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CASE REPORT Table of Contents  
Ahead of print publication
Successful management of a case of sudden cardiac arrest in a postoff-pump coronary artery bypass graft surgery patient on fourth postoperative day and lessons learned: A resuscitation challenge - A case report

 Department of Anesthesia and Critical Care, Army Hospital (Research and Referral), Delhi Cantt, New Delhi, India

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Date of Submission26-Aug-2021
Date of Decision08-Oct-2021
Date of Acceptance14-Oct-2021
Date of Web Publication21-Sep-2022


Background: Every patient who has undergone a cardiac surgery carries a risk of sudden hemodynamic instability in the postoperative period due to already compromised cardiovascular functional status which has not yet fully recovered. Recognition of dangers and their subsequent management requires accurate knowledge of resuscitation protocols which are quite different from the standard CPR guidelines. Case Presentation: We report a case of cardiac arrest in the postoperative period. The patient had been extubated satisfactorily postcardiac surgery. The hemodynamic instability leading to cardiac arrest occurred on the 4th postoperative day, while he was straining during defecation. The patient was revived and successfully extubated with full recovery. Conclusion: The patient was off any inotropic support and on course for full recovery when he had cardiac arrest, which not only makes the case unique but also teaches us to be forewarned about such incidences in future. In spite of adequate hydration and administrating stool softener into the medication regimen, there exists a real risk of hemodynamic instability and associated cardiac arrest while straining. Moreover, postcardiac surgery patients who experience cardiac arrest need specific resuscitation protocols for a successful recovery, which are different from guidelines for cardiopulmonary resuscitation in other cases and need to be highlighted.

Keywords: Cardiac arrest, cardiac surgery, postoperative

How to cite this URL:
Sarin K, Dhawan N, Shankhyan VK. Successful management of a case of sudden cardiac arrest in a postoff-pump coronary artery bypass graft surgery patient on fourth postoperative day and lessons learned: A resuscitation challenge - A case report. Apollo Med [Epub ahead of print] [cited 2022 Sep 27]. Available from: https://apollomedicine.org/preprintarticle.asp?id=356574

  Introduction Top

Valsalva maneuver and defecation associated with cardiac arrest was first reported in 1968 and sparingly thereafter in the literature.[1],[2],[3] In postcoronary artery bypass graft patients, the risk for an adverse cardiac event is much higher due to an already compromised cardiovascular system.[4] The syncopal response may be preceded by prodromal symptoms such as nausea, headache, sweating, hyperventilation, chest pain, and palpitation.

After taking informed consent from the patient, we present a patient who experienced sudden cardiac arrest on 4th postoperative day (POD) after cardiac surgery. The patient was off any inotropic support and on course for full recovery when he had cardiac arrest, which not only makes the case unique but also teaches us to be forewarned about such incidences in future. Conditions leading up to the episode and subsequent management are discussed. Management aspects are quite different from the standard cardiopulmonary resuscitation (CPR) guidelines and hence need to be reiterated for the medical staff awareness and preparedness.

  Case Report Top

Our patient is a 72-year-old hypertensive and diabetic male who presented with New York Heart Association Class III chest pain, diagnosed to have triple vessel disease (underwent coronary angiography) with ejection fraction of 60% and no regional wall motion abnormality (preoperative two-dimensional [2D] transthoracic echocardiography). The patient was taking beta-blockers, aspirin, oral hypoglycemics, atorvastatin, and angiotensin-converting enzyme inhibitors preoperatively. Patient underwent off-pump coronary artery bypass grafting which was uneventful and shifted to intensive care unit (ICU) on ionotropic and vasopressor support of infusion injection epinephrine (0.03 mcg/kg/min), injection norepinephrine (0.03 mcg/kg/min), and injection dopamine (5 mcg/kg/min). Ventricular epicardial pacing wires had been placed intraoperatively, although patient continued in sinus rhythm and pacing was not required. The patient was successfully weaned off the ventilator and extubated after 10 h of stay in ICU, postsurgery.

POD 1, the patient was weaned off vasopressors and started on soft diet with stool softeners (syrup lactulose 20 ml HS). The patient was ambulated and encouraged to do incentive spirometry on 2nd POD. The patient was restarted on oral medications and showed stable hemodynamics.

By fourth POD, the patient was off inotropes and off oxygen but still being continuously monitored for electrocardiogram (ECG), SPO2, and intermittent noninvasive blood pressure. The patient had right internal jugular central line in situ, being used to monitor central venous pressures. Around noon on fourth POD, while straining for passing stools in bedpan, suddenly he became unresponsive and ECG on monitor displayed asystole. Immediate, Institutional Advanced Cardiac Life Support protocols were initiated and CPR began. The patient, having epicardial pacemaker leads, was connected to external pacemaker with heart rate kept at 90 bpm and asynchronous mode. Epinephrine bolus dose was given, and infusion was started. External cardiac massage (ECM) was given for a brief time. The patient was also intubated and connected to a ventilator. Bilateral equal air entry was confirmed, and there was no rise in airway pressures. Return of spontaneous circulation (ROSC) was achieved after 10 min of CPR. During those 10 min, transthoracic 2D echocardiography was also done to rule out cardiac tamponade and hypovolemia. External pacing was kept in demand mode. Dopamine infusion and norepinephrine infusion were also started. Hemodynamics were closely monitored, and the patient showed signs of improvement after 20 h of ROSC. Gradually, inotropes were tapered off. The patient also displayed improvement in terms of neurocognitive function was able to respond and obey simple commands. After 2 days of ventilator support, the patient was weaned off and extubated successfully. The patient has been discharged from the hospital and is on regular 3 month follow-up at hospital outpatient department.

  Discussion Top

After a deep inspiration, Valsalva maneuver is performed by forced expiration against a closed glottis for 10–20 s and is divided into four phases. Phase 1 is when straining starts, characterized by a rise in systemic arterial blood pressure and fall in heart rate. Phase 2 or straining phase occurs due to decrease in systemic venous return and stroke volume, leading to fall in systolic, diastolic, and pulse pressure and reflex increase in heart rate. Phase 3 starts when forced expiration stops which results in sudden increase in systemic venous return and abrupt, transient fall in arterial pressure, and associated with persistent (and increased) heart rate. Phase 4 is the overshoot phase consisting of return of prevalsalva levels after 6–8 beats and is associated with transient elevation of systemic arterial pressure, reflex bradycardia, and wide pulse pressure.[5] Not only the coronary blood flow decreases, albeit transiently, the literature also reports incidences of high-grade atrioventricular block, nodal-type ectopic rhythms, other cardiac rhythm disturbances, decreased cerebral blood flow, and pulmonary embolism. Any of these can lead to syncope or even ventricular arrest.[1],[6],[7]

In our case, the patient had strong urge to defecate just before the syncopal event and eventual cardiac arrest. No other premonitory syncope symptoms such as nausea and vomiting were exhibited. The increased vagal tone during Valsalva maneuver is to be avoided to decrease the risk of cardiac arrest in postcardiac surgery patients.

Important points in management as per the consensus guidelines [Figure 1] (CALS)[8] are discussed here. First, the defibrillation for ventricular fibrillation (VF) or pacing for asystole has been given a higher priority than ECM. It is recommended to perform three sequential shocks for VF or the initiation of temporary pacing for asystole before ECM. Our patient had asystole with epicardial leads in place and was immediately connected to temporary pacemaker (dual-chamber pacing at a rate of 90 bpm). ECM was delayed for approximately for 1 min to maximize the temporary pacemaker output. The concern for early ECM is potential trauma induced by it.
Figure 1: Resuscitation Flow Chart of patients who arrest after cardiac surgery. (VF/VT - Ventricular Fibrillation/ Ventricular Tachycardia; PEA- Pulseles Electrical Activity; BLS- Basic Life Support; CPR - Cardiopulmonary Resuscitation; DC - Direct Current; ET - endotracheal tube; IABP - intra-aortic balloon pump; PEEP - positive end-expiratory pressure).

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Second, during cardiac arrest, epinephrine is not recommended in the routine arrest protocols and should only be administered by experienced physicians.[8] Epinephrine infusion was started in our patient once maximum temporary pacemaker output was achieved and ECM started under supervision of a senior cardiac anesthesiologist.

Conventional airway management applies during CALS. For cardiac arrest in patients on intra-aortic balloon pump (IABP) support, pressure trigger mode should be used (Class IIA, Level C). Internal mode for triggering (rate of 100 bpm) can be used in the event of a significant period without massage, until massage is recommenced (Class IIA, Level C). If cardiac arrest occurs with stable ECG rhythm (e.g., pulseless electrical activity), IABP may be continuously triggered with ECG and IABP generated pressure trace may give a false impression of a cardiac output (CO). If this occurs, it is suggested to pause IABP and look for other pulsatile traces. During external chest compression (ECC), pressure trigger in a 1:1 ratio is set with maximal augmentation to augment diastolic perfusion in line with ECC which would increase coronary and cerebral perfusion. Intrinsic trigger with 100 bpm is used if there is no ECC or CO.

Role of emergency resternotomy. The most likely causes of non-VF/VT arrest in cardiac surgical patients include tamponade, severe hypovolemia, or tension pneumothorax. Treatment of the underlying cause results in an excellent outcome. Resternotomy within 5 min is recommended in a nonVF/VT cardiac arrest that does not resolve after pacing and exclusion of readily reversible causes, emergency (Class I, Level C). This is more so relevant in case of systolic pressure with external massage <60 mm Hg.[8]

  Conclusion Top

The condition of defecation syncope is a well-recognized risk for cardiac arrest, more so in postcardiac surgery patients. Management of cardiac arrest postcardiac surgery is a multidisciplinary activity including, intensivists, cardiac anesthesiologists, cardiac surgeons, and cardiac-trained paramedical staff. Recognition of dangers and their subsequent management requires accurate knowledge of resuscitation protocols which are quite different from the standard CPR guidelines.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



Conflicts of interest

There are no conflicts of interest.

Author's contribution

Dr. Kunal Sarin- Management of the case, drafting the article. Dr. Naresh Dhawan- Management of the case, Critical revision of the manuscript. Dr. Vikas Kumar Shankhyan- Critical revision of the manuscript.

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  References Top

Schartum S. Ventricular arrest caused by the Valsalva maneuver in a patient with Adams-Stokes attacks accompanying defecation. Acta Med Scand 1968;184:65-8.  Back to cited text no. 1
Pathy MS. Defaecation syncope. Age Ageing 1978;7:233-6.  Back to cited text no. 2
Kapoor WN, Peterson J, Karpf M. Defecation syncope. A symptom with multiple etiologies. Arch Intern Med 1986;146:2377-9.  Back to cited text no. 3
Sikirov BA. Cardio-vascular events at defecation: Are they unavoidable? Med Hypotheses 1990;32:231-3.  Back to cited text no. 4
Vijay Raghawa Rao BN. Clinical Examination in Cardiology. 2nd Edition. Elsevier (India) 2017:p 376-7.  Back to cited text no. 5
Curtis B, Hughes T, Lo Bue D, Christopher JS. Defecation Syncope: Two Cases of Post-Operative Cardiac Arrest. Anaplastology 2015;4:142.  Back to cited text no. 6
McGuire J, Green RS, Courter S, Hauenstein V, Braunstein JR, Plessinger V, et al. Bed pan deaths. Trans Am Clin Climatol Assoc 1948;60:78-86.  Back to cited text no. 7
Dunning J, Levine A, Ley J, Strang T, Lizotte DE, Jr, Lamarche Y. STS expert consensus statement resuscitation after cardiac surgery. Ann Thorac Surg 2017;103:1005-20.  Back to cited text no. 8

Correspondence Address:
Kunal Sarin,
Department of Anesthesia and Critical Care (Cardiac Anaesthesia), Army Hospital (Research and Referral), Delhi Cantt, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_102_21


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