Sudden Cardiac Arrest Under Spinal Anesthesia in a Mission Hospital

A Case Report and Review of the Literature

Bamidele Johnson Alegbeleye

Disclosures

J Med Case Reports. 2018;12(144) 

In This Article

Case Presentation

The patient was a 25-year-old Cameroonian man weighing 65 kg who was recently operated on for acute appendicitis in Banso Baptist Hospital, Northwest Cameroon. All the preoperative investigations, including routine blood biochemistry, chest X-ray posterior and anterior view, and 12-lead electrocardiograms were normal. The abdominal ultrasound scan was essentially normal. In 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 parameters were recorded and were essentially normal. An intravenous (IV) access was secured with a cannula and our patient was preloaded with 500 mL of normal saline solution. Under all aseptic precautions, a subarachnoid block was performed at L3/L4 space in the left lateral position with a 25-gauge Quincke needle and 3.2 mL of hyperbaric bupivacaine was injected into the subarachnoid space after confirming a clear and free flow of cerebrospinal fluid (CSF). Five minutes after turning the patient to the supine position, the sensory level of block was found to be at T10. During skin preparation of the abdomen, and almost 25 min after the subarachnoid injection, our patient started complaining of difficulty in breathing and this was followed with a convulsion. Sensory level was rechecked and was found to be at T10. A bolus of atropine 0.6 mg was administered as his heart rate suddenly dropped to 40 beats/min, SpO2 to 65%, while his BP became unrecordable and peripheral pulses could not be palpated. Owing to diminishing consciousness, our patient was immediately intubated with a cuffed endotracheal tube (ETT) of 7.5 mm and positive pressure ventilation initiated with Bain circuit and 100% oxygen was administered. His heart arrested and cardiopulmonary resuscitation (CPR) was started immediately with pharmacologic intervention with adrenaline and dopamine and intravenous normal saline infusion. (Other vasopressors like mephenteramine, noradrenaline etc. were not available.) Within 4 min, our patient responded with a heart rate of 140 bpm, SpO2 of 90%, and BP of 90/60 mmHg. Our patient was restless even after administration of injection of diazepam 10 mg, and phenytoin 1.5 g in IV infusion. Considering his slow response to resuscitative measures, our patient was administered 150 mg propofol and was paralyzed with 6 mg vecuronium and electively ventilated in the OR. Apart from sinus tachycardia, all investigations results including serum electrolytes, complete blood counts and chest X-ray were normal. Arterial blood gas analysis (ABG) was not available in our facility. Our patient was adjudged by both the anesthetist and attending surgeon as being fit enough to proceed for the emergency open appendicectomy via a Lanz incision with uneventful postoperative course. After 2 h of elective ventilation and achievement of hemodynamic stability, our patient became conscious and started responding to verbal commands with good respiratory efforts, and extubation was done after reversing the relaxant effect with standard doses of neostigmine and glycopyrrolate. His postextubation hemodynamic parameters were normal, and he was transferred to the high dependency unit (HDU) for further observation. Our patient was discharged on the 4th postoperative day with an uneventful course in HDU. The follow-up visits at the 2nd, 4th, and 10th week in the postoperative period showed satisfactory clinical status.

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