Introduction:
Definite protocol for resuscitation after Cardiac arrest exists and practiced all over the world. But the success lies in early detection and early defibrillation .
It is also seen after 10 mins of resuscitation if the activity does not return there it is likely that the patient has residual neurological deficit because of ischaemic encephalopathy.
We describe here with 1 cases of Cardiac arrest lasting 21 minutes and 28 minutes, which was successfully revived with no neurological deficit
Case 1. A middle aged patient of 48 years undergoing open Cholicystectomy. The patient was of ASA- ! with no known abonormality of any parameter. The patient was premedicated with Midazolam 2mg , Pentazocine 30 mg and induced with Thiopentone 200 mg and intubated with Vecuronium 6mg . The anaesthesia was maintained with Oxygen 33%N2O 66% , Halothane 0.5- 0.7 % and IPPV Manually. About 45 mins after induction of Anaesthesia the operation was over there was no undue Hemodynamic changes intraoperatively. After the end of surgery about 40- 45 mins from the start, limited bagging was done so that respiratory activity can be noticed , some CO2 accumulation was allowed so as to stimulate the respiration.. Within a short time respiratory activity appeared and the the patient was allowed to breath spontaneously with 100 % Oxygen with intermittent support..Then Injection of Neostigmine and atropine mixture was given slow IV over 3 minutes. Before completion of all the prostigmine there was alarm in monitor with bizarre waves, thinking that the lead has come off, it was readjusted and the same pattern continued, When the radial pulse was examined , there was no pulse. Immidiately it was thought that the patient has gone to Ventricular fibrillation which was confirmed with another monitor. Immidiately a defibrillator was called for, Artificial ventilation continued with 100 % Oxygen and external Cardiac massage commenced . There was panic in OR ,I started a good and forceful cardiac massage and the assistants were encouraged to do the same where pulsatile plethysmographic waves were detected in Pulse Oxymeter with Saturation of 60 – 75 %. When a BPL defibrillator arrived it did not start because the battery was almost totally discharged The failed to charge 200 joules even when connected to electricity supply. The BPL supplier was contacted who advised to charge the battery before charging the defibrillator. With no other option the external Cardiac massage continued with full vigor. When somebody was fiddling with the defibrillator , it changed to the Pediatric mode. By this time more than 18 mins had elapsed . With the pediatric mode the defibrillator was charged with 50 joules, that was the upper limit in pediatric setting . Initially it also failed. Again after 3 mins it clicked. With intruption of External cardia c massage. 50 joules were delivered.
Alash ! It worked The rythm was convereted to sinus witha HR of 60 which increased to 90. The peripheral pulse was plabale and the NIBP recorded was 105/60 mmHg. and SpO2 99-100 %. There was no facility to do an ABG analysis or adminster any Sodi bicarb. The patient was hyperventilated for next 15 mins when ts respiratory effort returned and was vey normal. Consciousness returned too. Post op recovery was totally uneventful. When we checked with the monitor trend graph we found that the period of fibrillation was around 21 mins.
Discussion: what could be the cause ?
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| 24 Hrs after surgery with no damage, no memory of any incident |
The intresting part of story is that it responded well only to 50 joules, though the common recommendation is to go for 160 - 200 joules. even people apply 300 joules.
Cerebral anoxia was not evident was the patient was on 100 % Oxygen before during and after the critical incident.
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