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Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist Part 1

Moitra, Vivek K. MD, FCCM; Einav, Sharon MD; Thies, Karl-Christian MD; Nunnally, Mark E. MD; Gabrielli, Andrea MD; Maccioli, Gerald A. MD; Weinberg, Guy MD; Bannerjee, Arna MD; Ruetzler, Kurt MD; Dobson, Gregory MD; McEvoy, Matthew MD; O’Connor, Michael F. MD, FCCM

doi: 10.1213/ANE.0000000000003552
Letters to the Editor: Letter to the Editor
Free

Columbia University, New York, New York, vm2161@cumc.columbia.edu

Shaare Zedek Medical Center, Jerusalem, Israel

University Medical Center Greifswald, Greifswald, Germany

New York University, New York, New York

University of Pennsylvania, Philadelphia, Pennsylvania

Envision Healthcare, Plantation, Florida

The University of Illinois at Chicago, Chicago, Illinois

Vanderbilt University, Nashville, Tennessee

Cleveland Clinic, Cleveland, Ohio

Dalhousie University, Nova Scotia, Canada

Vanderbilt University, Nashville, Tennessee

University of Chicago, Chicago, Illinois

This manuscript that generated the Letter to the Editor was developed from previous iterations on behalf of the American Society of Anesthesiologists and the Society of Critical Care Anesthesiologists. Portions of this manuscript appear verbatim and are used with the permission of the American Society of Anesthesiologists.

Conflicts of Interest: V. K. Moitra is the American Society of Anesthesiologists’ liaison to the American Heart Association; Expert testimony. G. Weinberg is the founder and officer of ResQ Pharma, Inc and maintains the educational website lipidrescue.org.

The remaining authors declare no conflicts of interest.

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To the Editor

We thank Dr Bloomstone et al1 for their comments on our review article and for their thoughtful analysis of fluid responsiveness during the perioperative period. We agree that the generalizability of hemodynamic studies should be considered in the context of the conditions of the investigation and that larger studies are needed to validate previous findings.2,3 While there are no studies that demonstrate that dynamic indices predict fluid responsiveness after a cardiac arrest, El Hadouti et al4 recently found that the passive leg raise predicts fluid responsiveness in postoperative spontaneously breathing patients who had signs of hypovolemia. Additionally, predicting fluid responsiveness in right ventricular failure is challenging. For experts in advanced echocardiography, measurement of peak systolic velocity of tricuspid annular motion via tissue Doppler offers a potential parameter to identify false positives of fluid responsiveness in patients who have right ventricular dysfunction.5

We thank Dr Whitaker and O’Sullivan6 who correctly note that a sudden loss of end-tidal carbon dioxide (Etco2) with a flat trace of 0 mm Hg should prompt the clinician to consider esophageal intubation.7 The mental model of a flat trace of 0 in esophageal intubation contrasts with the reduction of Etco2 to the low levels of Etco2 observed during a cardiac arrest. Low levels of Etco2 can also occur in the setting of bronchospasm, endotracheal tube obstruction, and an air leak.8 The characteristics of carbon dioxide accumulation in the periarrest state are poorly studied in humans. Ongoing reviews by the European Society of Anesthesiologists, the American Society of Anesthesiologist, and the European Resuscitation Council may help inform our understanding of the issue and point to new opportunities for research.

Vivek K. Moitra, MD, FCCM
Columbia University
New York, New York
vm2161@cumc.columbia.edu

Sharon Einav, MD
Shaare Zedek Medical Center
Jerusalem, Israel

Karl-Christian Thies, MD
University Medical Center Greifswald
Greifswald, Germany

Mark E. Nunnally, MD
New York University
New York, New York

Andrea Gabrielli, MD
University of Pennsylvania
Philadelphia, Pennsylvania

Gerald A. Maccioli, MD
Envision Healthcare
Plantation, Florida

Guy Weinberg, MD
The University of Illinois at Chicago
Chicago, Illinois

Arna Bannerjee, MD
Vanderbilt University
Nashville, Tennessee

Kurt Ruetzler, MD
Cleveland Clinic
Cleveland, Ohio

Gregory Dobson, MD
Dalhousie University
Nova Scotia, Canada

Matthew McEvoy, MD
Vanderbilt University
Nashville, Tennessee

Michael F. O’Connor, MD, FCCM
University of Chicago
Chicago, Illinois

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REFERENCES

1. Bloomstone JA, Nathanson BH, McGee WT. Dynamic indices: use with caution in spontaneously breathing patients. Anesth Analg. 2018;127:e47–48.
2. Zöllei E, Bertalan V, Németh A, et al. Non-invasive detection of hypovolemia or fluid responsiveness in spontaneously breathing subjects. BMC Anesthesiol. 2013;13:40.
3. Hong DM, Lee JM, Seo JH, Min JJ, Jeon Y, Bahk JH. Pulse pressure variation to predict fluid responsiveness in spontaneously breathing patients: tidal vs forced inspiratory breathing. Anaesthesia. 2014;69:717–722.
4. El Hadouti Y, Valencia L, Becerra A, Rodríguez-Pérez A, Vincent JL. Echocardiography and passive leg raising in the postoperative period: a prospective observational study. Eur J Anaesthesiol. 2017;34:748–754.
5. Mahjoub Y, Pila C, Friggeri A, et al. Assessing fluid responsiveness in critically ill patients: false-positive pulse pressure variation is detected by Doppler echocardiographic evaluation of the right ventricle. Crit Care Med. 2009;37:2570–2575.
6. Whitaker DK, O’Sullivan EP. Capnography, esophageal intubation, and capnomanaging cardiac arrests in the operating room. Anesth Analg. 2018;127:e48–49.
7. Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106:617–631.
8. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S444–S464.
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