhorada identificando os doentes de alto risco, posicionando os doentes cuidadosamente, utilizando monitorização invasiva e colocando pás auto-adesivas de desfibrilhador. São discutidas as técnicas disponı́veis para reanimação cardio-pulmonar incluindo métodos de compressão torácica, desfibrilhação e abordagem da embolia gasosa.

Introduction

The prone position allows access for surgery [1], [2]. In the intensive care unit, patients with acute respiratory distress syndrome (ARDS) are increasingly being ventilated in the prone position [3], [4]. Cardiac arrest in these patients is difficult to manage as poor access makes cardiopulmonary resuscitation (CPR) and defibrillation difficult. These difficulties can be further exacerbated in the surgical patient with an open wound, protruding surgical metal work and an unstable spine. There are few case reports of such arrests and few guidelines as to how to manage them. Current methods of CPR are geared towards supine patients. We describe a case report of cardiac arrest due to ventricular fibrillation during surgery in the prone position. We discuss risk factors and suitable techniques for the management of patients with cardiac arrest whilst ventilated in the prone position.

Section snippets

Case report

A 60-year-old female patient (weight 67 kg), underwent thoracic spine decompression surgery for an invasive tumour between the T-11 and L-1 vertebral levels. The patient had no other past medical history of note and no abnormalities in pre-operative investigations.

Anaesthesia was induced with intravenous propofol, fentanyl and rocuronium. The patient was ventilated with oxygen, nitrous oxide and isoflurane via a reinforced 8 mm tracheal tube. Invasive arterial and central venous pressures were

Methods

We conducted a literature search using the medline database between 1966 and December 1999 for all publications in any language. The MeSH search headings ‘prone’, ‘spinal’, ‘resuscitation’, ‘cardiac’ and ‘arrest’ were used. Abstracts were used to identify relevant articles. The reference lists of all the identified articles were also used to capture any articles not identified by the medline search.

Results

We identified 16 suitable articles [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15],

Review of literature

Cardiac arrest during surgery in the prone position is rare judging from the scarcity of case reports. The majority of cases describe successful outcomes. Publication bias towards good outcome may underestimate the frequency of prone cardiac arrest. Interestingly most of the survivors are in the more recently published case reports (Table 1). Publication bias will also have had an influence on what is published as more extreme cases are likely to be published [23].

Conclusions

Cardiac arrest in patients undergoing surgery in the prone position is rare. Pre-operative risk factors include pre-existing cardiac disease. Intra-operative factors include haemorrhage, gas embolism and diminished venous return to the heart. Management of prone cardiac arrest may be improved by identification of high-risk patients, careful patient positioning, use of invasive monitoring and placement of self-adhesive defibrillator paddles. Successful methods for cardiac compressions and

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