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Case Report: A 76-year-old female patient underwent revision T12-L4 decompression and fusion surgery. During the procedure, a large dural defect occurred associated with an abrupt drop in end-tidal CO2, severe hypotension, bradycardia, and cardiac arrest. Prone chest compressions were initiated, and the patient survived without postoperative comorbidities. The sudden hemodynamic instability was attributed to a venous air embolism (VAE) confirmed by findings on intraoperative capnography., Conclusion: Managing cardiac arrest caused by VAE in lumbar spine surgery is challenging. This case showcases that prone chest compressions may lead to better survival chances compared with waiting to initiate supine chest compressions., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C497)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Although surgical competency and anesthesia for liver transplantation (LT) have evolved significantly in the past decades, intraoperative cardiac arrest (ICA) is still an event that brings a poor prognosis to the recipient. We report a second-decade experience of ICA as a follow-up study of our first report at our institution., Methods: This is a retrospective observational study of the medical records and the Liver Transplant Program database of our institution. LT from January 2011 to June 2023 were included. Of the 1735 LT cases, a total of 1730 cases were included, excluding three non-Asian and two simultaneous heart and liver transplants (1598 adult LT, 132 pediatric LT)., Results: The ICA incidence during adult LT was 0.7% (11/1598) which is significantly lower compared to our first report (1.5%; 14/919) (p = 0.042). ICA occurred only in adult recipients. Post-reperfusion syndrome (PRS, six cases) and bleeding (four cases) were the primary causes in most cases and most ICA occurred after reperfusion (10/11). The mortality rates within 24 h, 30 days, and 1 year were 27.3%, 45.5%, and 54.5%, respectively. The survival curve did not show a significant difference from our first report (p = 0.570), and the survival rate of the ICA group was significantly lower compared to the non-ICA group. (p = 0.000) CONCLUSION: The incidence of ICA has decreased, but the main causes of ICA as PRS and bleeding after reperfusion have not changed. Additionally, there was no significant difference in the survival curves from the first report. Because ICA is still fatal, efforts to reduce its incidence should be continued., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Intraoperative cardiac arrest (ICA) during liver transplantation (LT) is a rare surgical complication that results in devastating outcomes. Moreover, previous worldwide studies have found inconsistencies in the risk factors associated with ICA in LT., Methods: This was a retrospective cohort study of adult patients who underwent LT between January and October 2021 at Siriraj Hospital, a tertiary care hospital. The incidence of ICA and outcomes of patients who experienced ICA were examined. Risk factors associated with ICA were investigated as a secondary objective., Results: Among 342 patients, the incidence of ICA was 3.5% (95% CI 1.8%-6.1%). Of these, 33.3% died intraoperatively. Among patients with ICA, 41.7% died within 30 days, compared with only 7.6% in those without ICA (P = .002). Moreover, the in-hospital mortality rate of those with ICA was 58.3%, which was significantly higher than that of those without ICA (9.7%, P < .001). However, 41.7% of patients with ICA were discharged alive with long-term survival. Because ICA is a rare event, we found only 2 independent factors significantly associated with ICA. These factors include intraoperative temperature below 35°C, with an odds ratio (OR) of 6.07 (95% CI:1.32-27.88, P = .02) and elevated intraoperative serum potassium, with an OR of 4.57 (95% CI:2.15-9.67, P < .001)., Conclusions: ICA is associated with high perioperative and in-hospital mortality. However, our findings suggest that with effective management of ICA, more than 40% of these patients could be discharged with excellent long-term outcomes. Hypothermia and hyperkalemia were independent risk factors significantly associated with ICA., Competing Interests: Declaration of competing interest All the authors declare no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks., Methods: Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes., Results: ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA., Conclusions: We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.

Takotsubo cardiomyopathy (TTC) is a rare but life-threatening condition that is still not completely understood. Characterised by rapidly reversible ventricular dysfunction without any prior coronary artery disease, it can imitate a myocardial infarction and lead to death if not managed appropriately. This report examines a case of intraoperative cardiac arrest in a patient with no previous cardiac disease, and discusses the factors that may have precipitated this event, as well as the ways of distinguishing the cause of the arrest based on clinical course and investigations, eventually leading to a diagnosis of TTC., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The trigeminovagal reflex is a phenomenon that occurs rarely during maxillofacial surgery. Previously described as the oculocardiac reflex, this reflex can occur during ocular and periocular surgery. To be more anatomically precise, it was renamed the trigeminocardiac or trigeminovagal reflex, since stimulation of any part of the trigeminal nerve can elicit this reflex arc. We describe a case of asystole during mobilization of a maxilla following a Le Fort 1 osteotomy.

This paper describes a case of cardiac arrest during femtosecond laser enabled penetrating keratoplasty (FLEK) in a young, healthy patient with no known cardiac risk factors and discusses the risk of cardiac arrest during intraocular surgery. A healthy 22-year-old man who underwent repeat FLEK under general anaesthesia developed bradycardia and subsequent cardiac arrest while open sky during surgery. After resuscitation and completion of the transplant surgery, the patient recovered and the graft has survived with excellent uncorrected visual acuity over 1 year after surgery. Understanding the risks of cardiac arrest and death during intraocular surgery is imperative to discussing the systemic risks of surgery during the preoperative informed consent., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We present a case of sudden asystole that was elicited via the trigeminocardiac reflex in a patient undergoing surgery for a frontal sinus fracture. Asystole occurred after mild stimulation of the supraorbital nerve during dissection along the superior orbital rim. Anticholinergics were administered and lidocaine-soaked gauze was applied to the exposed wound. The patient was an athlete and had pre-existing sinus bradycardia. We hypothesise that the severe reflex response was associated with his underlying increased vagal tone. When performing surgery in patients with increased vagal tone, preventative measures to diminish the trigeminocardiac reflex are recommended. Further studies are needed., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Acute water intoxication after hysteroscopy is a rare, life-threatening condition, often accompanied with delayed diagnosis owing to masked symptoms because of general anesthesia., Case Presentation: Herein we presented a 39-year-old female who presented with cardiac arrest after hysteroscopic myomectomy because of acute water intoxication and survived after extracorporeal membrane oxygenation, continuous venous-venous hemofiltration, and aggressive high sodium fluid resuscitation., Conclusion: Failure to recognize and treat this condition appropriately may lead to potentially lethal cardiopulmonary complications.

Recruitment manoeuvres (RM) are common practice in anaesthesiology; however, they can have adverse effects. We present an unforeseen complication in a patient undergoing surgical resection of a bronchial tumour who presented cardiac arrest due to pulseless electrical activity immediately after RMs. A transoesophageal echocardiogram performed after return of spontaneous circulation showed a patent foramen ovale (PFO), left ventricular dysfunction with segmental changes, and air in the left ventricle, leading to suspicion of paradoxical air embolism. The contractility changes normalised spontaneously, and postoperative evolution was uneventful. RMs cause changes in intracavitary pressures that can lead to opening of a PFO (present in up to 30% of the population) and reversal of the physiological left-right shunt. Transoesophageal echocardiography facilitated immediate diagnosis and follow-up., (Copyright © 2019 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Venous air embolism (VAE) is a rare but, frequently, fatal complication that can occur during surgery. Several reported studies have shown visible bubbling of air at the surgical site as the first clinical indication of VAE-induced cardiovascular collapse during prone-position spine surgery. However, to the best of our knowledge, video imaging of this phenomenon has not been previously reported., Case Description: A 41-year-old man had undergone cervical laminoplasty for ossification of the posterior longitudinal ligament and thoracic laminectomy for ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum in the prone position. The entire surgery was recorded with video imaging. Before cardiac arrest due to the massive VAE, visible air bubbling had been observed at the operated site of the thoracic laminectomy, and this phenomenon had been incidentally recorded with the video. The patient recovered with cardiopulmonary resuscitation and intensive treatment against severe acute respiratory distress syndrome due to pulmonary damage., Conclusions: The present case report offers the first video imaging evidence of intraoperative visible air bubbling as a sign of a massive VAE during prone-position spine surgery. To the best of our knowledge, this is also the first report of intraoperative VAE in a patient with extensive ossification of the spinal ligaments., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The National Surgical Quality Improvement Program Myocardial Infarction & Cardiac Arrest (NSQIP MICA) calculator and the Revised Cardiac Risk Index (RCRI) were derived using currently outdated methods of diagnosing perioperative myocardial infarctions. We tested the external validity of these tools in a setting of a systematic perioperative cardiac biomarker measurement., Methods: Analysis of routinely collected data nested in the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study. A consecutive sample of patients ≥45 yr old undergoing in-hospital noncardiac surgery in a single tertiary care centre was enrolled. The predictive performance of the models was tested in terms of the occurrence of major cardiac complications defined as a composite of a nonfatal myocardial infarction, a nonfatal cardiac arrest, or a cardiac death within 30 days after surgery. The plasma concentration of high-sensitivity troponin T was measured before surgery, 6-12 h after operation, and on the first, second, and third days after surgery. Myocardial infarction was diagnosed according to the Third Universal Definition., Results: The median age was 65 (59-72) yr, and 704/870 (80.9%) subjects were male. The primary outcome occurred in 76/870 (8.7%; 95% confidence interval [CI], 6.9-10.8%) patients. The c-statistic was 0.64 (95% CI, 0.57-0.70) for the NSQIP MICA and 0.60 (95% CI, 0.54-0.65) for the RCRI. Predicted risks were systematically underestimated in calibration belts (P<0.001). The RCRI and the NSQIP MICA showed no clinical utility before recalibration., Conclusions: The NSQIP and RCRI models had limited predictive performance in this at-risk population. The recently updated version of the RCRI was more reliable than the original index., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Hip arthroplasty (hip replacement) surgery is a very common procedure and is particularly common in elderly individuals, where it is typically performed following traumatic hip fracture. As with any surgical procedure, hip arthroplasties are associated with a certain degree of morbidity and mortality, with many deaths occurring in the post-operative period. As most of these cases result from trauma (fractured hips), they are typically referred for medicolegal death investigation. Occasionally, sudden cardiorespiratory collapse and death occurs during hip arthroplasty surgery. In certain medicolegal jurisdictions, all intra-operative deaths must be investigated. Although many post-operative arthroplasty-related deaths might not require autopsy, those that occur intra-operatively may require autopsy. While clinical decision-making during recent years has resulted in fewer arthroplasty-related deaths, intraoperative deaths may still occur. In this review, the authors present their experience with three intra-operative arthroplasty-related deaths, followed by a discussion related to possible mechanisms involved in the deaths., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Objectives: Despite a long history of concerns regarding patient safety during clinical care, some patients undergoing thoracic surgery continue to experience adverse events (AEs). AEs are a major significant source of perioperative morbidity and mortality following thoracic surgery. This study analysed the causes, treatment and prognosis of perioperative AEs to provide a reference for further surgical safety., Methods: The authors collected a total of 62,571 thoracic surgery anaesthesia records via the Anaesthesia Information Management System (AIMS) from 14 August 2006 to 14 August 2017 and obtained 150 cases of perioperative serious AEs from the "adverse events registration" subsystem. The related hospitalization data of the 150 patients were analysed, including anaesthesia, recovery room time, ICU records and follow-up outcomes. The causes of these AEs were classified as follows: events related to the patients' pathogenic conditions(P); surgery-related factors(S); anaesthesia-related factors(A); and interactions between pathogenic, surgical and anaesthesia factors (P&S&A). We then analysed the main clinical manifestations, causes and treatment of these events., Results: The overall rate of perioperative AEs in thoracic surgery (n = 62,571) was 0.2%. Of these, 10.7% were. caused by P and 23.3% by A; neither cause led to patient death. S and P&S&A accounted for 55.3 and 10.7% of AEs, respectively; together, they accounted for 66%. Twelve patients with postoperative AEs caused by S or P&S&A died within 3 days (8% of 150 cases). A total of 33%(50/150) of patients experienced sudden cardiac arrest (SCA) and recovered successfully. Surgical massive haemorrhage (22%, 33/150) was reported as a predominant mortality-related outcome in this group, and 8 of the 12 deaths were caused by massive haemorrhage., Conclusions: The rate of perioperative AEs after thoracic surgery was 0.2%. AEs must be identified and treated immediately. An important factor in anaesthesia-related events was respiratory management. Two major clinical manifestations of surgery-related events were cardiac arrest and massive haemorrhage. Cardiac arrest was the major factor contributing to AEs, but its adverse consequences could be avoided with timely discovery and proper treatment. Massive haemorrhage is a significant cause of mortality that can be prevented with a surgeon's early diagnosis and appropriate interventions.

Cardiac arrest during scoliosis surgery is rare in idiopathic scoliosis. We present a case of cardiorespiratory collapse during corrective surgery in a young patient with idiopathic scoliosis. A diagnosis of venous air embolism was made by exclusion. A cardiorespiratory resuscitation was performed in supine position. Patient recovered without any sequelae and had operation completed 6 weeks later.

Background: The trigeminocardiac reflex is a sudden onset of bradycardia, hypotension, apnea, or gastric hypermotility in response to stimulation of the trigeminal nerve., Case Description: A 60-year-old female underwent a left orbitozygomatic craniotomy to debulk a large skull base epidermoid cyst compressing the brainstem and cranial nerves. Intraoperatively, retraction of the temporalis muscle consistently produced asystole. Cessation of retraction resulted in prompt return of sinus rhythm., Conclusions: Our report describes an unusual and extreme example of the trigeminocardiac reflex and explores possible etiologies. This is the third reported surgical case in which manipulation of the temporalis muscle alone was sufficient to elicit bradycardia and asystole, and the first such case within the context of neurosurgery. We emphasize the importance of surgical teams to be cognizant of such extreme examples of this reflex., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Perioperative cardiac arrest (PCA) is a rare but important event in the operating room., Aim: To describe PCA events at a Clinical Hospital in Santiago, Chile., Material and Methods: Registry of PCA that occurred in the operating room (OR) and during procedures not carried out in the OR between September 2006 and November 2017. Precipitating events, type of anesthesia and results of resuscitation maneuvers were described., Results: Eighty events (five outside of the OR) during 170,431 surgical procedures were recorded, resulting in an incidence of 4.4 events per 10,000 interventions. Hypotension/hypoperfusion was the most frequently found preexisting condition (42.5%). The main cause was the presence of preoperative complications (57.5%). Nineteen cases (23.8%) were attributable to anesthesia, with an incidence of 1.11 per 10,000 anesthetic procedures. Survival rate at hospital discharge was 52.5%. The figure for PCA caused by anesthesia was 84.2%., Conclusions: The incidence of PCA and its survival is similar to that reported abroad. In general, PCA has a better prognosis than other types of cardiac arrest, especially if it has an anesthetic cause.

Refractory intra-operative cardiac arrest is a challenging issue for anaesthetists. In this study, we analysed the outcomes of adult patients who received extracorporeal cardiopulmonary resuscitation for refractory intra-operative cardiac arrest between 2005 and 2016, using data from our institutional extracorporeal membrane oxygenation registry. We defined refractory intra-operative cardiac arrest as the failure of a return of spontaneous circulation after 30 min of cardiopulmonary resuscitation. The primary outcome measure was neurologically intact survival with a cerebral performance category score of 1 or 2 at hospital discharge. Between 2005 and 2016, extracorporeal cardiopulmonary resuscitation was used to treat 23 patients who experienced refractory cardiac arrest in the operating room. The survival rates of neurologically-intact subjects were 9/23 (39%) and 6/23 (26%) at 24 h postoperatively and at hospital discharge, respectively. The main cause of refractory-intra-operative cardiac arrest was haemorrhagic shock in 13 out of 23 (57%) patients, and the neurologically-intact survival rate in these patients was 3/13 (23%) at discharge. Our study showed that approximately a quarter of patients with refractory intra-operative cardiac arrest caused by haemorrhage would receive survival benefit from extracorporeal cardiopulmonary resuscitation. Therefore, extracorporeal cardiopulmonary resuscitation may be a possible option in this clinically-challenging situation., (© 2018 Association of Anaesthetists.)

Rationale: Although venous air embolism (VAE) during liver operation has been reported occasionally, fatal VAE in hepatic resection is uncommon. Prompt detection of VAE by transesophageal echocardiography (TEE) is crucial for effective therapy. We describe a case of fatal VAE that caused repeated cardiac arrest during hepatic resection and was confirmed by TEE., Patient Concerns: A 51-year-old woman with a body weight of 50 kg underwent partial liver resection due to intrahepatic duct calculus. She had a 1-year history of intrahepatic duct calculus without cardiopulmonary disease. The operation was performed under general anesthesia combined with epidural block. When the inferior vena cava was compressed, the PetCO2 level decreased abruptly from 30 to 10 mmHg, followed by a decrease in SpO2 and the development of hypotension. Her heart rate increased with ST interval elevation on electrocardiography monitoring. Ephedrine and phenylephrine were administered immediately but had little effect. Cardiac arrest occurred., Diagnoses: Air embolism was detected by TEE., Interventions: Resuscitation was successful although cardiac arrest occurred repeatedly., Outcomes: The patient returned to consciousness 6 hours postoperatively but died of multiorgan dysfunction 10 days later., Lessons: Fatal air embolism may happen during hepatic resection. Prompt detection of VAE by TEE is crucial for effective therapy and should always be available during hepatic resection.

Patients with Williams syndrome are considered at high risk for anesthesia-related adverse events. At our institution, all William syndrome patients undergoing cardiac surgical, cardiac catheterization/interventional procedures, and cardiac imaging studies are cared for by cardiac anesthesiologists. All William syndrome patients undergoing non-cardiac surgical, interventional, or imaging studies are cared for by main operating room pediatric anesthesiologists with consultative input from a cardiac anesthesiologist. We reviewed our experience with 75 patients undergoing 202 separate anesthetics for 95 non-cardiac procedures and 107 cardiac procedures from 2012 to 2016. The mean age was 7.5 ± 7.0 years and the mean weight was 22.3 ± 17.0 kg. One hundred and eighty-seven patients had a general anesthetic (92.6%). Medications used included etomidate in 26.2%, propofol in 37.6%, isoflurane in 47.5%, and sevoflurane in 68.3%. Vasopressors and inotropes were required including calcium (22.8%), dopamine (10.4%), norepinephrine (17.3%), phenylephrine (35.1%), vasopressin (0.5%), and ephedrine (5.4%). The median length of stay after anesthesia was 2.8 days (range 0-32). No adverse events occurred in 89.6% of anesthetics. There were two cases of cardiac arrest, one of which required extracorporeal life support for resuscitation. Of the non-cardiac surgical procedures, 95.7% did not have a cardiovascular adverse event. Patients with Williams syndrome are at high risk for anesthesia, especially when undergoing cardiac procedures. The risk can be mitigated with appropriate planning and adherence to the hemodynamic goals for non-cardiac surgical procedures.

Objective: Intraoperative cardiac arrest (CA) is usually attributable to pre-existing disease or intraoperative complications. In rare cases, intraoperative stress can demask certain genetic diseases, such as catecholaminergic polymorphic ventricular tachycardia (CPVT). It is essential that neurosurgeons be aware of the etiologies, risk factors, and initial management of CA during surgery with the patient in the prone position., Methods: We present a case of CA directly after spinal fusion for lumbar spondylolisthesis and review the literature on cardiac arrests during spinal neurosurgery in the prone position. We focus on etiologies of CA in patients with structurally normal hearts., Results: After resuscitation, a 53-years-old female patient achieved return of spontaneous circulation after 17 minutes, without any neurologic deficits and with substantial improvement of functional disability and pain scores. Extensive imaging, stress testing, and genetic screening ruled out common etiologies of CA. In this patient with a structurally normal heart, CPVT was established as the most likely cause. We identified 18 additional cases of CA associated with spinal neurosurgery in the prone position. Most cases occurred during deformity or fusion procedures. Commonly reported etiologies of CA were air embolism, hypovolemia, and dural traction leading to vasovagal response. In patients with structurally normal hearts, inherited arrhythmia syndromes including CPVT, Brugada syndrome, and long QT syndrome should be included in the differential diagnosis and specifically included in testing., Conclusions: Although intraoperative CA is rare during spine surgery, neurosurgeons should be aware of the etiologies and the specific difficulties in the management associated with the prone position., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The authors discuss about a patient who, while undergoing a routine procedure to drain a subcutaneous abscess within his forehead, suffered cardiac arrest that we conclude was caused by an activation of the diving response. This reflex affects homeostatic function which alters respiration and preferentially distributes oxygen stores to the heart and brain. Under some conditions, however, this reflex can also trigger cardiovascular collapse and death. The diving reflex is can begin with triggering receptors that are sensitive to cold water, submersion, or pressure within the nasal cavity and other areas supplied by the trigeminal nerve. Studies have shown that this afferent response primarily involves branches of the infraorbital nerve and the anterior ethmoidal nerve. However, other more superior nerves such as those exclusive to the forehead region may also be involved. This study demonstrates for the first time the risks and dangers involved in surgical procedures or manipulation of the trigeminal innervated areas of the human face and in particular the forehead.

Background: The etiologies of intraoperative cardiac arrest within otolaryngology are not well understood as they are rare events., Methods: A comprehensive review of the etiologies and corresponding pathophysiologic neural mechanisms of intraoperative cardiac arrest in otolaryngologic surgery are examined., Results: The occurrence of this rare complication has been described in a range of head and neck procedures, including but not limited to suspension laryngoscopy and oncologic resections in the neck, maxilla and thyroid. Three anatomically distinct pathways leading to intraoperative cardiac arrest are described: direct vagal stimulation, the trigeminocardiac reflex and the baroreceptor reflex. All three share the final common pathway of parasympathetic signaling to the sinoatrial node via the cardiac fibers of the vagus nerve., Conclusion: With a firm understanding of the mechanistic underpinning of this rare phenomenon, otolaryngologic surgeons can be better prepared for its occurrence., (© 2018 Wiley Periodicals, Inc.)

Williams-Beuren syndrome is the clinical manifestation of a congenital genetic disorder in the elastin gene, among others. There is a history of cardiac arrest refractory to resuscitation manoeuvres in anaesthesia. The incidence of myocardial ischaemia is high during anaesthetic induction, but there are patients who do not have this condition yet also have had very serious cardiac events, and issues that are still to be resolved. Case descriptions will enable the common pathophysiological factors to be defined, and decrease morbidity and mortality. We report the case of a 3-year-old boy with cardiac arrest at induction, rescued with circulatory assistance with extracorporeal membrane oxygenation and hypothermia induced for cerebral protection., (Copyright © 2017 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Cardiac arrest in the operating room (OR) environment is a rare but potentially catastrophic event with mortality rates of more than 50%. Contributing factors are known, and the event is generally rapidly recognized, as patients are usually under full monitoring. The nature of the cardiac arrest in the OR is different to other environments as it is not only related to the patient's conditions but likewise to the anaesthetic and the surgical procedure. The aim of this article is to review recent literature on cardiac arrest in the immediate perioperative environment with a focus on incidence, causes and treatment., Evidence Acquisition: Retrospective analysis of literature published in PubMed., Evidence Synthesis: Several recent retrospective registry studies have investigated the incidence of perioperative cardiac arrest; in non-cardiac surgery patients, the incidence is reported to range from 0.2 to 1.1 per 10,000 adults and from 1.4 to 4.6 per 10,000 children., Conclusions: Successful management of cardiac arrest during surgery and beyond requires not only individual technical skills and a well-organized team response, but also an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary cooperation. Evidence based guidelines and standardized treatment algorithms addressing the particularities of peri-operative cardiac arrest would be helpful to facilitate training. Existing guidelines are not comprehensive enough to cover specific aspects in depth; for the future, more detailed and more explicit guidelines are required.

Objective: Cardiac arrest following neurosurgery is a devastating complication associated with significant postoperative morbidity and mortality. There are no published studies that have used a large and robust multicenter database to specifically examine demographic and surgical risk factors associated with cardiac arrests following craniotomy and spine surgeries, respectively., Patients and Methods: We retrospectively analyzed data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the period between January 1, 2007 and December 31, 2013, focusing on cardiac arrest associated with craniotomy and spine surgery from the intraoperative period to 30days after surgery. A total of 73,584 neurosurgical patients were analyzed (59,609 spine surgeries and 13,975 craniotomies)., Results: There was an increased risk of cardiac arrest for both craniotomy and spine surgeries in patients with American Society of Anesthesiologists (ASA) Physical Status class 4 or 5, Black and Asian patients compared to White patients and patients totally dependent versus independent based on the ACS-NSQIP risk calculator. The risk of cardiac arrest for craniotomy was 66.5 per 10,000 anesthetics and for spine surgery was 21.3 per 10,000 anesthetics. Cardiac arrest associated with emergent non-traumatic craniotomy was 36.5% and with emergent non-traumatic spine surgery was only 17.3%. We found that 18% of cardiac arrests for craniotomy and 25% of cardiac arrests for spine surgery occurred from the intraoperative period through postoperative day (POD) 0. Both craniotomy and spine surgery patients who had a cardiac arrest were more likely to have acute kidney injury (AKI), failure to wean from the ventilator, postoperative dialysis, myocardial infarction (MI), venous thromboembolism (VTE) and sepsis in the postoperative period. The overall mortality rate for both craniotomy and spine surgeries who had a cardiac arrest from the intraoperative period to 30days postoperative was 61.8% versus 1.2% in the no cardiac arrest control group., Conclusions: Identification of patient and surgery specific characteristics from ACS-NSQIP data associated with cardiac arrest following craniotomy and spine surgery may lead to initiatives to reduce morbidity and mortality in the neurosurgical patient population., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Pacemaker magnet application during surgery for patients who are pacemaker-dependent is often utilized to avoid perioperative inhibition from electromagnetic interference. We present a case during which such routine magnet use resulted in an unexpected response and discuss the limitations and nuances of this common practice., (© 2017 Wiley Periodicals, Inc.)

Background: Cardiac arrest is a lethal complication of Nuss repair of pectus excavatum which is strongly related to heart or big vessels injury. A rare case developed cardiac arrest without direct cardiac injury during Nuss procedure is presented in this article., Case Presentation: In July 2015, a previously healthy 18-year-old man undergoing Nuss repair for pectus excavatum developed cardiac arrest while the Nuss bar was being inserted into the chest. After successful resuscitation and exclusion of direct cardiac injury, the Nuss procedure was continued. The patient suffered a second cardiac arrest during rotation of the Nuss bar. This time, the patient had poor initial response to resuscitation and defibrillation until the retrosternal bar was removed. He ultimately recovered well from the episodes of cardiac arrest, but was unable to receive surgical correction of his pectus excavatum deformity., Conclusions: The possible mechanisms of cardiac arrest and lessons we can learn from this complication are discussed.

Intraoperative cardiac arrest (IOCA) is a lethal complication of noncardiac surgery. According to several reports, immediate survival after IOCA is approximately 50%. In this study, a retrospective case analysis was performed to determine the incidence of IOCA, the potential causes of cardiac arrest, and the risk factors of no resuscitation in patients undergoing tumorous surgery.The medical records of surgery patients who experienced cardiac arrest during the intraoperative period between 2005 and 2014 were reviewed. The general conditions of the patients with IOCA were compared between the successfully resuscitated group and the unresuscitated group.Fifteen patients with IOCA among 142,853 patients undergoing tumorous surgery were reviewed during the study period. Immediate survival after IOCA was 60%. Hospital survival was 46.7%. The incidence of IOCA decreased during 2010 to 2014 when compared with the rate during 2005 to 2009 (P < .05). The risk factors affecting the success of resuscitation after IOCA included American Society of Anesthesiologists Physical Status (ASA PS) classification ≥ III (P < .05) and preoperative tachycardia (heart rate ≥100/min, P < .05). The methods of anesthesia had no effects on the results of resuscitation.The incidence of IOCA in patients undergoing tumorous surgery was 1.05 per 10,000 anesthesia. The overall mortality of IOCA was 0.56/10,000. The frequency of IOCA decreased within 10 years. There was no cardiac arrest primarily attributable to anesthesia over this study period. The risk factors leading to unsuccessful resuscitation after IOCA were ASA PS classification ≥ III and preoperative tachycardia.

A 28-year-old woman with preeclampsia at 32 weeks of gestation underwent a cesarean delivery under spinal anesthesia. Administration of nitroglycerin at 200 μg to relax uterine smooth muscles and the application of fundal pressure led to severe bradycardia and loss of consciousness, followed by cardiac arrest. Delivery was completed immediately and recovery was achieved 10 seconds later following cardiopulmonary resuscitation. Neurally mediated syncope was considered the cause of cardiac arrest. Anesthetists should be aware of the potential risk during cesarean delivery following the administration of nitroglycerin, fundal pressure, regional anesthesia, and hypovolemia because of preeclampsia.

Design: Case report., Setting: Operating room., Patient: 25YF, ASA IV E who underwent an emergent decompressive craniectomy for refractory intracranial hypertension secondary to acute intracranial hemorhage., Interventions: A 25Y caucasian female presented with acute intracranial hemorrhage with intraventricular extension secondary to Moya Moya disease. Post admisison, she underwent an emergent decompressive craniectomy for medically refractory intracranial hypertension. Introperatively (post dural closure and bone flap removal) the patient developed acutely worsening peak and plateau pressures followed by pulseless electrical activity necessitating CPR with epinephrine and Vasopressin before return of circulation before return of circulation. Intraoperative TEE done during return of circulation, was essentially non diagnostic, the patient had normal breath sounds throughout, and non-contributory bronchoscopy findings., Measurements: EKG, arterial blood pressure, heart rate, resp. rate, introperative tranesophageal echocardiogram (TEE), Pulse oximetry, serial arterial blood gases, introperative bronchoscopy, ventilatory peak pressures., Main Results: A post operative chest CT revealed extensive pneumomediastinum with subcutaneous emphysema. The focussed introperative echocardiogram showed preserved left ventricular function and no evidence of tamponade physiology., Conclusions: Tension pneumomediastinum was the likely etiologic factor for the acute hemodynamic collapse and should be considered in the differential diagnosis of intraoperative circulatory arrest., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We report cardiac arrest due to obstruction of the right ventricular outflow tract (RVOT) caused by an RVOT mass that was not identified preoperatively. A 62-year-old woman with renal cell carcinoma (RCC) experienced deteriorating hypotension and bradycardia during radical nephrectomy. Hemodynamic stability was maintained on extracorporeal membrane oxygenation, and after surgery, she was transferred to the intensive care unit. On postoperative day 3, transthoracic echocardiography showed an intracardiac mass obstructing the RVOT, which caused severe functional pulmonary stenosis and moderate resting pulmonary hypertension. Despite maintaining extracorporeal membrane oxygenation, the patient died of cardiac arrest. Our findings suggest that it may be necessary to perform additional tests if RCC has invaded the renal vein and inferior vena cava or if a patient with RCC has abnormal cardiovascular symptoms without definite etiology for exclusion of cardiac metastasis or tumor thrombus. In addition, intraoperative transesophageal echocardiography might be the procedure of choice for the evaluation of these conditions because other diagnostic tests are difficult to perform during surgery. In conclusion, for patients with acute hemodynamic instability for whom other possible causes have been excluded, we recommend that anesthesiologists use transesophageal echocardiography to detect outflow tract obstruction or pulmonary thromboembolism and perform anesthetic management., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Hemodynamic perturbation during hepatic graft reperfusion in patients undergoing liver transplantation (LT) is challenging and is frequently accompanied by bradyarrhythmia and even asystole. However, detailed data on electrocardiographic (ECG) changes during reperfusion are almost nonexistent, although the correct diagnosis by record is important for the treatment. We aimed to identify ECG rhythm disturbances during graft reperfusion and to investigate risk factors and outcomes. Data from 1065 consecutive patients who underwent adult LT were analyzed. The incidence, type, and detailed characteristics of ECG changes immediately after graft reperfusion were assessed using an electronically archived intraoperative ECG database. We analyzed risk factors, postoperative outcomes including major cardiovascular events, 30-day and 1-year mortalities of recipients based on the occurrence of atrioventricular (AV) block, and asystole during reperfusion. The typical pattern of postreperfusion bradyarrhythmia was progressive PR interval prolongation until a Mobitz type 1 AV block occurred. The overall incidence of AV block was 5.0% (53/1065), and 30.2% of them (16/53) had initiated as AV block and then progressed into ventricular asystole. Fulminant hepatic failure was a significant predictor for occurrence of AV block (odds ratio [OR], 7.20; 95% confidence interval, 3.38-15.32; P < 0.001). Patients with AV block showed significantly higher incidence of postoperative major cardiovascular events (P < 0.001) and 30-day mortality (P = 0.002) than those without AV block, whereas the 1-year mortality was not different between the 2 groups (P = 0.10). The postreperfusion asystole was consistently preceded by a Mobitz type 1 AV block. The occurrence of AV block and asystole appears to be an important prognosticator. Therefore, maintaining an optimal range of physiological status and gradual unclamping of the vena cava to avoid sudden atrial distension are recommended in high-risk patients during reperfusion period. Liver Transplantation 22 956-967 2016 AASLD., (© 2016 American Association for the Study of Liver Diseases.)

Study Design: Retrospective review., Objective: To report the incidence of and risk factors for intraoperative cardiopulmonary arrest (ICA) in children undergoing spinal deformity surgery., Summary of Background Data: Spinal deformities in children are associated with comorbidities that can pose substantial risks during surgery., Methods: We reviewed records of patients who underwent surgery at two pediatric tertiary-care hospitals from 2004 through 2014. Fisher exact test and the Student t test were used to compare ICA and non-ICA groups by patient diagnosis, estimated blood loss, number of vertebral levels fused, and proportion of blood volume lost (significance, P < 0.05). We classified proximate causes of ICA based on hemoglobin, metabolic panel/electrolyte imbalance, electrocardiogram/echocardiography, and vital signs., Results: ICA occurred in 11 of 2524 (0.4%) patients. Patients with neuromuscular disorders had a 3-fold higher risk of ICA compared with those without neuromuscular disorders. At the time of ICA, hemoglobin levels were 5  g/dL or less in four patients, potassium was higher than 5.5  mEq/L in six patients, and ionized calcium was less than or equal to 1  mmol/L in two patients. There were significant differences between the ICA and non-ICA groups in mean number of vertebral levels fused (15 vs. 12), patient weight (34 vs. 49  kg), estimated blood loss (2623 vs. 959  mL), and proportion of blood volume lost (1.03 vs. 0.33) (all P < 0.01). Suspected causes of ICA were cardiovascular causes (eight patients) and anaphylaxis, primary rhythm disturbance, and respiratory/airway cause (one patient each). The incidence of ICA for patients with idiopathic scoliosis was 0.13%. Ten of the 11 patients were successfully resuscitated, and one patient died., Conclusion: ICA occurs in approximately 0.4% of children undergoing spinal fusion surgery. Patients with neuromuscular disorders are at greater risk of ICA than those without these disorders., Level of Evidence: 3.

We present a case of intraoperative coronary artery vasospasm during thoracic surgery causing profound hemodynamic instability. A 68-year-old man undergoing completion right pneumonectomy exhibited intraoperative widespread ST elevation with associated hypotension. Transesophageal echocardiography performed by the anesthetist revealed hypokinetic apical and lateral walls, prompting transportation to the catheterization laboratory, with angiography demonstrating widespread coronary artery spasm. Intracoronary nitroglycerin relieved the vasospasm; however, heparin administration caused significant postoperative bleeding, resulting in cardiac arrest requiring resuscitation and return to the operating room. He ultimately recovered and was discharged to a rehabilitation facility 3 weeks later., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Mortality rates for pulmonary embolectomy in patients with acute massive pulmonary embolism have decreased in recent years. However, it still ranges from 30 to 45% when surgery is performed on critically ill patients, and the mortality rates reach 60% in patients who have experienced a cardiac arrest before the procedure. The causes of death in these patients are generally attributed to right heart failure due to persistent pulmonary hypertension, intractable pulmonary oedema, and massive parenchymal and intrabronchial haemorrhage. Clinical and experimental findings indicate that venous air embolism causes severe or even lethal damage to the pulmonary microvasculature and the lung parenchyma consequent to the release of endothelium-derived cytokines. These findings are similar to those observed when severely compromised patients undergo pulmonary embolectomy for air entrapped in the pulmonary artery during embolectomy, which may lead to fatal outcomes. Retrograde pulmonary perfusion (RPP), besides enabling the removal of residual thrombotic material from the peripheral branches of the pulmonary artery, fills the pulmonary artery with blood and prevents pulmonary air embolism. We believe that the use of RPP as an adjunct to conventional pulmonary embolectomy decreases the morbidity and mortality rates associated with pulmonary embolectomy in critically ill patients., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Little information is known about factors that influence perioperative and anesthesia-related cardiac arrest (CA) in older patients. This study evaluated the incidence, causes and outcome of intraoperative and anesthesia-related CA in older patients in a Brazilian teaching hospital between 1996 and 2010., Methods: During the study, older patients received 18,367 anesthetics. Data collected included patient characteristics, surgical procedures, American Society of Anesthesiologists (ASA) physical status, anesthesia type, medical specialty team and outcome. All CAs were categorized by cause into one of four groups: patient's disease/condition-related, surgery-related, totally anesthesia-related or partially anesthesia-related., Results: All intraoperative CAs and deaths rates are shown per 10,000 anesthetics. There were 100 CAs (54.44; 95% confidence intervals [CI]: 44.68-64.20) and 68 deaths (37.02; 95% CI: 27.56-46.48). The majority of CAs were patient's disease-/condition-related (43.5; 95% CI: 13.44-73.68). There were six anesthesia-related CAs (3.26; 95% CI: 0.65-5.87) - 1 totally and 5 partially anesthesia-related, and three deaths, all partially anesthesia-related (1.63; 95% CI: 0.0-3.47). ASA I-II physical status patients presented no anesthesia-related CA. Anesthesia-related CA, absent in the last five years of the study, was due to medication-/airway-related causes. ASA physical status was the most important predictor of CA (odds ratio: 14.52; 95% CI: 4.48-47.08; P<0.001) followed by emergency surgery (odds ratio: 8.07; 95% CI: 5.14-12.68; P<0.001)., Conclusions: The study identified high incidence of intraoperative CAs with high mortality in older patients. The large majority of CAs were caused by factors not anesthesia-related. Anesthesia-related CA and mortality rates were 3.26 and 1.63 per 10,000 anesthetics, with no anesthesia-related CA in the last five years of the study. Major predictors of intraoperative CAs were poorer ASA physical status and emergency surgery. All anesthesia-related CAs were medication-related or airway-related, which is important for prevention strategies.

Importance: The trigeminocardiac reflex refers to the sudden development of bradycardia or even asystole with arterial hypotension from manipulation of any sensory branches of the trigeminal nerve. Although it has only rarely been associated with morbidity and tends to be self-limited with removal of the stimulus, it is an important phenomenon for head and neck surgeons to recognize and respond to., Observations: We present the case of a woman in her late 60s with maxillary alveolar ridge squamous cell carcinoma who developed episodes of asystole and bradycardia during posterior maxillary manipulation for an infrastructure maxillectomy at a tertiary academic medical center. Administration of atropine and removal of the inciting stimulus sufficed to extinguish the episodes and allow procedure completion., Conclusions and Relevance: The trigeminocardiac reflex can be provoked by a number of head and neck and skull base procedures including parotidectomy and posterior maxillectomy. Surgeons and anesthesiologists should be wary of inciting the reflex during manipulation of trigeminal branches. Careful dissection for prevention and early intervention with stimulus removal and anticholinergic use as needed are paramount to ensure good outcomes.

We report a patient with concealed sick sinus syndrome who developed intraoperative bradycardia and asystole. An 81-year-old man was scheduled to undergo total gastrectomy under general and epidural anesthesia. There was no history of syncope, and preoperative 12-lead ECG showed normal sinus rhythm. Anesthesia was induced with propofol and remifentanil, maintained with sevoflurane, remifentanil and thoracic epidural infusion of lidocaine, fentanyl and levobupivacaine. Bradycardia was detected on ECG 110 minutes after the start of surgery. Intravenous atropine (0.5 mg, repeated up to a total dose of 1.5 mg) was ineffective in restoring a normal heart rhythm. Ten minutes later, the ECG changed to asystole lasting for about 15 seconds. Regular chest compression and intravenous administration of dopamine (5 microg x kg(-1) x min(-1)) resulted in successful recovery of sinus rhythm. Postoperative ECG showed sinus rhythm. The final diagnosis by a cardiologist was concealed sick sinus syndrome. Many anesthetic agents have some effects on the cardiac conduction system. Remifentanil may have played a role in the development of asystole in this patient. The existence of concealed sick sinus syndrome should be kept in mind even in patients who show no clinical abnormalities on preoperative assessment.

Background: Little information on the factors influencing intraoperative cardiac arrest and its outcomes in trauma patients is available. This survey evaluated the associated factors and outcomes of intraoperative cardiac arrest in trauma patients in a Brazilian teaching hospital between 1996 and 2009., Methods: Cardiac arrest during anesthesia in trauma patients was identified from an anesthesia database. The data collected included patient demographics, ASA physical status classification, anesthesia provider information, type of surgery, surgical areas and outcome. All intraoperative cardiac arrests and deaths in trauma patients were reviewed and grouped by associated factors and also analyzed as totally anesthesia-related, partially anesthesia-related, totally surgery-related or totally trauma patient condition-related., Findings: Fifty-one cardiac arrests and 42 deaths occurred during anesthesia in trauma patients. They were associated with male patients (P<0.001) and young adults (18-35 years) (P=0.04) with ASA physical status IV or V (P<0.001) undergoing gastroenterological or multiclinical surgeries (P<0.001). Motor vehicle crashes and violence were the main causes of trauma (P<0.001). Uncontrolled hemorrhage or head injury were the most significant associated factors of intraoperative cardiac arrest and mortality (P<0.001). All cardiac arrests and deaths reported were totally related to trauma patient condition., Conclusions: Intraoperative cardiac arrest and mortality incidence was highest in male trauma patients at a younger age with poor clinical condition, mainly related to uncontrolled hemorrhage and head injury, resulted from motor vehicle accidents and violence.