Page 1 of 6
British Journal of Healthcare and Medical Research - Vol. 11, No. 6
Publication Date: December 25, 2024
DOI:10.14738/bjhmr.116.17998.
Mahmood, A., Yaakovian, M., Ellis, B. K., Nazareth, K., Patel, A., Mahmood, A. M., Mahmood, E. A., & Mock, E. (2024). Intraoperative
Cardiac Arrest: An Algorithm to Address the Synchronous Underlying Pathology. British Journal of Healthcare and Medical Research,
Vol - 11(6). 239-244.
Services for Science and Education – United Kingdom
Intraoperative Cardiac Arrest: An Algorithm to Address the
Synchronous Underlying Pathology
Ali Mahmood
Underwood Digestive Disease Center, Houston Methodist Sugar
Land Hospital, Department of Surgery, Adjunct Assistant Professor,
Texas A&M School of Medicine 16605 Southwest Freeway Suite 430
Sugar Land, TX 77479 USA
Michael Yaakovian
Houston Methodist Sugar Land Hospital Institute of Academic Medicine,
Department of Surgery 16605 Southwest Freeway Suite 450 Sugar Land,
TX 77479 USA
Byron Keith Ellis
Houston Methodist Sugar Land Hospital, Division of Cardiology,
Department of Medicine Houston Methodist Hospital, 16605
Southwest Freeway Suite 625 Sugar Land, TX 77479 USA
Karl Nazareth
Houston Methodist Sugar Land Hospital Department of Anesthesia
Houston Methodist Hospital 16605 Southwest Freeway Suite 430
Sugar Land, TX 77479 USA
Apoor Patel
Houston Methodist Sugar Land, Department of Cardiology
16605 Southwest Freeway Suite 600 Sugar Land, TX 77479 USA
Aiva Mariam Mahmood
Houston Methodist Sugar Land Hospital, Department of Surgery
16605 Southwest Freeway Suite 430 Sugar Land, TX 77479
Emaan Anya Mahmood
Houston Methodist Sugar Land Hospital, Department of Surgery
16605 Southwest Freeway Suite 430 Sugar Land, TX, 77479
Emily Mock
Houston Methodist Sugar Land Hospital, Department of Anesthesia,
16605 Southwest Freeway Suite 430 Sugar Land, TX 77479
ABSTRACT
Intra-operative cardiac arrest (IOCA) is a rare yet feared complication. It has been
reported with diverse range: from 0.8/10,000 cases to 21/100,000 cases. [1,2,3]
Page 2 of 6
240
British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 06, December-2024
Services for Science and Education – United Kingdom
The immediate mortality and subsequent 30 days mortality are paramount, from
62% to 75%, respectively. [1,2] Patients that had incurred an operation due to
trauma had an even worse prognosis, in some studies. [4] Elective cases, where the
arrest was addressed with a resuscitation algorithm, unobstructed communication,
and teamwork between the surgery and anesthesia teams, fared the most favorable
outcomes. [5] Some literature has even reported that the use of CPR, when
necessary, was a poorer prognostic indicator. [6] Often successful resuscitation and
rescue of the patient from IOCA is performed before the surgeon has had the
opportunity to address the pathology that originally scheduled the patient for an
operation. There is not an established algorithm of how or when to take the patient
back to the operating room to address the underlying pathology. We propose an
algorithm where a successfully resuscitated patient, without sustaining a
myocardial infarction (MI), can be appropriately worked up, managed, undergo
prophylactic cardiac protection, and return to the operating room for a successful
operation.
CASE PRESENTATION
We present a 53 y/o female that presented to her primary care physician with intermittent dull
abdominal pain. She was subsequently referred to a gastroenterologist. She underwent a
screening colonoscopy and was found to have a near obstructive mass in the transverse colon.
The patient was referred to surgery for further evaluation. Her past medical history was
pertinent for hypertension that was well controlled with medication. Upon consultation with
the surgeon, a plan for a laparoscopic segmental colon resection was outlined. Informed
consent was obtained.
After successful induction of anesthesia, the patient underwent insertion of a 5 millimeter (mm)
port. The abdomen was insufflated to 15 atmospheres (atm) of pressure. A second 5 mm port
was introduced into the abdominal cavity under direct visualization. The first port site was
inspected and looked excellent. We commenced with our mobilization of the intra abdominal
contents for exposure. All vital signs were stable and there was negligible blood loss.
Approximately 5 minutes into the dissection, anesthesia announced that the patient was
becoming bradycardic. The patient went into asystole. Chest compressions were started and
the abdominal cavity was decompressed. Epinephrine and Atropine were administered. CPR
continued and the patient regained a pulse within a minute. The case was aborted and the
patient was awakened and taken to the post anesthesia care unit, PACU. She was in stable
condition. She was extubated in the PACU.
The patient was taken urgently to the cardiac catheterization lab, where she underwent
strenuous interrogation of her coronary vasculature. There were not any marked abnormalities
found.
The following day (hospital day #2) she underwent implantation of a temporary permanent
pacemaker (PPM). She tolerated the procedure well.
On hospital day #3, she underwent a laparoscopic segmental colon resection without any
incidents. She recovered well, was discharged home on post operative day four. Upon her six
week follow up, she is doing well and has resumed all pre-operative activities.
Page 3 of 6
241
Mahmood, A., Yaakovian, M., Ellis, B. K., Nazareth, K., Patel, A., Mahmood, A. M., Mahmood, E. A., & Mock, E. (2024). Intraoperative Cardiac Arrest:
An Algorithm to Address the Synchronous Underlying Pathology. British Journal of Healthcare and Medical Research, Vol - 11(6). 239-244.
URL: http://dx.doi.org/10.14738/bjhmr.116.17998.
RESULT AND PROPOSED ALGORITHM
Intra-operative cardiac arrest (IOCA) is the most feared complication during surgery. The
acuity of surgery coupled with cardiac arrest create a stressful environment on the patient and
the surgical team. Continual communication between the anesthesiology team and surgical
team is paramount in handling this catastrophe. The patient in our case had malignant
pathology that could not be postponed. It is the intent of the authors of this manuscript to
propose a plan to address patients following IOCA that have a malignant process: Figure 1.
Following the successful resuscitation of a patient, the patient should be monitored and
evaluated for extubation. A cardiac catheterization should be undertaken to interrogate the
coronary vasculature. If the coronaries are found to have limited to absent disease, without an
infarction, we recommend placement of a temporary PPM. Surgery can be undertaken the
following day. The temporary PPM is removed prior to the patient leaving the hospital.
Figure 1: Houston Methodist Sugar Land IOCA Flow Diagram: Flow diagram depicting an
algorithm of IOCA to potential definitive surgery.
Page 4 of 6
242
British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 06, December-2024
Services for Science and Education – United Kingdom
DISCUSSION
Intra-operative cardiac arrest is a potentially devastating complication. Although the reported
rates vary, the incidence is reported to be decreasing worldwide. [7,8, 9] Data from Brazil,
pooling 4 studies that amassed 204,000 patients, showed the incidence decrease from
39/10,000 to 13/10,000. Furthermore, the mortality also decreased over that time period from
48.3% to 30.8% [7]. There are multiple reported causes of IOCA. These range from weakening
cardiac conditions, metabolic abnormalities, hypovolemia, local anesthetic systemic toxicity,
trauma, and malignant hyperthermia to name a few. [5] There are some obscure reasons for
IOCA, such as Kounis syndrome, whereby the arrest is triggered from mast cell activation. [10]
An example would be the administration of cephalosporin causing a marked allergic reaction
to the patient and leading to an allergic acute coronary syndrome.[10] While the immediate
cause of the arrest is often not identified, the ACLS protocol is immediately initiated. Supporting
the patient and restoring circulation and maintaining an airway are paramount in patient
survival and safety. Operating rooms that have the surgical team and anesthesia team in
synchronous partnerships fare better in successfully resuscitating and rescuing the patient.
[3,4,11]
The immediate recognition of bradycardia and subsequent asystole allowed quick action in our
patient. While the anesthesia team was administering medications and ensuring the airway was
continually secure, the surgical team was simultaneously performing CPR and decompressing
the abdominal air from the laparoscopic insufflation. These concerted efforts led to the patient
being immediately resuscitated and successfully rescued.
The advances in technology and medicine have also contributed to better outcomes from IOCA.
The aging and sicker population do pose challenges for the surgeon and anesthesiologist in the
operating room. Patients with congestive heart failure, circulation disorders, vascular disease,
end-stage renal disease had a 15.44 fold increase in risk-adjusted in-hospital mortality, with an
even higher IOCA mortality. [12] Interestingly, with the onset of COVID, the incidence of cardiac
arrests was higher in COVID patients, however the data for IOCA in COVID patients needs
further evaluation and analysis. [13] Transplant patients fared poor outcomes when faced with
an intr-operative arrest. [14] Data from 7 academic centers showed IOCA higher with BMI > 40,
MELD > 40, and incidence of post perfusion syndrome. The 30 day and 1 year mortality, post
liver transplant, was 43.9% and 52% respectively. [14]
Once our patient was successfully resuscitated, she still had her underlying pathology, a near
obstructive, cancerous mass, that had to be addressed. It was important to evaluate her
cardiopulmonary status prior to continuing with the operation. The cardiology team
immediately consulted upon the patient and she was taken to the catheterization lab. Her
coronaries were found to have minimal disease so an acute myocardial infarction was ruled
out. Her airway and circulation post recovery were excellent and stable. The patient’s vitals
signs had maintained their baseline well after insufflation of the abdominal cavity, thus a
vasovagal event was unlikely the etiology of her arrest. A decision was made to implant a
temporary PPM, to ensure that she could safely undergo a major abdominal operation with
general anesthesia.
Multiple research and reports recommend postponing an elective surgery after a myocardial
infarction. [15] The risk of peri-operative mortality following an acute MI is markedly increased
Page 5 of 6
243
Mahmood, A., Yaakovian, M., Ellis, B. K., Nazareth, K., Patel, A., Mahmood, A. M., Mahmood, E. A., & Mock, E. (2024). Intraoperative Cardiac Arrest:
An Algorithm to Address the Synchronous Underlying Pathology. British Journal of Healthcare and Medical Research, Vol - 11(6). 239-244.
URL: http://dx.doi.org/10.14738/bjhmr.116.17998.
in the first 30 days with a continual increase of morbidity and mortality for the first six months.
Cardiac catheterization is paramount to ensure the cause of IOCA is not an MI, and allows the
surgeon to follow the algorithm proposed in this paper.
The medical teams consisting of surgery, anesthesia, interventional cardiology and
electrophysiology all worked in conjunction to ensure the safety and well being of the patient.
The communication was constant and the interventions were expedient. The careful yet
efficacious timings of the management allowed the patient to undergo a successful operation
and address her cancerous tumor. As IOCA continues to be a dreaded complication, the
implementation of this algorithm facilitates an approach and pathway that can result in a
successful outcome.
References
1. Sebbag I, Carmona MJ, Gonzalez, MM, Alcantara HM, Lelis RG, Toledo F, Aranha GF, Nuzzi RX, Auler JO.
Frequency of intraoperative cardiac arrest and medium-term survival. Sao Paulo Med J. 2013;131(5):309-14.
Doi: 10.1590/1516-3180.2013.1315507.
2. Hur M, Lee HC, Lee KH, Kim JT, Jung CW, Park HP. The incidence and characteristics of 3-mont mortality after
intraoperative cardiac arrest in adults. Acta Anaesthesiol Scand. 2017;61(9):1095-1104. Doi:
10.1111/aas.12955
3. Jolissaint JS, Nehra D. How Should a Surgeon and Anesthesiologist Cooperate During Intraoperative Cardiac
Arrest? AMA J Ethis. 2020;22(4):E291-297. Doi: 10.1001/amajethics.2020.291.
4. An JX, Zhang LM, Sullivan EA, Guo QL, Williams J. Intraoperative cardiac arrest during anesthesia: a
retrospective study of 218,274 anesthetics undergoing non-cardiac surgery. China Med J (English).
2011;124(2):227-32.
5. McEvoy MD, Thies KC, Einav S, Ruetzler K, Moitra VK, Nunnally ME, Banerjee A, Weinberg G, Gabrielli A,
Maccioli GA, Dobson G, O’Connor MF. Cardiac Arrest in the Operating Room: Part 2 – Special Situations in the
Perioperative Period. Anesth Analg. 2018;126(3):889-903. Doi: 10.1213/ANE.0000000000002595
6. Kaiser HA, saied NN, kokoefer AS, Saffour L, Zoller JK, Helwani MA. Incidence and prediction of
intraoperative and postoperative cardiac arrest requiring cardiopulmonary resuscitation and 30-day
mortality in non-cardiac patients. PLoS One. 2020;15(1):e0225939. Doi: 10.1371/journal.pone.0225939.
7. Vane MF, Nuzzi RX, Aranha GF, da Luz VF, Malbouisson LM, Gonzalez MM, Auler JO, Carmona MJ.
Perioperative cardiac arrest: an evolutionary analysis of the intra-operative cardiac arrest incidence in
tertiary centers in Brazil. Brazil J Anesthesiol. 2016;66(2):176-82. Doi: 10.1016/j.bjane.2014.06.007.
8. Zuercher M, Ummenhofer W. Cardiac arrest during anesthesia. Curr Opin Crit Care. 2008;14(3):269-74. Doi:
10.1097/MCC.0b013e3282f948cd.
9. Han F, Wang YW, Dong J, Nie C, Hou MC. Intraoperative cardiac arrest: A 10-year study of patients
undergoing tumorous surgery in a tertiary referral cancer center in China. Medicine. 2017;96(17):e6794.
Doi: 10.1097/MD.0000000000006794.
10. Kumaran T, Damodaran S, Singh AP, Kanch M. Intraoperative cardiac arrest due to allergic acute coronary
syndrome (Kounis syndrome) triggered by cephalosporin. Ann Card Anaesthesia. 2023;26(2):219-22. Doi:
10.4103/aca.aca_302_20.
Page 6 of 6
244
British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 06, December-2024
Services for Science and Education – United Kingdom
11. Hinkelbein J, Andres J, Thies KC, de Robertis E. Perioperative cardiac arrest in the operating room
environment: a review of the literature. Minerva Anestesiol. 2017;83(11):1190-98. Doi: 10.23736/S0375-
9393.17.11802-X.
12. Singh VF, Willingham MD, Fischer MA, Grogan T, Benharash P, Neelankavil JP. A Population-Based Analysis
of Intraoperative Cardiac Arrest in the United States. Anesth Analg. 2020;130(3):627-634. Doi:
10.1213/ANE.0000000000004477.
13. Soar J, Becker LB, Berg KM, Einav S, Ma Q, Olasveengen TM, Paal P, Parr MJ. Cardiopulmonary resuscitation
in special circumstances. Lancet. 2021;398(10307):1257-1268. Doi: 10.1016/S0140-6736(21)01257-5.
14. Smith NK, Zerillo J, Kim SJ, Efune GE, Wang C, Pai SL, Chadha R, Kor TM, Wetzel DR, Hall MA, Burton KK,
Fukazawa K, Hill B, Spad MA, Wax DB, Lin HM, Liu X, Odeh J, Torsher L, Kindscher JD, Mandell MS, Sakai T,
DeMaria S. Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor
Analysis From 7 Academic Centers in the United States. Anesh Analg. 2021;132(1):130-139. Doi:
10.1213/ANE.0000000000004734.
15. Vernick, J. How long to postpone an operation after a myocardial infarction?: When perioperative
consultants contradict the literature, leaving the anesthesiologist in the middle. Journal of Clinical
Anesthesia. 2006;18(5):325-7. Doi: 10.1016/j.jclinane.2006.05.008