BJA Advance Access originally published online on December 16, 2005
British Journal of Anaesthesia 2006 96(2):167-170; doi:10.1093/bja/aei303
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CARDIOVASCULAR |
Use of transoesophageal echocardiography during cardiac arrest in patients undergoing elective non-cardiac surgery
1 Department of Anesthesia, Far Eastern Memorial Hospital, Taipei, Taiwan. 2 Department of Surgery and 3 Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
* Corresponding author: Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, 7 Chung Shan South Road, Taipei, Taiwan 100. E-mail: canon{at}ha.mc.ntu.edu.tw
Accepted for publication November 20, 2005.
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Abstract |
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Background. Sudden unexpected intraoperative cardiac arrests in patients undergoing elective non-cardiac operations are rare but catastrophic complications. The efficacy and utility of transoesophageal echocardiography (TOE) in the diagnosis and management of these events have not been reported earlier.
Methods. Unexpected intraoperative cardiac arrests in patients undergoing elective non-cardiac operations were prospectively studied during a 6 yr period. In these patients, TOE was performed within 5 min after initiation of external chest compression to identify the causes of the cardiac arrests.
Results. Among a total of 125 965 surgical operations, 10 patients who suffered intraoperative cardiac arrests were studied. The causes of the cardiac arrests including myocardial infarction in five, pulmonary embolism in two, and severe hypovolaemia and ventricular arrhythmia without specific pathology in the other two patients were correctly identified using TOE. Seven patients survived.
Conclusion. We conclude that TOE was useful in cardiac arrest during non-cardiac surgery for identifying or excluding pulmonary embolism and for directing investigations and treatment in those patients who had suffered myocardial infarction.
Keywords: complications, cardiac arrest; equipment, transoesophageal echocardiography; surgery, non-cardiac
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Introduction |
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Intraoperative sudden cardiac arrest in patients undergoing elective non-cardiac surgery is rare. A number of causes including myocardial ischaemia, pulmonary embolism caused by gas, fat or thrombi, and various anaesthetic or surgical complications can be responsible for these events.1–6 Immediate diagnosis of the cause is mandatory for successful resuscitation and management of these patients. Transoesophageal echocardiography (TOE) was shown to accurately define a broad range of cardiac and circulatory abnormalities in emergency situations.7 The purpose of the present study was to investigate the utility of TOE in the diagnosis and management of intraoperative cardiac arrest in patients undergoing elective non-cardiac surgery.
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Patients and methods |
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The study was approved by the local Ethics Committee. Adult patients undergoing elective non-cardiac surgery and who suffered sudden cardiac arrests between August 1997 and August 2003 were studied. The non-cardiac operation was defined as surgical procedures not involving the heart or thoracic aorta. Patients who had cardiac arrests due to obvious causes such as difficult airway problems during induction of anaesthesia or significant blood loss (as judged by the attending anaesthesiologist) and patients who had known oesophageal disease were excluded. Cardiac arrest was defined as an event that required resuscitation with external chest compression. The investigators and the team equipped with the ECG machine and TOE probe were moved to the operating room within 3–5 min after receiving emergency request from the attending anaesthesiologists.
A 5 or 6.7 MHz multiplane TOE probe with a CFM 800SV or Vivid 3 or 7 machine (Vingmed or GE Vingmed, Horten, Norway) was used for the study. Several TOE views including the four chamber view, the main and right pulmonary artery view, the long and short axis view of aortic valve and ascending aorta, the aortic arch and descending aorta view, and the transgastric short axis view of left ventricle were obtained in every patient. It took between 5 and 10 min after the placement of the TOE probe to obtain information regarding presence/absence of pulmonary embolism, aortic dissection, or cardiac tamponade. The TOE probe was retained in the oesophagus for monitoring the ventricle during cardiopulmonary resuscitation (CPR) until either the diagnosis was made, or circulation was restored, or persistent absence of spontaneous cardiac rhythms was established. Informed consent could not be obtained from the unconscious patient whereas the patients' relatives or family were informed about the resuscitation and the use of TOE for management.
Myocardial infarction or severe myocardial dysfunction was suspected when a large segmental wall motion abnormality was found during spontaneous ventricular contractions. Acute pulmonary embolism was diagnosed in case there was severe dilatation of the right heart and poor filling of the left heart, or in case there was any mass in the right heart or the main or right pulmonary artery with dilatation of the right ventricle. The diagnostic criteria for aortic dissection were the presence of an intimal flap in two or more planes, and those for cardiac tamponade were the presence of a pericardial effusion, collapse, and compression of the cardiac chambers.
After the cardiac arrest, the ongoing surgical procedure was terminated and the wound was closed as soon as possible. The definite diagnosis was confirmed by the surgical or post-mortem findings if rescue operations were performed or if the family members of the patients agreed to autopsy. In patients who survived the events, definite diagnoses were confirmed using diagnostic studies including 12 lead ECG, precordial ECG during stable cardiac rhythm, cardiac catheterization and coronary angiography, computerized tomography, and magnetic resonance imaging when applicable. Cardiac biochemical markers including creatinine phosphokinase and its MB fraction, and cardiac troponin T (cTnT, ENZYMUN-Test®, Boehringer Mannheim, Germany) were used to diagnose acute myocardial infarction.8
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Results |
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From August 1997 to August 2003, 125 965 patients underwent elective non-cardiac operations in our tertiary referral centre. Among these, 10 patients who developed unexpected intraoperative cardiac arrests were studied. The characteristics and operative and anaesthetic data of these patients are shown in Table 1. No patient was excluded on the basis of pre-existing oesophageal disease or the unavailability of TOE. Among the 10 patients, 3 were undergoing bypass grafting for arterial occlusive disease of the lower limbs, 4 orthopaedic procedures, 2 lower segment Caesarean section, and 1 ovarian cancer surgery. General anaesthesia was used in five patients and regional anaesthesia in the others. The ASA physical status, coexisting medical disease, TOE findings during resuscitation, and the final diagnoses and outcomes are shown in Table 2. Three of these patients did not survive cardiac arrest.
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Acute myocardial infarction was diagnosed with TOE during resuscitation in 5 of the 10 patients (Patients 1, 2, 3, 6, and 10 in Table 1). Severe anterior wall motion abnormality was found in Patients 1 and 3. The cTnT levels 2–6 h after CPR were 8.5 and 3.9 ng ml–1 in Patients 1 and 3, respectively, and the ECG ST-T changes were found in all the leads in both patients. Coronary artery spasm, diagnosed with intracoronary ergonovine provocative test9 during coronary angiography after resuscitation, was shown to be the cause of the myocardial infarction in these two patients. The cTnT levels after CPR were 3.2 ng ml–1 with ECG ST-T elevated in leads V2–V4 in Patient 2. The cTnT level was 7.5 ng ml–1 with ECG ST-T elevated in all precordial leads, and leads II, III, and aVF in Patient 10. In these patients, TOE showed wall motion abnormality in the anterior wall, and in the anterior and inferior walls, respectively. Two- and three-vessel coronary artery diseases were demonstrated with coronary angiography. In Patient 6, who died 1 day after CPR, the cTnT level was 12.6 ng ml–1 and the ECG ST-T was elevated in leads I, aVL, and V2–V6 whereas cardiac catheterization and coronary angiography was not performed.
Acute pulmonary embolism was diagnosed with TOE in two patients who underwent orthopaedic surgery for the fracture of the right tibia and the osteoarthritis of the left knee. Thrombi were found in the right ventricle and the pulmonary artery in both patients. Cardiopulmonary bypass was instituted and emergency pulmonary embolectomy was performed immediately in Patient 7 who survived the event with the postoperative support of extracorporeal membrane oxygenation for several days. Pulmonary embolectomy was performed 6 h after the recovery of cardiac rhythm and blood pressure in the other patient who was discharged from the hospital 14 days after the operation.
Sudden cardiac arrest was found after the delivery of a baby in Patient 4. Severe hypovolaemia and a empty left ventricle with a large amount of fluid in the left pleural space was found by TOE; however, the aorta could not be clearly visualized and there was no evident haemorrhage from the operative field. Although severe haemothorax was suspected from the TOE findings and the drop of haemoglobin level from 13.5 g dl–1 preoperatively to 4 g dl–1 during resuscitation, emergency thoracotomy was not carried out. More than 15 units of whole blood and packed red cells were transfused but the patient did not survive. The causes of the severe hypovolaemia and possible haemorrhage in the chest cavity could not be confirmed due to the denial of autopsy.
The TOE in Patient 5 during resuscitation revealed dilated left ventricle only without other evident abnormalities. In this patient, sudden ventricular fibrillation occurred during the debulking procedure for ovarian cancer. The cardiac rhythm was converted from ventricular fibrillation to sinus rhythm after DC shock. No regional wall motion abnormality, aortic dissection, or pulmonary emboli was found by TOE and the postoperative diagnostic workup did not reveal any pathology of the heart or aorta.
The TOE examination in Patient 8 who did not regain spontaneous cardiac rhythm despite prolonged resuscitation could only exclude the possibility of aortic dissection and massive pulmonary embolism. Although intra-aortic balloon counterpulsation and potent inotropic agents were used, the patient died in the operating room. The consent for autopsy was not obtained from the patient's family.
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Discussion |
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TopAbstractIntroductionPatients and methodsResultsDiscussionReferences |
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We found TOE to be very helpful in identifying the causes of intraoperative cardiac arrests during non-cardiac operations. Of the 10 patients with intraoperative cardiac arrests, TOE could correctly identify the causes in 7. For these patients, TOE findings not only could lead to emergency pulmonary embolectomy but also helped to initiate the diagnostic workup for acute myocardial infarction and further treatment. In the two patients in whom the cause of cardiac arrest was not identified, the TOE findings could also help to rapidly exclude several surgically correctable conditions, for example aortic dissection, cardiac tamponade, or pulmonary embolism.
Another main finding of this study is that the acute myocardial infarction, which may be caused by coronary artery spasm or coronary artery disease, and acute pulmonary embolism were the two main causes of unexpected non-anaesthetic intraoperative cardiac arrests in adult patients undergoing elective non-cardiac operations.
It was generally not possible to ascertain whether regional wall motion abnormality found by TOE during cardiac arrest was new or longstanding. As the patient had suffered a cardiac arrest we assumed such an abnormality to be due to acute myocardial infarction. This was confirmed to be the case by subsequent diagnostic tests.
In a study to evaluate the diagnostic accuracy of TOE during CPR in a setting of emergency room and hospital wards, the causes of cardiac arrest, including acute myocardial infarction, cardiac tamponade, pulmonary embolism, aortic dissection, papillary muscle rupture, ruptured aorta and cardiac arrhythmia, were correctly diagnosed with TOE in 90% of patients.7 We found similar diagnostic accuracy of TOE in our study of intraoperative setting when the causes were not clear. Prompt diagnosis with TOE could not only clarify the possible aetiology but also identify surgically correctable conditions and therefore initiate the therapeutic manoeuvres immediately after cardiac arrest events.
In two of the younger patients with acute myocardial infarction (Patients 1 and 3), the aetiology was found to be coronary artery spasm. It has been suggested that coronary spasm should be included in the differential diagnosis of intraoperative cardiac arrest during cardiac surgery.10 There are also reports implicating it as a cause of cardiac arrest in non-cardiac surgery.11–14 Zainea and colleagues15 suggested that general anaesthesia may be a trigger of coronary spasm in patients with normal coronary arteries. TOE has been reported to be more sensitive than the ECG for the detection of early coronary spasm.16 The findings of our study suggest that for younger patients who develop sudden cardiac arrest intraoperative myocardial infarction caused by coronary artery spasm should be considered as the possible cause.
Pulmonary embolism has been shown to cause sudden cardiovascular collapse intraoperatively in a number of reports.17–19 As shown in these reports, and also in our two cases, patients who underwent orthopaedic operations were at higher risk for intraoperative acute pulmonary embolism. The development of more sensitive markers and diagnostic tests for the detection of venous thromboembolism and the use of the TOE in the high risk patients to monitor their occurrences should help to reduce the risks of pulmonary embolism. We could not determine the causes of cardiac arrest in two patients; however, the TOE findings of severe hypovolaemia and fluid in left pleural space in Patient 4 and the negative findings in Patient 5 were helpful in excluding other possible diagnoses and in facilitating further management.
We conclude that TOE was useful in the management of intraoperative cardiac arrest during elective non-cardiac operations. In particular, it identified or excluded pulmonary embolism and helped in directing postoperative investigations and treatment in patients who suffered myocardial infarction.
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References |
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