Spinal anesthesia after intraoperative cardiac arrest during general anesthesia in an infant

Whitaker, Emmett E; Miler, Veronica; Bryant, Jason; Proicou, Stephanie; Jayanthi, Rama; Tobias, Joseph D

At the time of the initial surgery, the patient was an 8-month-old, 9.4 kg boy scheduled for diagnostic laparoscopy and bilateral orchidopexy. The patient had a known history of proximal hypospadias and bilateral nonpalpable testes, but was otherwise well. He had no allergies. His medication history was significant only for cetirizine, which he took for seasonal allergies. Preoperative laboratory studies were not performed. His vital signs on the morning of the procedure were unremarkable, and the child had been NPO for 5 hours (clear liquids) and >8 hours for solids. The patient underwent an uneventful inhalation induction with the incremental administration of sevoflurane up to 8% in 100% oxygen. A 22-gauge peripheral intravenous catheter was placed in the right foot and propofol (50 mg) was administered intravenously to deepen the level of anesthesia and allow for endotracheal intubation without the use of a neuromuscular blocking agent. Direct laryngoscopy followed by endotracheal intubation with a 4.0 mm cuffed tracheal tube was performed without difficulty. Transition to maintenance anesthesia with isoflurane was initiated. Isoflurane was used for maintenance of anesthesia to minimize cost to the patient and to provide smooth emergence. Fentanyl (2.5 µg/kg) and dexamethasone (0.5 mg/kg) were administered intravenously. The first 35 minutes under general anesthesia were uneventful. A 5 mm port was placed in the umbilicus using an open technique. A Veress needle was not used. Coincident with the initiation of insufflation for laparoscopy, there was a sudden and marked decrease in the end-tidal carbon dioxide (ETCO 2 ) as well as a progressive decrease in heart rate and exhaled tidal volume. At this time, the end-tidal isoflurane concentration was 1.1%. Glycopyrrolate (0.1 mg) was administered intravenously while breath sounds were auscultated. It was determined that an endobronchial intubation had occurred. The ETCO 2 , heart rate, and tidal volumes recovered as the endotracheal tube was repositioned. It was also noted that, during the event, there was a loss of the pulse oximeter plethysmograph waveform, which recovered with the increase in heart rate and ETCO 2 after repositioning of the endotracheal tube. Laparoscopic findings included bilateral intra-abdominal testes, and the total laparoscopy time was ~5 minutes. The laparoscopy port was removed and the umbilical incision closed. A left inguinal incision was made, the abdomen entered, and an initial mobilization of the testis begun. Approximately 10 minutes later, there was again a sudden and marked decrease in ETCO 2 , an erratic heart rate with precipitous bradycardia, and loss of pulse oximeter plethysmograph waveform. At this time, the end-tidal isoflurane concentration was 0.7%. Atropine (0.1 mg) was administered intravenously and chest compressions were initiated with return of spontaneous circulation in <1 minute. Surgery was suspended (the inguinal incision rapidly closed with the testis left in the inguinal canal) and the patient was observed in the operating room. An intra-operative chest radiograph was normal. The surgical procedure was cancelled, the patient's trachea was left intubated, and he was transferred to the pediatric intensive care unit for further management and evaluation. With the discontinuation of the anesthetic agents, the patient quickly regained consciousness and his trachea was extubated shortly after arrival to the pediatric intensive care unit.