Cardiopulmonary Resuscitation in the Lateral Position: Is It Feasible during Pediatric Intracranial Surgery?

Abstract

INTRAOPERATIVE cardiac arrest during neurosurgical operations can occur after massive blood loss in adults and in children. 1,2,3,4 Many of these procedures are performed in positions other than supine, and this could pose a major hurdle in successful resuscitation. 3 The practice of turning the patient supine for cardiopulmonary resuscitation (CPR) during neurosurgical operations has recently been questioned. 5 Although successful resuscitation has been reported in the prone position, there are no studies available on the feasibility of CPR in the lateral position. This is a case report of cardiac arrest due to massive blood loss in a child undergoing excision of a large brain tumor in the lateral position followed by successful resuscitation in the same position. Case ReportA 6-yr-old boy (height, 103 cm; weight, 18 kg) with clinical features of severe intracranial hypertension on ventilatory support was referred to this hospital for definitive management. Magnetic resonance imaging revealed a large and vascular right intraventricular tumor. The child suffered a cardiac arrest in the intensive care unit the day before surgery. He was successfully resuscitated and scheduled for emergency craniotomy under American Society of Anesthesiologists grade IV. On the day of surgery, his pulse rate was 130 beats per minute, blood pressure was 130/80 mmHG, and he was on pressure support ventilation. He had normal-sized pupils that were reacting to light and normal flexor motor response and spontaneous respiratory efforts. The child was placed in the left lateral decubitus position with the head resting on a doughnut for surgery. Intraoperative monitoring included intraarterial blood pressure and central venous pressure. During surgical decompression of the tumor, there was sudden and rapid blood loss associated with bradycardia (50 -60 beats per minute) and severe hypotension and hypovolemia (systolic blood pressure, 30 -40 mmHG; central venous pressure, -5 mmHG) followed by pulseless electrical activity. External cardiac massage was commenced in the lateral position itself using the two thumb-encircling hand technique to avoid any delay in resuscitation. This technique of CPR produced a pulsatile arterial trace and systolic pressures of approximately 50 -60 mmHG, Epinephrine boluses along with rapid transfusion of blood products and inotrope infusions (dopamine and adrenaline) were administered.Life-sustaining rhythm and blood pressure (70 -80 mmHG) were obtained within 3 min. One hour later, during hemostasis, the child had another episode of severe hypotension for which similar resuscitative measures were taken. After both episodes of successful resuscitation, the surgeon could proceed with tumor decompression and hemostasis. The surgery lasted 4 h and the blood loss was 1 l, which was replaced. At the end of surgery, he was shifted to the intensive care unit in a stable hemodynamic condition. Inotropic support was tapered off by the third postoperative day, and he was weaned off the ventilator on the eighth postoperati...

Delayed Time to Defibrillation after Intraoperative and Periprocedural Cardiac Arrest

“…A focus on advanced cardiac life support and rapid defibrillation may conflict with optimal management of surgical hemorrhage if the effort inhibits surgical access to the operative site. 23,24 More broadly, with intraoperative arrest, if providers are engaged in activity that is expected to reverse the etiology of the arrest, they may defer defibrillation to focus on performing the critical actions as rapidly and reliably as possible.…”

Cardiac arrest in the left lateral decubitus position and extracorporeal cardiopulmonary resuscitation during neurosurgery: a case report

“…However, there was no detailed description of chest compression performed in this position, and no requirement for defibrillation because normal sinus rhythm was restored spontaneously within several minutes. In another case report, CPR in the lateral decubitus position was administered to a 6-year-old boy during neurosurgery [3]. In this case, chest compression was performed by one rescuer because of the patient's small body size, and he too did not require defibrillation.…”

Semiprone position is superior to supine position for paediatric endotracheal intubation during massive regurgitation, a randomized crossover simulation trial

“…Some patients can be expected to be in cardiac arrest during an actual situation, and the quality of CPR may be affected by turning the patient away from the supine position. Effective chest compressions in the lateral position have been described in the literature, but evidence is limited [ 27 ]. In the incident described in the introduction, chest compressions by a well-trained health professional with a depth of the recommended approximate five centimetres could be continued in the semiprone position by placing one hand on the chest and the other on the child’s back; this would probably not have been easily achieved in an adult patient [ 27 – 29 ].…”