Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery

Failure to Rescue After Brain Tumor Resection: A National Surgical Quality Improvement Program Analysis (2012-2020)

BACKGROUND AND OBJECTIVES

Failure to rescue (FTR) occurs when mortality happens within 30 days after a major postoperative complication. The surgical literature contains varying FTR rates based on various patient characteristics and postoperative complication rates. The impact of frailty on FTR has yet to be described within the context of brain tumor resection (BTR). Our study identified patient characteristics and postoperative complications predictive of FTR in this cohort.

METHODS

BTR patients were identified from the American College of Surgeons-National Surgical Quality Improvement Program database (2012-2020) based on craniotomy codes. Frailty was measured using the Risk Analysis Index as has been previously described.

RESULTS

There were 31 667 BTR patients and 2443 (7.71%) developed a major complication, and 387 (15.8%) experienced FTR. The median age of the cohort was 60 years (IQR 49-69). On multivariate analysis, transfer status (odds ratio [OR]: 1.36, 95% CI: 1.01-1.81) and nonelective surgery (OR: 1.60, 95% CI: 1.22-2.10) were independent predictors of FTR. Frail and severely frail patients who underwent BTR had 4.03-fold and 7.90-fold higher odds of FTR. Postoperative complications predictive of FTR were cardiac arrest (OR: 12.75, 95% CI: 8.16-19.92), unplanned reintubation (OR: 2.46, 95% CI: 1.89-3.16), and septic shock (OR: 2.02, 95% CI: 1.37-2.98). The final predictive model demonstrated excellent discriminatory accuracy (c-statistic: 0.81, 95% CI: 0.79-0.83).

CONCLUSION

Preoperative patient characteristics, including frailty, and the occurrence of certain expected postoperative complications, such as cardiac arrest, are predictive of FTR in BTR patients. Knowledge of baseline frailty could guide preoperative interventions to optimize patients before surgery.

Perioperative Extracorporeal Cardiopulmonary Resuscitation in Adults: A Single-center Retrospective Review and Analysis

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (CPR) for refractory in-hospital cardiac arrest has been associated with improved survival compared with conventional CPR. Perioperative patients represent a unique cohort of the inpatient population. This study aims to describe and analyze the characteristics and outcomes of patients who received extracorporeal CPR for perioperative cardiac arrest.

METHODS

A single-center retrospective review of perioperative extracorporeal CPR in adults from January 2015 to August 2022 was performed. Patient demographics, cardiac arrest variables, and outcome data were obtained and analyzed. The primary study outcome was survival with favorable neurologic outcome.

RESULTS

A total of 33 patients received extracorporeal CPR for perioperative cardiac arrest. Of the 33 patients, 24 (73%) had a cardiac arrest in the cardiac catheterization laboratory, while 9 (27%) had a cardiac arrest in the operating room or interventional radiology suite. Survival to discharge was 57.6%, of whom 17 (89.5%) had neurologically favorable outcomes with cerebral performance category scores of 1 or 2 at discharge. The mean total CPR time was significantly lower in the survivor group than in the nonsurvivor group (16.5 vs . 25.0 min; P < 0.05). Survivors had significantly lower lactate levels (73 mg/dl vs . 115 mg/dl; P = 0.005) and higher pH levels (7.17 vs. 7.03; P = 0.005) compared with nonsurvivors.

CONCLUSIONS

The use of extracorporeal CPR for adults with perioperative cardiac arrest can be associated with excellent survival with neurologically favorable outcomes in carefully selected patients. Longer CPR time, higher lactate levels, and lower pH were associated with increased mortality. Given the small sample size, no other prognostic factors were identified, although certain trends were detected between survival groups.

A case of intraoperative arrest & mobile ECMO

Over the past two decades, extracorporeal membrane oxygenation (ECMO) has been increasingly used to support critical patients with cardiac and respiratory failure who fail to respond to conventional management. In refractory cardiac arrest, ECMO can restore perfusion in patients who meet specific criteria designed to maximize survival benefit and good neurological outcomes. In recent literature, there is no report of mobile ECMO in a case of prolonged cardiac arrest with direct cardiac massage. We describe our experience with a 34-year-old man with multiple traumatic injuries following a motor vehicle collision. He was treated in a trauma center hospital in the same city as our center. He was initially in stable condition (spontaneous ventilation with FiO2 0.21, no vasoactive drugs, Glasgow 15, no acute kidney injury or other organ dysfunction). One week after admission, a retained left hemopneumothorax required surgical intervention, as previous drainage was ineffective. Computed tomography imaging was also concerning for parencyhmal injury by the thoracotomy tube. Intraoperatively, when the patient was placed in lateral position, he experienced cardiac arrest, presumed to be secondary to pulmonary embolism. After 18 min, we were asked to rescue this patient with ECMO, as he had no contraindications to support. After 81 min of advanced life support, including direct cardiac massage, return of spontaneous circulation was achieved seconds after ECMO was initiated. He was then transported to our hospital. The patient achieved a favorable neurological outcome (Glasgow Coma Scale score of 15 at 24 h) and was discharged after a 2 month stay. This case highlights the potential benefits of prolonged cardiopulmonary resuscitation and ECMO in patients with refractory in-hospital cardiac arrest. In this case, proper ACLS and CPR allowed time for mobile ECMO support to be initiated from a remote center.

Frailty Predicts Failure to Rescue Following Malignant Brain Tumor Resection: A National Surgical Quality Improvement Program Analysis of 14,721 Patients/ (2012-2020)

OBJECTIVE

Failure to rescue (FTR) is defined as mortality within 30 days following a major complication. While FTR has been studied in various brain tumor resections, its predictors in malignant brain tumor resection (mBTR) remain unexplored. This study aims to identify FTR predictors in mBTR resection patients using a frailty-driven model.

METHODS

Patients undergoing craniotomy for mBTR were identified from the American College of Surgeons-National Surgical Quality Improvement Program database (2012-2020), with frailty measured by the Risk Analysis Index (RAI).

RESULTS

Of 14,721 mBTR patients, 1275 (8.66%) developed major postoperative complications and 166 (13.01%) experienced FTR. The cohort's median age was 59 years (interquartile range: 47-68). Multivariate analysis revealed nonelective surgery (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.02-2.16, P < 0.05) as an independent risk factor for FTR. Frailty was a significant independent predictor of FTR with mBTR, with both frail (N = 110) and very frail (N = 22) patients having a 5.34-fold and 8.10-fold higher odds of FTR, respectively (P < 0.001). Expectedly, major postoperative complications were predictive of FTR, including unplanned intubation (OR: 2.56, CI: 1.66-3.95, P < 0.001), prolonged ventilation (OR: 2.00, CI: 1.37-3.14, P < 0.01), cardiac arrest (OR: 16.64, CI: 8.20-33.74, P < 0.001), and septic shock (OR: 2.08, CI: 1.10-3.91, P < 0.05). The RAI-driven frailty model demonstrated excellent discriminatory accuracy for predicting FTR patients undergoing mBTR (c-statistic: 0.82, 95% CI: 0.79-0.85).

CONCLUSIONS

Preoperative RAI-measured frailty, alongside nonelective surgery, and major postoperative complications were significant predictors of FTR in mBTR patients. Identifying mBTR patients at risk for FTR using frailty strata may aid in preoperative neurosurgical risk stratification to optimize patients prior to surgery.

In-hospital cardiac arrest characteristics, causes and outcomes in patients with cardiovascular disease across different departments: a retrospective study

BACKGROUND

Cardiac etiologies arrest accounts for almost half of all in-hospital cardiac arrest (IHCA), and previous studies have shown that the location of IHCA is an important factor affecting patient outcomes. The aim was to compare the characteristics, causes and outcomes of cardiovascular disease in patients suffering IHCA from different departments of Fuwai hospital in Beijing, China.

METHODS

We included patients who were resuscitated after IHCA at Fuwai hospital between March 2017 and August 2022. We categorized the departments where cardiac arrest occurred as cardiac surgical or non-surgical units. Independent predictors of in-hospital survival were assessed by logistic regression.

RESULTS

A total of 119 patients with IHCA were analysed, 58 (48.7%) patients with cardiac arrest were in non-surgical units, and 61 (51.3%) were in cardiac surgical units. In non-surgical units, acute myocardial infarction/cardiogenic shock (48.3%) was the main cause of IHCA. Cardiac arrest in cardiac surgical units occurred mainly in patients who were planning or had undergone complex aortic replacement (32.8%). Shockable rhythms (ventricular fibrillation/ventricular tachycardia) were observed in approximately one-third of all initial rhythms in both units. Patients who suffered cardiac arrest in cardiac surgical units were more likely to return to spontaneous circulation (59.0% vs. 24.1%) and survive to hospital discharge (40.0% vs. 10.2%). On multivariable regression analysis, IHCA in cardiac surgical units (OR 5.39, 95% CI 1.90-15.26) and a shorter duration of resuscitation efforts (≤ 30 min) (OR 6.76, 95% CI 2.27-20.09) were associated with greater survival rate at discharge.

CONCLUSION

IHCA occurring in cardiac surgical units and a duration of resuscitation efforts less than 30 min were associated with potentially increased rates of survival to discharge.

Advanced life support interventions during intra-operative cardiac arrest among adults as reported to the 7th National Audit Project of the Royal College of Anaesthetists

BACKGROUND

Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols.

METHODS

We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists.

RESULTS

In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures.

CONCLUSIONS

The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.

Anesthetic and Intensive Care Approaches Following Radical Pneumonectomy: A Short Review of Patient Management and a Case Report

Around the world, lung cancer is the leading cause of cancer-related death and the most commonly diagnosed cancer. In the early stages, surgery is the preferable therapeutic strategy. We present the case of a male patient aged 49 years diagnosed with non-small cell lung cancer of the left lower lobe who was referred for a radical left pneumonectomy. After careful preoperative preparation, the surgery was proceeded with. During the surgery, the patient needed bronchoscopy for the aspiration of the trachea and bronchial tree; after the aspiration procedure, an intraoperative massive hemorrhage started, with shock and ventricular tachycardia. Nine days after surgery, the patient developed a pulmonary embolism and returned to the ICU. The patient benefited from transfusion, intrathoracic cardiac compressions, pulse index continuous cardiac output (PiCCO), renal replacement therapy (RRT), anticoagulation, and intensive care. After a complicated clinical course, the patient is discharged, and after more than 18 months, the patient comes regularly for follow-up consultation in good health.