Abdominal only CPR during cardiac arrest for a patient with an LVAD during resternotomy: A case report

Journal of Cardiothoracic Surgery Abdominal only CPR during cardiac arrest for a patient with an LVAD during resternotomy: A case report Eric M Rottenberg 3 Jarrett Heard 2 Robert Hamlin 1 Benjamin C Sun 4 Hamdy Awad 0 0 The Ohio State University Medical Center, Department of Anesthesiology , N411 Doan Hall, 410 West 10 1 The Ohio State University College of Veterinary Medicine , 1900 Coffey Road, Columbus, OH, 43210 , USA 2 The Ohio State University College of Medicine , 370 West 9 3 301B Fenway Road , Columbus, OH, 43214 , USA 4 The Ohio State University Medical Center, Department of Surgery, Division of Cardiothoracic Surgery , N847 Doan Hall, 410 West 10 We present a case in which a patient with a previous sternotomy and left ventricular assist device (LVAD) implantation developed cardiac arrest during resternotomy for LVAD exchange. The surgeon refused chest compressions for fear of potential damage to the inflow cannula directly beneath the sternum. The perioperative team had no alternatives to external cardiac massage other than rapid deployment of extra-corporeal membrane oxygenation for mechanical support, so the anesthesiologist advised the nursing personnel to perform abdominal only cardiopulmonary resuscitation while the surgeon performed a femoral bypass to cannulate the groin for extracorporeal membrane oxygenation support. - Background Cardiac arrest during cardiac surgery is a unique situation. In 2009, the European Society of Cardiothoracic Surgery published a separate guideline that addressed these particular situations, including the timing of emergency resternotomy, the number of attempts at defibrillation before reopening, the administration of epinephrine, and emergency resternotomy sets [1]. However, this guideline did not address the treatment of patients with a mechanical assist device in cardiac arrest situations since their treatment is highly complicated. Cardiac arrest may be due to mechanical failure and external cardiac massage (ECM) is not appropriate, as stated by the European Society of Cardiothoracic Surgery [1]. We present a case in which the patient with a previous sternotomy and LVAD (HeartMate II, Thoratec Corporation) implantation developed cardiac arrest during resternotomy for LVAD exchange due to hemolysis. The surgeon denied chest compressions for fear of potential damage of the inflow cannula directly beneath the sternum. As there were no alternatives to ECM offered by the American Heart Association and the European Society of Cardiothoracic Surgery [1,2] other than Case Presentation A 56-year-old male with multiple co-morbidities, including a long-standing history of non-ischemic dilated cardiomyopathy, stage III chronic kidney disease, and congestive hepatopathy, underwent LVAD implantation two months prior to the most recent admission. He returned to the hospital due to persistent atrial fibrillation, progressively worsening dyspnea on exertion and rest, abdominal distension with ascites, and suspected ongoing hemolysis due to positioning of the inflow cannula at the apex of the LVAD. It was decided that the patient should return to the operating room for placement of a new LVAD due to hemolysis and hypotension refractory to medical management. The night before the scheduled surgery, the patient was intubated due to worsening cardiopulmonary parameters, including increased work to breathe, and maintained on epinephrine 0.15 mcg/kg/min, norepinephrine 0.1 mcg/kg/min and dobutamine 3 mcg/kg/ min. He was transferred to the operating room to replace the pump. Pre-op vitals included: temp 37.6 degrees Celsius, arterial blood pressure 64/50, mean arterial pressure 55, heart rate 118 and respiratory rate of 16. Prior to induction of anesthesia, labs included: white blood cells 15.2, hemoglobin 10, hematocrit 29.4, platelets 96, Na+ 130, K+ 3.1, Cl- 95, CO2 25, blood urea nitrogen 24, creatine 2.08, glucose 84, and international normalized ratio 3.5. Preoperative arterial blood gases were pH 7.48, pCO2 35.9, pO2 184.2, and HCO3 26.1. In the operating room, hemodynamic parameters were continuously monitored via radial arterial line and Swan-Ganz catheter. Induction was uneventful with etomidate 10 mg and cisatracurium 10 mg. The transesophageal echocardiography (TEE) probe was placed uneventfully. The surgeons entered the mediastinum using the previous sternal incision. Once they began dissecting out the mediastinum, the patient became severely hypotensive and asystolic, and the TEE did not detect any movement on both the left and right side of the heart. The anesthesiologist alerted the surgeon that Advanced Cardiac Life Support (ACLS) protocol was needed and the surgeon communicated that chest compressions were contraindicated due to the position of the inflow cannula directly beneath the sternum. The anesthesiologist recommended AO-CPR with manual mid-abdominal compressions 1 to 2 inches left of midline (left paramedian) at a rate of 80 beats/min with maximal force while the surgeon cannulated the groin to provide long-term mechanical support in the form of ECMO. As instructed, two members of the team performed AO-CPR (Figure 1). During ACLS, the patient continued to be mechanically ventilated and epinephrine, vasopressin, and sodium bicarbonate were given per ACLS protocol, and the hemodynamic parameters as a result of AO-CPR continued to be monitored (Figure 2). The duration of the CPR was 15 minutes, during which time the surgeon was able to cannulate the femoral artery and vein and institute ECMO support. The chest was closed and the patient was transferred to the intensive care unit. The patient spent 24 hours in the intensive care unit on ECMO support and mechanical assist device. A decision was made to withdraw care after 24 hours and the patient expired. Our case represents a difficult situation where the perioperative team faced a new challenge in the operating room: what are the alternatives to ECM when chest compressions are contraindicated due to position of the inflow cannula directly beneath the sternum? Neither the new guidelines published in the European Journal of Cardiothoracic Surgery in 2009 nor the American Heart Association in 2010 provided alternatives to ECM for patients with a mechanical assist device. It became evident that there was a need for an alternative to ECM, such as AO-CPR, to protect the recent sternotomy until re-opening of the chest to provide internal cardiac massage. The Interactive Cardiovascular Thoracic Surgery e-community conducted a discussion to address whether AO-CPR could be used instead of ECM to either protect the recent sternotomy or while chest compressions are not possible during resternotomy [3]. After reviewing this evidence, Dunning et al. [1] concluded that AO-CPR theoretically has the potential to provide adequate systemic perfusion while an emergency resternotomy is being performed, but further Figure 1 Abdominal only cardiopulmonary resuscitation during car (...truncated)