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CARDIAC ARREST ON THE OPERATING TABLE! (July, 2004)


Cardiac arrest - complete stoppage of the beating of the heart is fatal unless corrective measures restore the beating within a couple of minutes. During cardiac arrest, blood flow to all vital organs stops and within a short period of time, measured in seconds, either permanent and serious damage occurs to these vital organs, particularly the brain or death ensues. Cardiac arrest can occur anytime and anywhere and with or without any recognizable provocation. It is more likely in someone who has already some underlying disease of the heart. Prompt recognition and quick resuscitative measures can and has saved many lives. Even a first aider is expected to be familiar with resuscitative measures called as Cardio respiratory resuscitation. An important component of this emergency measure is external cardiac message. If it happens in a Hospital or if the patient is rushed to a Hospital, next level of diagnosis, facilities and expertise would be available. Exact type of cardiac problem can be recognized and emergency facilities and trained doctors can give better and faster treatment to restore and resuscitate. Hospitals and doctors specialized in "Acute Care" can often successfully restore life, compared to an average doctor or Hospital.

But when "cardiac arrest" occurs during a surgical operation, almost always, doctors trained to recognize and correctly treat it are already in place. And almost always they are able to revive the heart beat. Alertness on the part of the Anaesthesiologist and other attending doctors and paramedics during the entire surgery is most important. Currently most modern Operation Theatres are equipped with automatic machines with alarm systems to record the BP, pulse. Oxygen concentration in blood and ECG. Quick recognition of the complication and immediate and timely treatment usually tides over the crisis. Rarely however, treatment methods may not yield favourable results and "Death on Table" may occur! Such a situation is,of course, most distressing to the patient's family and the surgical team. Such unfavourable and distressing situation is more likely to occur in "high risk" patients undergoing surgery. The surgical team will have to evaluate realistically the need and urgency for surgery and the risk involved and discuss this with the patient and/or his relatives. Time and again,doctors refuse to perform the surgery requested or needed, if the risks are more than the likely benefits and outcome of the procedure. However, if surgery is necessary as a life saving procedure or likely to result in serious disability or death if not operated, calculated risks will be taken after detailed discussion with the patient's family.

Kidney tumour surgery in a 60 years old patient:
This patient had a Cancer of right kidney and he was undergoing "radical nephrectomy" under regional (spinal) anaesthesia. After mobilization of most of the tumour, suddenly the whole of the operating field got literally flooded with torrential bleeding! Almost immediately, the anaesthetist shouted that the heart has stopped beating! There was a grave life threatening surgical emergency which unless tackled properly will inself lead to fatality. At the same time, due to this torrential bleed or some other unidentified reason, cardiac arrest had occurred. This arrest unless reversed within a couple of minutes will cause permanent damage to vital organs or death itself. Both the teams - the surgical team and the anaesthetic team had to take immediate corrective measures without any delay!

The surgeon grabbed a couple of large abdominal pads and exerted gentle but firm pressure at the suspected bleeding point, sucked out the collected blood and to his immense relief found that bleeding was arrested for the time being. Meanwhile he instructed procuring and starting infusion of blood and till it was procured, a blood substitute to make up for the blood loss. The highly experienced anaesthetist quickly passed an endotracheal tube ( tube into the respiratory passage or trachea) and started 100 % oxygen and ventilated the lungs; gave some emergency I.V. injections and also gave external cardiac message. All these were completed in about 1 ½ minutes and fortunately the heart started beating again. Within another 4-5 minutes, patient was revived; his heart beat was steady; BP was recordable and patient was stable. One more unit of blood was ordered and further action to find the cause of bleeding and its control had to be planned.

Right sided kidney tumours are often adherent to the major vein, the Inferior Vena Cava, almost as thick as the thumb. This vessel returns to the heart all the blood from both lower limbs and abdominal organs to the right chambers of the heart. Tear of this major vessel in right sided kidney tumour operations is a well known possible hazard and this was what did happen in this patient. This tear in the vessel needed special instruments and sutures and the surgeon must be capable and experienced enough to perform this repair work. This is presently in the domain of "Vascular surgeons". But any good general surgeon or urologist should be capable of handling this crisis. Taking all possible precautions to do a watertight repair of the IVC and also complete the surgery of removal of the cancerous growth in the kidney was carefully and expeditiously completed. The patient made an uneventful recovery.

The patient was given other ancillary treatment for the cancer and he lived for some more years, free from cancer.

In spite of taking all possible proactive measures by the surgeon and anaesthetist and taking corrective measures in the event of a life threatening emergency during operation, death on operating table, during surgery is very distressing to the surgeon and other doctors and patient's kith and kin. Such an event leaves a permanent scar in the surgeon's mind and remains a blot in his professional career. There are instances, where the surgeon makes a strategic retreat - leaves the operation half way through - and closes up the wound. He has to explain to the relatives why he had to retreat. It is certainly better to retreat to save the life of a dear one to the family rather than stand on false prestige and "boldly" complete the operation and have the patient die on the operating table or immediate post operative period. Sometimes after such an operation patient is kept on life maintainance measures in an ICU , only to be told after some time, that there is no chance of recovery. In any life threatening medical emergency, cool and composed mind by the attending doctors, quick and split seconds decisions and correct action can often save life. This is all the more true during a major surgical operation!

Be well informed; but do have complete trust in the doctors to whom you submit yourself or your dear ones for treatment or surgery. You should do all the enquiries and clear all your doubts before taking treatment. Trust and expressing your trust in the doctor will result in the doctor doing his very best for the patient!

 

Dr. M.Mohan Rao, MBBS,MS,FICS,MCH,

M.D. & Chief Surgeon, Dr. U Mohan Rau Memorial Hospital.
E-mail:mmr@mohanraohospital.com




 

Updated on 01.07.2004.
 

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