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Sudden Cardiac Arrest Under Spinal Anesthesia in a Mission Hospital: a Case Report and Review of the Literature Bamidele Johnson Alegbeleye

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Sudden Cardiac Arrest Under Spinal Anesthesia in a Mission Hospital: a Case Report and Review of the Literature Bamidele Johnson Alegbeleye Alegbeleye Journal of Medical Case Reports (2018) 12:144 https://doi.org/10.1186/s13256-018-1648-5 CASEREPORT Open Access Sudden cardiac arrest under spinal anesthesia in a mission hospital: a case report and review of the literature Bamidele Johnson Alegbeleye Abstract Background: Sudden cardiac arrest following spinal anesthesia is relatively uncommon and a matter of grave concern for any anesthesiologist as well as clinicians in general. There have been, however, several reports of such cases in the literature. Careful patient selection, appropriate dosing of the local anesthetic, volume loading, close monitoring, and prompt intervention at the first sign of cardiovascular instability should improve outcomes. The rarity of occurrence and clinical curiosity of this entity suggest reporting of this unusual and possibly avoidable clinical event. Case presentation: We report the occurrence of unanticipated delayed cardiac arrest following spinal anesthesia in a 25-year-old Cameroonian man. Incidentally, the index patient was successfully resuscitated with timely and appropriate cardiopulmonary resuscitative measures. He went ahead to have emergency open appendectomy with good post-operative outcome and recovery. Conclusions: The management of such cardiac arrest under spinal anesthesia is very challenging in resource- limited settings such as ours. Anesthetists and clinicians need to be well informed of this grave complication. A good understanding of the physiologic changes caused by spinal anesthesia and its complications, adequate patient selection, respecting the contraindications of the procedure, adequate monitoring, and constant vigilance are of paramount importance to the eventual outcome. Keywords: Anesthesia-spinal, Cardiac arrest, Intraoperative complications, Resuscitation Background and prompt intervention in the management of sud- Ever since August Bier administered the first clinical den cardiac arrest under spinal anesthesia in a low- spinal anesthesia more than a century ago, it has become resource setting. an integral part of the modern day anesthesia practice. Although considered simple to perform and a relatively Case presentation safe technique, life-threatening complications do occur The patient was a 25-year-old Cameroonian man weigh- under spinal anesthesia [1, 2]. In the literature, the re- ing 65 kg who was recently operated on for acute appen- ported incidence of cardiac arrest is 1.3–18 in 10,000 dicitis in Banso Baptist Hospital, Northwest Cameroon. patients [3–5]. All the preoperative investigations, including routine We are reporting the occurrence of unanticipated de- blood biochemistry, chest X-ray posterior and anterior layed cardiac arrest following spinal anesthesia in a view, and 12-lead electrocardiograms were normal. The young and healthy patient. This communication is to abdominal ultrasound scan was essentially normal. In bring to the fore the importance of vigilant monitoring the operating theater (OT), routine monitoring included heart rate 78 beats/min, electrocardiogram, noninvasive blood pressure (BP) 120/78 mmHg, and pulse oximetry with SpO2 at 99% in room air, and these baseline param- Correspondence: [email protected] Department of Surgery, Banso Baptist Hospital, P.O Box 9, Nso-Kumbo, eters were recorded and were essentially normal. An Northwestern Region, Cameroon intravenous (IV) access was secured with a cannula and © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Alegbeleye Journal of Medical Case Reports (2018) 12:144 Page 2 of 5 our patient was preloaded with 500 mL of normal saline Discussion solution. Under all aseptic precautions, a subarachnoid Spinal anesthesia is considered to be a safe procedure block was performed at L3/L4 space in the left lateral but complications rarely can occur in the clinical scene position with a 25-gauge Quincke needle and 3.2 mL of [1, 2]. Ever since Caplan et al. [6] reported 14 cases of hyperbaric bupivacaine was injected into the subarach- cardiac arrest during spinal anesthesia in an American noid space after confirming a clear and free flow of Society of Anesthesiologists closed claim analysis, numer- cerebrospinal fluid (CSF). Five minutes after turning ous case reports and reviews have been published [7, 8]. the patient to the supine position, the sensory level of The mechanism that triggers severe bradycardia [7–10] block was found to be at T10. During skin preparation and the etiology of cardiac arrest under spinal anesthesia of the abdomen, and almost 25 min after the subarach- remain controversial and unclear. Oversedation, respira- noid injection, our patient started complaining of tory arrest, unintentional total spinal, myocardial infarc- difficulty in breathing and this was followed with a con- tion, and local anesthetic toxicity have all been suggested vulsion. Sensory level was rechecked and was found to as the causative factors. However, contribution of intrinsic be at T10. A bolus of atropine 0.6 mg was administered cardiac mechanisms and autonomic imbalance with the as his heart rate suddenly dropped to 40 beats/min, background of parasympathetic predominance may pro- SpO2 to 65%, while his BP became unrecordable and vide a more convincing and physiologic explanation for peripheral pulses could not be palpated. Owing to the occurrence of abrupt severe bradycardia and cardiac diminishing consciousness, our patient was immedi- arrest under spinal anesthesia [6–9]. It is established that ately intubated with a cuffed endotracheal tube (ETT) the final pathway is the absolute or relative increase in ac- of 7.5 mm and positive pressure ventilation initiated tivity of the parasympathetic nervous system [11]. Cardiac with Bain circuit and 100% oxygen was administered. arrest has been reported within 12–72 min of spinal His heart arrested and cardiopulmonary resuscitation anesthesia, while other cardiovascular side effects have (CPR) was started immediately with pharmacologic been reported as late as 3–5 h after the administration of intervention with adrenaline and dopamine and intra- spinal anesthesia [12]. venous normal saline infusion. (Other vasopressors like Our patient was hemodynamically stable and well oxy- mephenteramine, noradrenaline etc. were not available.) genated prior to the administration of spinal anesthesia. Within 4 min, our patient responded with a heart rate No ischemic changes were noticed in the electrocardio- of 140 bpm, SpO2 of 90%, and BP of 90/60 mmHg. Our gram. Causative factors like myocardial infraction, re- patient was restless even after administration of injec- spiratory depression, local anesthetic toxicity, subdural tion of diazepam 10 mg, and phenytoin 1.5 g in IV infu- injection, and high level of spinal anesthesia were con- sion. Considering his slow response to resuscitative sidered and excluded by the sequence of events and la- measures, our patient was administered 150 mg propo- boratory investigations. Our patient had acute appendicitis fol and was paralyzed with 6 mg vecuronium and with right iliac fossa pain, leading to sympathetic stimula- electively ventilated in the OR. Apart from sinus tachy- tion to maintain BP and cardiac output with normocardia cardia, all investigations results including serum elec- or relative tachycardia. Once the spinal analgesia was trolytes, complete blood counts and chest X-ray were established, our patient became pain free and the sympa- normal. Arterial blood gas analysis (ABG) was not thetic drive was aborted. Subsequently, the resulting available in our facility. Our patient was adjudged by bradycardia and hypotension occurred. The other con- both the anesthetist and attending surgeon as being fit tributory factor is that this patient with abdominal pain, enough to proceed for the emergency open appendicec- nausea, and a few bouts of vomiting might have been tomy via a Lanz incision with uneventful postoperative avoiding fluids or food for some unspecified period. Hence course. After 2 h of elective ventilation and achieve- our patient was probably in negative fluid balance. The ment of hemodynamic stability, our patient became 500 mL of fluid loading at spinal anesthesia might be conscious and started responding to verbal commands inadequate to counter the vasodilator effect of the spinal with good respiratory efforts, and extubation was done anesthesia. These two factors, including aborted sympa- after reversing the relaxant effect with standard doses thetic overdrive and negative fluid balance, must have of neostigmine and glycopyrrolate. His postextubation been the cause for sudden cardiac arrest. hemodynamic parameters were normal, and he was Thus, contributing to autonomic imbalance was a pos- transferred to the high dependency unit (HDU) for fur- sible primary trigger resulting in bradycardia and asys- ther observation. Our patient was discharged on the tole in our patient [13–15]. 4th postoperative day with an uneventful course in Reports from the literature also implicate autonomic
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