RevBrasAnestesiol.2017;67(5):544---547
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Cardiac
arrest
after
epidural
anesthesia
for
a
esthetic
plastic
surgery:
a
case
report
Larissa
Cardoso
Pinheiro
a,∗,
Bruno
Mendes
Carmona
a,
Mário
de
Nazareth
Chaves
Fascio
a,
Iris
Santos
de
Souza
a,
Rui
Antonio
Aquino
de
Azevedo
a,
Fabiano
Timbó
Barbosa
baCentrodeEnsinoeTreinamentodoServic¸odeAnestesiadoOphirLoyola,Belém,PA,Brazil
bUniversidadeFederaldeAlagoas(UFAL),Maceió,AL,Brazil
Received3January2015;accepted23March2015 Availableonline15September2016
KEYWORDS
Cardiacarrest; Epiduralanesthesia; Resuscitationafter spinalanesthesia
Abstract Cardiacarrestduringneuraxialanesthesiaisaseriousadverseevent,whichmaylead tosignificantneurologicaldamageanddeathifnottreatedpromptly.Theassociated mecha-nismsareneglectedrespiratoryfailure,extensivesympatheticblock,localanaesthetictoxicity, totalspinalblock,inadditiontothegrowingawarenessofthevagalpredominanceasa predis-posingfactor.Inthecasereported,thepatientwas25yearsold,ASAI,scheduledforaesthetic
lipoplasty.Aftersedationwithmidazolamandfentany,epiduralanesthesiaininterspacesT12-L1 andT2-T3andcatheterinsertionintoinferiorpuncturewereperformed.Thepatientremained in the supineposition for 10min. Then, she was placed in the proneposition, developing asystoliccardiacarrest20minafterthecompletionofneuraxialblockade.Themedicalteam immediatelyplacedthepatientinthesupinepositionandbegancardiopulmonaryresuscitation. Spontaneouscirculationwasachievedaftertwentyminutesofresuscitation.Wediscussinthis reporttheexacerbatedvagalresponseasthemaineventmechanism.Thepatient’ssuccessful outcomeemphasizestheimportanceofanaestheticmonitoringby anesthesiologists,prompt recognitionandtreatmentofrhythmchangesontheelectrocardiogram.
©2015SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Paradacardíaca; Anestesiaperidural; Reanimac¸ãoapós peridural
Paradacardíacaapósperiduralparacirurgiaplásticaestética:relatodecaso
Resumo A parada cardíacadurante anestesianeuroaxial éum eventoadverso grave,que podeocasionar sequelasneurológicasimportantes emorte senão tratada emtempo hábil. Os mecanismos associados são insuficiência respiratória negligenciada, bloqueio simpático extenso,toxicidadeporanestésicoslocais,raquianestesiatotal,alémdacrescenteconsciência dapredominânciavagalcomofatorpredisponente.Nocasoreportado,apacientetinha25anos
∗Correspondingauthor.
E-mail:laricardoso@hotmail.com(L.C.Pinheiro).
http://dx.doi.org/10.1016/j.bjane.2015.03.008
0104-0014/©2015SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC
Cardiacarrestafterepiduralanesthesiaforaestheticplasticsurgery 545
eestadofísicoASAIefoiprogramadaparalipoplastiaestética.Apóssedac¸ãocommidazolam
efentanil,foifeitaanestesiaperiduralnosinterespac¸osT12-L1eT2-T3einserc¸ãodecateter napunc¸ãoinferior.Apacientefoimantidaemdecúbitodorsalhorizontaldurante10minutos. Em seguida,foiposicionadaem decúbitoventral,evoluiucomparadacardíacaem assistolia 20minutosapósobloqueiodoneuroeixo.Aequipemédicaimediatamentecolocouapaciente em decúbitodorsal einiciouasmanobrasderessuscitac¸ãocardiorrespiratória. Oretorno da circulac¸ãoespontâneafoiobtidoapós20minutosdereanimac¸ão.Édiscutida nesterelatoa respostavagalexacerbadacomoprincipalmecanismocausaldoevento.Osucessododesfecho dapacienteemquestãoressaltaaimportânciadavigilânciadoanestesiologista,edopronto reconhecimentoetratamentodemudanc¸asderitmonoeletrocardiograma.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Thoracic epidural anesthesia for cosmetic breast surgery, or combined breast and abdomen, provides satisfactory results both peri-andpostoperatively. The use ofa small numberof drugs, earlyawakening, amnesia, andthe pos-sibilityofhospitaldischargewithin24hoursmakethoracic epiduralanesthesiaanexcellenttechniqueforthistypeof surgery,withahigherpercentage ofsurvivalcomparedto generalanesthesia.1 Thistechniqueshowedareductionin
postoperativestressandonsystemicsympatheticresponse, withconsequentreductionofadversecardiacevents.2,3The
incidence of cardiopulmonary arrest (CPA) during neurax-ialblockade is associatedwithgoodoutcomes.4,5Although
severalfactorsmayleadtoCPAduringepiduralanesthesia, increasingevidencesuggests thevagal predominance asa commonmechanism.6Inthisreportwediscussacaseof
car-diacarrestassociatedwithexacerbatedvagotonicresponse.
Case
report
Femalepatient,25yearsold,ASAI,scheduledforaesthetic lipoplasty. Preanaesthetic evaluation was performed in office,whenshereceivedtheproperorientationandgave written informed consent. In the operating room, the patientwasmonitoredwithcardioscope,noninvasiveblood pressure, and pulse oximetry. After establishing venous accessintheleftarmwitha20Gcatheter,midazolam4mg andfentanyl50mcgwereusedforsedation.
Doubleepiduralpuncture wasperformed in theT12-L1 and T2-T3 interspaces with a 18G Tuohy needle with an insertionofa18Gepiduralcatheterintheinferiorpuncture, uneventfully.IntheT12-L1interspace,alocalanaesthetic bupivacaine S75:R25 (simocaína) 0.5% with vasoconstric-tor(14mL),morphine2mg,fentanyl50mcg,anddistilled water(3mL)wereadministered.IntheT2-T3interspace,a localanaestheticbupivacaineS75:R25(simocaína)0.5%with vasoconstrictor(8mL),fentanyl50mcg,anddistilledwater (2mL)wereadministered.Therewerenocomplications dur-ingtheproceduresorinsertionofcatheters.
Subsequently,thepatientremainedinthesupineposition for10min,atwhichtimeaslightdecreaseinoxygen periph-eralsaturation from98%to92% wasobserved,which was
reversedwithtwodeepbreathsinstructedbytheattending physician.Thenthepatientwasplacedintheproneposition, andsheevenhelpedherselftomove.
Aboutfiveminutesintheproneposition,thepatienthad anewepisodeofdesaturation(92%),reversedattherequest ofthe anesthesiologist. However,afterfive moreminutes thepatientdevelopedcardiacarrestinasystolianoticedby theattended anesthesiologist, who immediately arranged for the patient’s repositioning in the supine position and began the cardiopulmonary resuscitation maneuvers rec-ommendedby the Advanced Cardiac Life Support(ACLS), withhigh-qualitychestcompressions,vasopressor adminis-tration,andairwaycontrolinatimelymanner.
Afterabout20minofcardiopulmonaryresuscitation,the patient regained spontaneous circulation, and vasoactive drugswererequired toensurehemodynamicstability.Ina jointdecision, the surgical teamand the anesthesiologist optedforthecancelationofthesurgicalprocedure,andthe patientwastakentotheICUwiththefollowingparameters: HR120bpm, sinus rhythm, BP 120×70mmHg, SpO2 98%,
EtCO230mmHg,receivingvasoactivedrugs(noradrenaline),
sedated(midazolam),andwithmioticpupils.
IntheICU,thepatientdevelopedoliguriaandpulmonary edema,treatedwithimprovementofmechanicalventilation parameters(highPEEPandalveolarrecruitmentmaneuvers) anddiuretic.Approximately24hoursafteradmissiontothe ICU,thepatientwasextubatedsuccessfullyandmaintained thehemodynamicparametersuptoadischargefromtheICU tothewardthenextday.
Discussion
Thefrequency,predisposingfactors,andoutcomes associ-atedwithcardiacarrestduringneuraxialanesthesiaremain undefined.5 Auroy et al. found that cardiac arrest during
neuraxial anesthesia is associated with good neurological outcomes.4
The Neuraxial blockade canreduce perioperative mor-talitycomparedtogeneralanesthesia,especiallyinpatients undergoingsurgeryofmoderatetohighcardiacrisk.7
Partic-ularly,theuseofthoracicepiduralanesthesiacouldreduce theincidenceofperioperativemyocardialinfarction.8
546 L.C.Pinheiroetal.
for thedual-epiduralcatheterization puncturedue tothe needforextensivesurgicalfieldcoverage,reachingawide rangeofdermatomes,inadditiontothemoreuniform dis-tributionoftheanaestheticmassthroughthetwopunctures andthepossibilityofanaestheticsupplementation.10
Cardiopulmonaryarrest(CPA)inepiduralanesthesiamay berelatedtothefollowingfactors:accidentalsubarachnoid administration, extensive sympathetic block, myocardial ischemia, respiratory depression secondary to sedation, anaphylacticshock,localanaestheticpoisoning.Conditions not justified by these reasons can be explained by vagal predominance.11
LocalanaestheticpoisoningisalikelymechanismofCPA afterepiduralanesthesia.However,negativeaspirationof bloodinthesyringeweremadeduringtheprocedure,aswell asanaesthetictestdoseadministrationwithvasoconstrictor, and therewas nochange in heart rate, QRS morphology, rhythm,orcomplexes.
Moreover, resuscitation after circulatory collapse induced by local anaesthetic is described as difficult, prolonged, and refractory to the approaches set out in the ACLS.12 Increasing evidences support the efficacy of
lipidemulsionforuseinthiscontext;itsuseisreleasedby the AmericanSociety of RegionalAnesthesia afterairway managementandseizurecontrol.13Literaturereportscases
inwhichtherapidinstitutionofextracorporealmembrane oxygenation was related to the return of spontaneous circulationinpatientswithbupivacainecardiotoxicity.14
Intrathecalblockisanever-presentriskwhenlargedoses of local anaesthetic is accidentally administeredinto the spinal catheter when it is assumed to be in the epidural space.Thispossibilitywasnotconsideredasapossiblecause ofthe cardiac arrestbecausethe anaesthetic administra-tion wasuneventful, as it would be expected immediate apnea, loss of consciousness, paralysis, and mydriasis if there were accidental subarachnoid blockade after dural puncture.15 Although the literature reports this classical
presentation,itispresentinlessthanhalfoftheconfirmed casesofinadvertentsubduralinjection,throughstudieswith epidurography.16
Vasovagal exacerbatedresponse is characterizedby an inappropriate combination of bradycardia and paradoxi-calvasodilation.17 Studies reinforce that bradycardia and
hypotension are the most frequent complications after neuraxialblockade,justifiedbytheblockadeof cardioaccel-eratorfibers(T1-T4),sympatheticstimulationblockadewith reductionofinotropicandheartchronotropism,inaddition tothe parasympathetic cardiac protective reflex (Bezold-Jarischreflex)triggeredbyadecreaseinvenousreturnand peripheralvasculartone.18---20
Althoughbradycardiaandhypotensionarefrequentand welltoleratedeventsafterepiduralanesthesia,immediate treatmentisrequired,considering bradycardiadescription as an indicator of imminent cardiovascular collapse.20,21
Brownetal.reportedsuddenseverebradycardiaand asys-tole,evenasuddenlossofconsciousnessduringpatientchat withtheanesthesiologist.22,23
Malegender,beta-blockers,ASAphysicalstatusI,sensory levelaboveT6,andunder-50sagegrouparefactorsrelated toinappropriatevagotonicresponse.6Besidesthese,severe
pain,anxiety,fearandemotionalstressmayactastriggers forvagotonicresponse.24,25
In this case, the patient had three of the aforemen-tioned characteristics, which along with CPA, emphasizes thepossibilityofvagalpredominanceasthemaincausative mechanism. Furthermore, other factors suchas sedation, hypoxemia,useofopioids,andpositioningchangemayhave contributed.16,17
JangandCaplan,indifferentstudies,foundsimilarcases of sudden onset of severe bradycardia and heart failure in patients who were hemodynamically stable and well oxygenated.11,26
AfterthefindingofCPA,cardiopulmonaryresuscitation maneuverswereinitiatedandadrenalinewastheonlydrug used. CPA during epidural anesthesia is considered diffi-cultbecauseitdecreasescoronaryperfusionpressure.27The
optimumresuscitationvasopressorshouldincreasecoronary perfusionpressureanddiastolicpressureintheaorticroot, improvecoronary andbrainblood flow without increasing cellularoxygendemand.28
Adrenalinehas been the leadingdrug therapy in cases of cardiac arrest, although associated with increased myocardiumoxygendemand,arrhythmogenicpotential,and hypertensionafterresuscitation.29Whilevasopressinoffers
atheoreticaladvantageoveradrenalinefornotincreasing theoxygenconsumption.However,unlikeadrenaline,ithas nostimulatingeffectontheheart.28
StudiesperformedinEuropefoundbetteroutcomewith vasopressinincardiacarrestpatientswithasystole.30
How-ever,regardingthemechanismsofcardiacarrestrelatedto epiduralanesthesia,studiesarescarceandtheeffectiveness ofadrenalineandvasopressininthiscontextisunknown.27
ImmediaterecognitionofCPAwasessentialforthe spon-taneous circulation returnandgoodneurological outcome of this patient,it stressedthe need for anesthesiologist’s constantvigilance,therecognitionofthepacechangingin electrocardiogram,andimmediatetreatmentaspillarsfor thesuccessofanesthesia.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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