Open indirect cardiac massage in neonate
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《美国医学杂志》
1 Department of Anaesthesiology and Critical Care, University College of Medical Sciences Warrington, United Kingdom
2 Guru Teg Bahadur Hospital, Delhi, India
Abstract
Open, direct cardiac massage (OCM), as a technique of resuscitation has not been very inspiring due to its various limitations. We report a case of resuscitation where open 'indirect' cardiac massage was used to resuscitate a neonate successfully. A 24 hr old neonate with multiple gastrointestinal anomalies presented for emergency laparotomy. Intraoperatively she suffered a cardiac arrest. External chest compressions (ECC) failed to produce detectable circulation and surgeons were asked to initiate direct cardiac compressions. They could palpate and successfully compress the heart without the need to split the diaphragm. This 'infra-diaphragmatic' approach resulted in adequate circulation and subsequent uncomplicated recovery.
Keywords: Resuscitation; Neonate; Cardiac massage; Internal; Open
German surgeon Moritz Schiff[1] has been credited with the recognition of cardiac massage as a technique of resuscitation following cardiac arrest. His technique involved opening up the chest walls of dogs and squeezing of their hearts. This 'open cardiac massage' (OCM) or 'internal cardiac massage' (ICM) generated a lot of interest, but even today, a majority of us remain unconvinced about its utility in clinical practice. OCM due to its inherent technical difficulties and possibility of complications has been reserved for special situations only. The guidelines of indications and techniques of OCM have also been described,[2] but for adults, only. Here is presented a case where internal cardiac massage was used to resuscitate a neonate following a cardiac arrest on the operation-table.
Case report
A 24-hour-old female neonate weighing 2.2 kg presented to the surgery emergency with complaints of progressively increasing abdominal distension. The child was not taking feeds and had not passed any faeces. There was no significant maternal, family or birth history. On examination, the child was listless with a pulse rate of 130 bpm. Abdominal examination revealed dilated colonic loops; anorectal malformation similar to cloaca was present. There was no evidence of any other congenital abnormality. Her investigations revealed a hemoglobin value of 12 g% and renal function tests were within normal limits.
Exploratory laparotomy was planned and she was taken up for anaesthesia under ASA physical status grade IV E. Following the establishment of an intravenous line (with an infusion of 5% dextrose in 0.45% saline) monitoring for continuous heart rate, ECG, SPO2 (pulse oximetry) and temperature were instituted. Anaesthesia was induced with morphine 0.1 mg iv, thiopentone sodium 15 mg iv and following succinylcholine chloride 4 mg iv, the trachea was orally intubated with a size 3.0 mm tracheal tube. Anaesthesia was maintained with oxygen in nitrous oxide (1: 1) with halothane (0.5 %) and atracurium was used for muscle relaxation.
The surgical findings included severe intestinal adhesions, dilated colonic loops filled with meconium, hydro-uterus and hydrosalpinx. The urinary bladder and uterus were also found to be collapsed and adherent to adjacent structures. Adhesiolysis and resection - anastomosis of the bowel was planned.
During surgery, the patient lost approximately 50-75 ml of blood. Resuscitation with crystalloids (normal saline) was in progress till the blood was made available. The patient had become considerably pale and absence of a pulse oximeter plethysmographic waveform suggested inadequate peripheral perfusion. N2O and halothane were switched off. As soon as the blood arrived, a bolus of about 25 ml of blood was transfused over a period of 15 minutes. Following this, the patient had bradycardia, for which injection atropine 0.04 mg iv was administered. This was followed by asystole (on ECG monitor COLINS- BP306) confirmed by the absence of cardiac activity on auscultation of the precordium.; blood transfusion was stopped and external cardiac massage (ECM) was initiated. Adrenaline 0.02 mg iv and calcium gluconate 50 mg iv were administrated. ECM was continued for about 3 minutes, but due to its inability to produce any carotid or abdominal aortic pulsations, it was considered ineffective. The surgeons were then asked to palpate the heart and initiate cardiac compressions by an 'infra diaphragmatic' approach. They were able to compress the heart against the sternum using one hand, without the need of splitting the diaphragm. These cardiac compressions resulted in palpable carotid and aortic pulsations and in about 3 minutes, spontaneous cardiac activity returned.
Once the patient's vital parameters stabilized, surgery was continued. Blood transfusion was restarted following a repeat cross-check, but at a very slow rate. Subsequently, the patient's condition improved; heart rate stabilized at 130 bpm, plethysmographic waveform reappeared and pulse oximetry showed a saturation of 100%. Over the next one hour another 30 ml of blood was transfused, uneventfully. Postoperatively, elective ventilation was planned and patient was shifted to the ICU. The patient gradually improved, regained consciousness, had her trachea extubated and was subsequently shifted to the ward from the ICU on the 3rd postoperative day.
Discussion
Open cardiac massage involves opening up of the thorax via a midline sternotomy or more commonly, an anterolateral incision in the left 4th intercostal space.[3] Following the incision, direct compression of the heart between the two hands (two hand technique) or one hand and the sternum (one hand technique) is commenced.
Mauclaire suggested an abdomino transdiaphragmatic approach of OCM which involved laparotomy followed by incision of the diaphragm and pericardium followed by cardiac compressions.[4] This was considered a safer and easier alternative to the thoracic approach.[5]
OCM has been found to generate better cardiac output, better myocardial and cerebral blood flow in both animals and adult human beings, although in a few studies.[6],[7] Birchner et al[8] while experimenting on dogs found OCM to be advantageous over the standard ECM following over four minutes of cardiac arrest with respect to the survival and recovery of neurological functions. According to the ILCOR guidelines, it is considered only a class IIb recommendation, in conditions like; (a) cardiac arrest due to hypothermia, pulmonary embolism or pericardial tamponade, (b) chest deformity and c) penetrating abdominal trauma with deterioration.[2] However, in children and infants, OCM hasn't been found to offer any advantages over ECM. Beaver et al[9] found that emergency room thoracotomy did not improve survival in paediatric trauma patients with no detectable vital signs, thus suggesting that OCM in paediatric trauma patients should only be reserved for patients with penetrating thoracic injuries or blunt injuries with deterioration despite maximal conventional therapy. Sheikh et al[10] also reported that OCM is both futile and cost ineffective in paediatric patients, after 20 minutes of cardiac arrest.
Due to the obvious difficulties this technique offers, decision to switch over from ECM to OCM even in an operating room setup with the availability of expert surgeons is subjective, not being well supported with clinical evidence. However in cases where the thorax or abdomen has been opened up for a procedure, this decision becomes straightforward and there is no reason for OCM or ICM to be withheld.
In the present case, ECM which was tried for 3 minutes should have been successful considering the maintained integrity of the thoracic cage. Yet evidence of successful compressions, e.g. carotid pulsations or abdominal aortic pulsations was lacking. So this 'infra diaphragmatic', indirect cardiac massage was advised to the surgeons who could effectively compress the heart without the need for splitting the diaphragm and pericardium. This was possible, considering the anatomical immaturity of the neonatal diaphragm.
The probable causes of cardiac arrest in the present case were; profound or sustained anemia, hyperkalemia, hypocalcaemia or mismatched blood transfusion. Profound anemia resulting in cardiac arrest, while it was being treated, is highly unlikely as the patient received 25 ml of blood and responded quickly to cardiac massage. The possibility of an anaesthetic overdose in a hypovolemic patient cannot be ruled out. Calcium gluconate, which is not routinely used in resuscitation, was given in this case, considering a possibility of hyperkalemia / hypocalcaemia; blood transfusion was stopped, injection adrenaline and hydrocortisone were given considering mismatched blood transfusion reaction. But re-cross-match of the blood and post resuscitation electrolytes' reports were within normal limits.
This report thus highlights that ECM might not be effective with an open abdominal wall and during such times urgency in instituting ICM should be sought. Also, in neonates, ICM or OCM via the abdominal 'infra diaphragmatic' approach, without incising the diaphragm and pericardium may be less traumatic than the abdominal 'trans-diaphragmatic' or thoracic approach while being equally effective. We recommend this approach in paediatric cases where ECM is ineffective especially with an open abdominal wall. Further evaluation of the efficacy of this approach is, obviously, needed.
References
1. Schiff M. Ether et chloroforme.Benda Lausanne, ed. Recueil des me′moires physiologiques. Switzerland, 1896: 1-25.
2. Circulation, 2000; 102(S1): I-107-108.
3. Blakeman B. Open cardiac resuscitation. A surgeon's viewpoint. Postgrad Medicine 1990; 87 (1) : 247-248, 251, 253.
4. Mauclaire M. Massage du coeur. Bull Mem Soc Chir Paris 1906; 32 : 712-715.
5. Green TA. Heart massage as a means of restoration in cases of apparent sudden death, with a synopsis of 40 cases. Lancet 1906; 2 : 1706-1714.
6. Boczar ME, Howard MA, Rivers EP et al. A technique revisited: Hemodynamic comparison of closed and open-chest cardiac massage during human cardiopulmonary resuscitation. Critical Care Medicine 1995; 23 (3): 498-503.
7. Byrne D, Pass HI, Neely WA et al. External versus internal cardiac massage in normal and chronically ischemic dogs. Am Surgeon 1980; 46 (12): 657-662.
8. Birchner N, Safar P. Manual open chest cardiopulmonary resuscitation. Ann Emerg Med 1984; 13 : 770-773.
9. Beaver BL, Colombani PM, Buck JR et al. Efficacy of emergency room thoracotomy in pediatric trauma. J Pediatr Surgery 1987; 22(1): 19-23.
10. Sheikh A, Brogon T. Outcome and cost of open-and closed-chest cardiopulmonary resuscitation in pediatric cardiac arrests. Pediatrics 1994; 93 : 392-398.(Saxena Neeraj, Chaudhary )
2 Guru Teg Bahadur Hospital, Delhi, India
Abstract
Open, direct cardiac massage (OCM), as a technique of resuscitation has not been very inspiring due to its various limitations. We report a case of resuscitation where open 'indirect' cardiac massage was used to resuscitate a neonate successfully. A 24 hr old neonate with multiple gastrointestinal anomalies presented for emergency laparotomy. Intraoperatively she suffered a cardiac arrest. External chest compressions (ECC) failed to produce detectable circulation and surgeons were asked to initiate direct cardiac compressions. They could palpate and successfully compress the heart without the need to split the diaphragm. This 'infra-diaphragmatic' approach resulted in adequate circulation and subsequent uncomplicated recovery.
Keywords: Resuscitation; Neonate; Cardiac massage; Internal; Open
German surgeon Moritz Schiff[1] has been credited with the recognition of cardiac massage as a technique of resuscitation following cardiac arrest. His technique involved opening up the chest walls of dogs and squeezing of their hearts. This 'open cardiac massage' (OCM) or 'internal cardiac massage' (ICM) generated a lot of interest, but even today, a majority of us remain unconvinced about its utility in clinical practice. OCM due to its inherent technical difficulties and possibility of complications has been reserved for special situations only. The guidelines of indications and techniques of OCM have also been described,[2] but for adults, only. Here is presented a case where internal cardiac massage was used to resuscitate a neonate following a cardiac arrest on the operation-table.
Case report
A 24-hour-old female neonate weighing 2.2 kg presented to the surgery emergency with complaints of progressively increasing abdominal distension. The child was not taking feeds and had not passed any faeces. There was no significant maternal, family or birth history. On examination, the child was listless with a pulse rate of 130 bpm. Abdominal examination revealed dilated colonic loops; anorectal malformation similar to cloaca was present. There was no evidence of any other congenital abnormality. Her investigations revealed a hemoglobin value of 12 g% and renal function tests were within normal limits.
Exploratory laparotomy was planned and she was taken up for anaesthesia under ASA physical status grade IV E. Following the establishment of an intravenous line (with an infusion of 5% dextrose in 0.45% saline) monitoring for continuous heart rate, ECG, SPO2 (pulse oximetry) and temperature were instituted. Anaesthesia was induced with morphine 0.1 mg iv, thiopentone sodium 15 mg iv and following succinylcholine chloride 4 mg iv, the trachea was orally intubated with a size 3.0 mm tracheal tube. Anaesthesia was maintained with oxygen in nitrous oxide (1: 1) with halothane (0.5 %) and atracurium was used for muscle relaxation.
The surgical findings included severe intestinal adhesions, dilated colonic loops filled with meconium, hydro-uterus and hydrosalpinx. The urinary bladder and uterus were also found to be collapsed and adherent to adjacent structures. Adhesiolysis and resection - anastomosis of the bowel was planned.
During surgery, the patient lost approximately 50-75 ml of blood. Resuscitation with crystalloids (normal saline) was in progress till the blood was made available. The patient had become considerably pale and absence of a pulse oximeter plethysmographic waveform suggested inadequate peripheral perfusion. N2O and halothane were switched off. As soon as the blood arrived, a bolus of about 25 ml of blood was transfused over a period of 15 minutes. Following this, the patient had bradycardia, for which injection atropine 0.04 mg iv was administered. This was followed by asystole (on ECG monitor COLINS- BP306) confirmed by the absence of cardiac activity on auscultation of the precordium.; blood transfusion was stopped and external cardiac massage (ECM) was initiated. Adrenaline 0.02 mg iv and calcium gluconate 50 mg iv were administrated. ECM was continued for about 3 minutes, but due to its inability to produce any carotid or abdominal aortic pulsations, it was considered ineffective. The surgeons were then asked to palpate the heart and initiate cardiac compressions by an 'infra diaphragmatic' approach. They were able to compress the heart against the sternum using one hand, without the need of splitting the diaphragm. These cardiac compressions resulted in palpable carotid and aortic pulsations and in about 3 minutes, spontaneous cardiac activity returned.
Once the patient's vital parameters stabilized, surgery was continued. Blood transfusion was restarted following a repeat cross-check, but at a very slow rate. Subsequently, the patient's condition improved; heart rate stabilized at 130 bpm, plethysmographic waveform reappeared and pulse oximetry showed a saturation of 100%. Over the next one hour another 30 ml of blood was transfused, uneventfully. Postoperatively, elective ventilation was planned and patient was shifted to the ICU. The patient gradually improved, regained consciousness, had her trachea extubated and was subsequently shifted to the ward from the ICU on the 3rd postoperative day.
Discussion
Open cardiac massage involves opening up of the thorax via a midline sternotomy or more commonly, an anterolateral incision in the left 4th intercostal space.[3] Following the incision, direct compression of the heart between the two hands (two hand technique) or one hand and the sternum (one hand technique) is commenced.
Mauclaire suggested an abdomino transdiaphragmatic approach of OCM which involved laparotomy followed by incision of the diaphragm and pericardium followed by cardiac compressions.[4] This was considered a safer and easier alternative to the thoracic approach.[5]
OCM has been found to generate better cardiac output, better myocardial and cerebral blood flow in both animals and adult human beings, although in a few studies.[6],[7] Birchner et al[8] while experimenting on dogs found OCM to be advantageous over the standard ECM following over four minutes of cardiac arrest with respect to the survival and recovery of neurological functions. According to the ILCOR guidelines, it is considered only a class IIb recommendation, in conditions like; (a) cardiac arrest due to hypothermia, pulmonary embolism or pericardial tamponade, (b) chest deformity and c) penetrating abdominal trauma with deterioration.[2] However, in children and infants, OCM hasn't been found to offer any advantages over ECM. Beaver et al[9] found that emergency room thoracotomy did not improve survival in paediatric trauma patients with no detectable vital signs, thus suggesting that OCM in paediatric trauma patients should only be reserved for patients with penetrating thoracic injuries or blunt injuries with deterioration despite maximal conventional therapy. Sheikh et al[10] also reported that OCM is both futile and cost ineffective in paediatric patients, after 20 minutes of cardiac arrest.
Due to the obvious difficulties this technique offers, decision to switch over from ECM to OCM even in an operating room setup with the availability of expert surgeons is subjective, not being well supported with clinical evidence. However in cases where the thorax or abdomen has been opened up for a procedure, this decision becomes straightforward and there is no reason for OCM or ICM to be withheld.
In the present case, ECM which was tried for 3 minutes should have been successful considering the maintained integrity of the thoracic cage. Yet evidence of successful compressions, e.g. carotid pulsations or abdominal aortic pulsations was lacking. So this 'infra diaphragmatic', indirect cardiac massage was advised to the surgeons who could effectively compress the heart without the need for splitting the diaphragm and pericardium. This was possible, considering the anatomical immaturity of the neonatal diaphragm.
The probable causes of cardiac arrest in the present case were; profound or sustained anemia, hyperkalemia, hypocalcaemia or mismatched blood transfusion. Profound anemia resulting in cardiac arrest, while it was being treated, is highly unlikely as the patient received 25 ml of blood and responded quickly to cardiac massage. The possibility of an anaesthetic overdose in a hypovolemic patient cannot be ruled out. Calcium gluconate, which is not routinely used in resuscitation, was given in this case, considering a possibility of hyperkalemia / hypocalcaemia; blood transfusion was stopped, injection adrenaline and hydrocortisone were given considering mismatched blood transfusion reaction. But re-cross-match of the blood and post resuscitation electrolytes' reports were within normal limits.
This report thus highlights that ECM might not be effective with an open abdominal wall and during such times urgency in instituting ICM should be sought. Also, in neonates, ICM or OCM via the abdominal 'infra diaphragmatic' approach, without incising the diaphragm and pericardium may be less traumatic than the abdominal 'trans-diaphragmatic' or thoracic approach while being equally effective. We recommend this approach in paediatric cases where ECM is ineffective especially with an open abdominal wall. Further evaluation of the efficacy of this approach is, obviously, needed.
References
1. Schiff M. Ether et chloroforme.Benda Lausanne, ed. Recueil des me′moires physiologiques. Switzerland, 1896: 1-25.
2. Circulation, 2000; 102(S1): I-107-108.
3. Blakeman B. Open cardiac resuscitation. A surgeon's viewpoint. Postgrad Medicine 1990; 87 (1) : 247-248, 251, 253.
4. Mauclaire M. Massage du coeur. Bull Mem Soc Chir Paris 1906; 32 : 712-715.
5. Green TA. Heart massage as a means of restoration in cases of apparent sudden death, with a synopsis of 40 cases. Lancet 1906; 2 : 1706-1714.
6. Boczar ME, Howard MA, Rivers EP et al. A technique revisited: Hemodynamic comparison of closed and open-chest cardiac massage during human cardiopulmonary resuscitation. Critical Care Medicine 1995; 23 (3): 498-503.
7. Byrne D, Pass HI, Neely WA et al. External versus internal cardiac massage in normal and chronically ischemic dogs. Am Surgeon 1980; 46 (12): 657-662.
8. Birchner N, Safar P. Manual open chest cardiopulmonary resuscitation. Ann Emerg Med 1984; 13 : 770-773.
9. Beaver BL, Colombani PM, Buck JR et al. Efficacy of emergency room thoracotomy in pediatric trauma. J Pediatr Surgery 1987; 22(1): 19-23.
10. Sheikh A, Brogon T. Outcome and cost of open-and closed-chest cardiopulmonary resuscitation in pediatric cardiac arrests. Pediatrics 1994; 93 : 392-398.(Saxena Neeraj, Chaudhary )