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Brain & Heart Prone cardiopulmonary resuscitation

In addition, we discuss the intricacies and effectiveness resuscitation in the supine position. EtCO was maintained
2
of resuscitation in a prone position and neuroprotective at 20 – 25 mmHg, and propofol 1 mg/kg and midazolam
strategies in the perioperative setting to optimize long- 0.05 mg/kg IV were administered. Advanced cardiac life
term functional outcomes. support (ACLS) then proceeded in the supine position,
and ROSC was achieved after 3 min. BIS was noted at 51
2. Case presentation – 55. The assessment at this time was hypovolemic shock.

A 57-year-old male, weighing 70 kg, with a history of Propofol and remifentanil infusions were continued
mitral valve prolapse (MVP), hypertension, dyslipidemia, throughout the intraoperative course. The patient was
asymptomatic bronchial asthma, and a previous shifted to the supine position, and central access was
cerebrovascular infarct, presented with a 5-month secured through the left subclavian vein for inotropic
history of nape pain and numbness in the upper and support, fluid resuscitation, and blood transfusion. Once
lower extremities. Spine magnetic resonance imaging stable, the patient was shifted back to the prone position
revealed progressive spinal cord compression classified as for hemostasis and surgical closure of the C1-C3 partial
American Spinal Injury Association Impairment Scale C left and complete right laminectomy and excision of
from a C2-C3 Schwannoma, which was consistent with the dumbbell schwannoma. Total anesthesia time was 8 h, with
patient’s quadriparesis. an estimated blood loss of 3 L, which was replaced.

2.1. Pre-operative course 2.3. Post-operative course
The patient was hemodynamically stable and oriented to At post-anesthesia care unit (PACU), the patient was
three spheres, with a Glasgow Coma Scale score of 15. fully awake and responsive, hemodynamically stable, and
Manual muscle testing results were as follows: C5-T1 was tolerated a trial of extubation well. The patient developed
4/5 on the right and 0/5 on the left; L2-S2 was 2/5 on the right hospital-acquired pneumonia during his admission,
and 4/5 on the left. The last normal sensory level was noted requiring ventilatory support. He was eventually discharged
th
at C2, and proprioception was intact on all extremities. on the 46 post-operative day with a tracheostomy tube in
Pre-operative blood tests were all within normal range. place.
A 12-lead electrocardiogram showed regular sinus rhythm
and normal axis. A 2D echocardiogram showed MVP with 3. Discussion
moderate mitral regurgitation, good cardiac wall motion Post-cardiac arrest brain injury is the main cause of death
and contractility, normal cardiac chamber dimensions, and disability in resuscitated patients. As its oxygen reserve
and adequate left ventricular systolic function, with aortic is limited and 65% of body glucose consumption mainly
sclerosis and a 64% ejection fraction. occurs in the brain, the brain’s tolerance to ischemia and
hypoxia is low. Brain viability strongly depends on a
6,7
2.2. Intraoperative course consistent supply of oxygen and energy substrates, and
Induction and intubation were well tolerated, and general cessation of cerebral blood flow results in an immediate
anesthesia was maintained with a target-controlled interruption of brain activity. The mechanism of brain
infusion of remifentanil and propofol, along with injury during cardiac arrest and resuscitation after ROSC
sevoflurane at 0.5 minimum alveolar concentration. are complex and include excitotoxicity, disrupted calcium
End-tidal carbon dioxide (EtCO ) was maintained at 35 homeostasis, free radical formation, pathological protease
2
– 38 mmHg, with controlled ventilation. Bispectral index cascades, and neuronal apoptosis. 8-10 Selective neuronal
(BIS) values were maintained at 40 – 60, and pulse pressure damage increases with longer ischemic duration, especially
variations were sustained at 12 – 15%. Brief hypotensive in areas of higher vulnerability, such as subcortical regions.
episodes were noted as the patient was shifted to the prone This consequential cascade of secondary insult occurs over
position, eventually requiring low-dose norepinephrine hours to days, suggesting a broad therapeutic window for
to maintain a mean arterial pressure >85 mmHg. Two neuroprotective strategies post-cardiac arrest. 2,11-16 Cerebral
hours into the surgery, a sudden massive blood loss of blood flow decreases to 50% as the cerebral metabolic rate of
approximately 2 L was noted and was simultaneously oxygen and oxygen extraction fraction are both decreased
addressed with fluid resuscitation and blood transfusion. within 24 – 72 h. Post-resuscitative neuroprotective efforts
17
The patient continued to be hemodynamically unstable should aim to achieve cerebral autoregulation, ensuring
despite resuscitative efforts. Oxygen saturation decreased that derangements in temperature, blood pressure,
16
to 80% with sinus bradycardia, which eventually converted oxygenation, ventilation, and fluid status are addressed.
to pulseless ventricular fibrillation. CPR was started in the In our patient, fluid resuscitation and blood transfusion,
prone position during surgical closure, in preparation for as well as correction of electrolyte and arterial blood gas

Volume 2 Issue 3 (2024) 2 doi: 10.36922/bh.3392