A high-quality and prolonged cardiopulmonary resuscitation after cardiac arrest in a spinal endoscopic surgery: a case report

A high-quality and prolonged cardiopulmonary resuscitation after cardiac arrest in a spinal endoscopic surgery: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A high-quality and prolonged cardiopulmonary resuscitation after cardiac arrest in a spinal endoscopic surgery: a case report Qiong Wang, Bin Lu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5269261/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Mar, 2025 Read the published version in BMC Anesthesiology → Version 1 posted 10 You are reading this latest preprint version Abstract Background: There are many reasons for perioperative cardiac arrest, and early identification, rapid diagnosis, and effective resolution of the etiology can generally lead to treatment for patients. However, for patients with unexplained cardiac arrest or those who have undergone prolonged cardiopulmonary resuscitation, how anesthesiologists can effectively rescue them and improve the quality of their recovery is a question worth considering. Case presentation: The patient was a 50-year-old man with a cervical spondylotic radiculopathy. He was scheduled for cervical discectomy under spinal endoscopy under general anesthesia. We performed routine anesthesia induction and monitor. Half an hour after the operation, the patient had sudden cardiac arrest and then we immediately performed cardiopulmonary resuscitation. At the same time, we also performed physical examination on the patient and placed an esophageal ultrasound probe, hoping to find out possible causes such as anaphylactic shock, pulmonary embolism, cardiac tamponade, etc. Although we did not find the exact etiology finally, we continued to perform high-quality cardiopulmonary resuscitation for up to 90 minutes and never stopped rescuing the patient. Fortunately, the patient returned to spontaneous circulation, and he was discharged after about a month of treatment and rehabilitation. After one year of follow-up, the patient still had no sequelae and resumed daily activities. Conclusions: We want to express that not all cardiac arrest can be explained in a limited time, especially in complex surgical procedures. But early identification of cardiac arrest and adherence to high-quality cardiopulmonary resuscitation can increase survival rates to a certain extent and improve the prognosis of patients. cardiac arrest cardiopulmonary resuscitation transesophageal echocardiography Figures Figure 1 Background The causes of peri-operative cardiac arrest (PERIOPCA) may not only be related to the patient's own disease, but also to anesthesia and surgery [ 1 , 2 ]. Sometimes it is difficult to identify the cause in a short period of time, which may prolong the time for cardiopulmonary resuscitation (CPR) and lead to poor survival [ 3 ]. It is crucial to know how to perform a high-quality CPR during this period when the reason is unclear, as it affects the outcome of the patient and whether there will be any residual effects [ 4 ]. In this case, although we did not find the etiology, the patient not only successfully recovered spontaneous circulation after a prolonged CPR, but also had no complications, which brought us a lot of inspiration. Case presentation This patient was a 50-year-old man (height: 170 cm; weight: 60 kg) with a cervical radiculopathy in C4 ~ C5. He was suffering from pain and numbness in his left upper extremity, and was scheduled to undergo cervical discectomy under spinal endoscopy. The patient had undergone appendectomy and hernia repair, and both operations were successful. He was usually in good health and his medical history, physical examination results, and blood chemistry findings were unremarkable. Cardiac ultrasound and lower limb color Doppler ultrasound did not show any abnormalities (Fig. 1A, Fig. 1B). We evaluated the functional status of each system and considered ASA Ⅱ. After the patient entered the operating room, we monitored electrocardiogram, pulse oxygen saturation, noninvasive blood pressure, end tidal carbon dioxide concentration, and body temperatureand, and completed radial artery catheterization under local anesthesia to monitor invasive blood pressure. The patient's HR was 61 bpm, BP was 120/70 mmHg, and SpO 2 was 98% then. Preoperative blood gas analysis was also normal. While breathing oxygen through the mask, we used midazolam 2 mg, propofol 80 mg, etomidate 8 mg, sufentanil 25 ug, rocuronium 50 mg to complete anesthesia induction and endotracheal intubation. When the anesthesia is successfully completed, turned the patient over to prone position and prepared for disinfection. During this period, 1g of aminotoluene acid was instilled. During the operation, 2% sevoflurane was inhaled to maintain anesthesia, and rocuronium and sufentanil were added every hour. The patient was stabled at the beginning of the surgery, and the vital signs were as follows: BP 100/65 mmHg, HR 60 bpm, and SpO2 100%. Half an hour later, HR gradually increased to 85 bpm, then increased to 97 bpm after one minute, and the BP remained around 100/59 mmHg. About a minute later, the waves of ECG and S P O2 suddenly disappeared, while the invasive blood pressure was 30/24 mmHg, and its waveform was similar to that of venous blood pressure. We immediately touched the brachial artery and found that there was no beat, which was judged to be cardiac arrest, so we immediately asked the surgeon in operation to perform chest compressions. During chest compressions, we found that the wave of SpO2 appeared and the invasive blood pressure began to rise, which further confirmed our judgment. The surgeon immediately covered the surgical area, and then we rolled the patient onto a stretcher to continue CPR, while epinephrine was given every 5 min [ 5 ]. However, we found it was difficult to return to spontaneous circulation (ROSC). We checked the patient and found no signs of skin allergy or tension pneumothorax. Then we realized that the problem might be complex, so we placed an esophageal ultrasound (TEE) to observe whether the heart was abnormal or whether there was pulmonary embolism. No obvious abnormalities were found in the pericardium and four cardiac chambers under ultrasound. We can't find the inducement for the moment, so we can't remove the crisis immediately. We can only continue CPR and correct the internal environment. We adjusted the amplitude of pressing the thorax so that MAP reached to 60 mmHg, and adjusted the position of pressing according to the ultrasonic display so that the force on the heart is uniform. Manual lung recruitment was performed intermittently to ensure oxygen supply. During the period, multidisciplinary consultation was invited, and everyone was helpless. We thought it would be a pity to give up the rescue, so we continued CPR for an hour and a half. To our surprise, we first observed isolated valve movement, then we continued to press the chest (Fig. 1C). After a while, we found the synchronized movement of the ventricular wall and the monitor showed that the ECG activity also recovered. Slowly, the heart beated more and more forcefully (Fig. 1D), and finally there was no need for chest compressions to assist. When adrenaline is pumped and pure oxygen was inhaled by mechanical ventilation, MAP can be maintained above 60 mmHg, and SpO2 can be maintained above 98%. Then we transferred the patient to ICU for further supportive treatment, further brain protection, and treatment of pulmonary edema, acute renal failure and other complications In the evening, the patient could open his eyes for a short time when we call him. On the third day, the patient's consciousness has recovered and he could nod his head to respond, but still needed vasoactive drugs to maintain BP. When the seventh day, the patient's consciousness had recovered well, and the drug could be stopped. After another three days, the patient's lung function also recovered well, so we removed the tracheal tube for the patient. When we talked with him, he could recall the things before the operation, and there was no obvious damage to the advanced brain function. On day 20, we transferred the patient to the nephrology department to continue the treatment of renal failure, and on day 32, the patient's renal function recovered well and no longer needed dialysis. After several days of observation, the patient was discharged after ensuring that his condition was stable. Conclusions We showed a healthy middle-aged man who had sudden cardiac arrest during cervical surgery. After one and a half hours of CPR, the patient finally recovered and was discharged after more than a month. To our surprise, after such a long time of CPR, the function of each organ of the patient finally recovered well without serious sequelae and we know this good outcome is not easy [ 6 ]. Although the resuscitation time after cardiac arrest varies from 21 minutes to 315 minutes, the good prognosis is often due to the young age of patients, good functional status, and ultimately reversible causes of cardiac arrest, and immediate high-quality CPR [ 7 ]. This case has given us a lot of thoughts. We believe that the causes of cardiac arrest are worth exploring, but how to do a good job of high-quality CPR after cardiac arrest is often more important. Usually, cardiac arrest in the operating room is related to hypovolemia, drugs, electrolyte disturbance, hypoxia, surgical operation, allergy, heart disease, etc [ 8 ]. Through physical examination and blood gas analysis, we ruled out most of these possible causes, but we cannot rule out the possibility of air embolism caused by surgical procedures. Based on the ultrasound images, we found a small amount of gas in the right ventricle that is difficult to confirm, but no signs of right ventricular enlargement and dysfunction, and because the patient's condition was unstable, we could not further perform pulmonary CTA [ 9 , 10 , 11 ]. Therefore the evidence of pulmonary embolism is insufficient (Fig. 2A). We also suspected the existence of anaphylactic shock, but there was no relevant manifestation in the whole body skin, and the symptoms were not relieved after the use of epinephrine [ 12 , 13 ]. We have not yet found the exact cause of the patient's cardiac arrest. However, the most important inspiration for us from this case is how to do a good job in perioperative monitoring, and how to do high-quality CPR. In this case, the ECG, invasive blood pressure, and SpO2 showed abnormalities simultaneously. We immediately became alert to it and then judged it as cardiac arrest by touching the artery. We emphasize the importance of invasive blood pressure because it is timely and synchronized. If there is no invasive blood pressure monitoring, we may suspect whether the wire of the instrument falls off or the instrument is faulty, which may delay the best rescue time [ 14 ]. After all, we often encounter false alarms from sensors, and this experience will interfere with our judgment at this time [ 15 ]. Although the change of end tidal carbon dioxide can also provide some information, it needs to be analyzed in combination with the patient's situation at that time [ 16 ]. Therefore, for surgeries where it is inconvenient to observe patients in special positions or for surgeries with complex procedures, it is crucial to monitor before surgery. In addition, invasive blood pressure provides us with certain guidance during CPR. We know that in order to ensure cerebral perfusion, the MAP cannot be lower than 60mmHg [ 17 , 18 ]. Therefore, the effectiveness of our chest compressions can be timely feedback from invasive blood pressure, and we can make timely adjustments accordingly. Personalized hemodynamic-directed CPR aims at the quality of CPR, and achieves the predetermined hemodynamic goals including systolic blood pressure, diastolic blood pressure, coronary perfusion pressure, etc. by operating the chest compression depth and vasopressor dose [ 19 ]. Compared with standardized CPR, it can increase brain tissue oxygenation, improve survival, and improve neurological prognosis. We believe that this is also an important reason why the patients' cognitive function is not affected after a long-term CPR. The first advantage of TEE is etiological diagnosis. The identification of cardiac activity, heart rhythm, left and right ventricular function, and pericardial effusion / tamponade were listed as the key objectives of TEE examination [ 20 ]. When we found that the problem was quite complex, we ruled out hypovolemia, pericardial tamponade, and myocardial infarction through ultrasound examination in this case. It provided us with continuous images which mean that we have more chance for diagnosis. At the same time, it also reduces the interruption time of chest compressions compared with TTE [ 21 , 22 , 23 ]. During chest compressions, we will continuously observe the force on the heart to ensure that our compression site and amplitude are effective. Although there are uniform regulations on the location, amplitude, and frequency of chest compressions, it must be acknowledged that through ultrasound, we can make an assessment of area of maximal compression and provide real-time feedback on the quality of chest compressions [ 24 ]. Therefore, shortening the interval time of CPR and improving the quality of CPR is another major advantage of TEE. In addition, Cardiac ultrasound can also provide us with vital signs such as cardiac standstill or pseudo-pulseless electrical activity [ 25 ]. In this case, we first noticed that the heart valves began to move, followed by activity on the ECG, and finally observed a strong contraction of the entire heart. If there is no ultrasound monitoring, we will not detect the improvement of the condition in a timely manner. On the contrary, we may give up the rescue due to the long rescue time. In general, TEE monitoring can provide continuous myocardial activity images, identify most reversible causes of cardiac arrest, shorten the interruption of CPR, optimize the quality of chest compressions, and guide the resuscitation process [ 26 ]. Our case suggests that in the perioperative period, when encountering unexplained cardiac arrest, quick judgment is the first step, which relies on sufficient monitoring equipment and rich clinical experience. Secondly, ultrasound should be used early for bedside diagnosis, while guiding us to perform high-quality CPR and providing us with timely CPR results. Third, CPR will inevitably produce complications such as pulmonary edema, so it is particularly important to actively deal with the lung condition in order to ensure that the brain is not hypoxic. Finally, even if you don't find the exact etiology of cardiac arrest after a long period of CPR, we should not give up easily. When we perform high-quality CPR, we can minimize the complications caused by cardiac arrest to the greatest extent possible. Abbreviations cm centimetre kg kilogram µg microgram mg milligram BP blood pressure MAP average arterial pressure HR heart rate SpO2 pulse oxygen saturation bpm beats per min CTA computed tomography angiography ICU intensive care unit Declarations Ethics approval and consent to participate This case report was approved by the Institutional Ethics Committee of Zigong Fourth People’s Hospital. The patient had signed the informed consent for this anesthesia procedure. Consent for publication Written informed consent was obtained from the patient for publication of this article and any accompanying images. Availability of data and materials The datasets are available from the corresponding author on request. Competing interests The authors declared that they have no competing interests. Funding This case report was funded by Sichuan Key Clinical Specialty project (2022-16). Authors ’ contributions Qiong Wang collected all the patient initial data and drafted the manuscript; Bin Lu completed the anesthesia management; Both authors read and approved the fnal manuscript. Acknowledgements None. References Armstrong RA, Soar J, Kane AD, et al. Peri-operative cardiac arrest: epidemiology and clinical features of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia. 2024;79(1):18-30. Kane AD, Cook TM, Armstrong RA, et al. The incidence of potentially serious complications during non-obstetric anaesthetic practice in the United Kingdom: an analysis from the 7th National Audit Project (NAP7) activity survey. Anaesthesia. 2024; 79(1):43-53. Rattana-Arpa S, Chaikittisilpa N, Srikongrak S, et al. Incidences and outcomes of intra-operative vs. postoperative paediatric cardiac arrest: A retrospective cohort study of 42 776 anaesthetics in children who underwent noncardiac surgery in a Thai tertiary care hospital. Eur J Anaesthesiol. 2023; 40(7):483-494. Harper NJN, Nolan JP, Soar J, et al. Why chest compressions should start when systolic arterial blood pressure is below 50 mm Hg in the anaesthetised patient. Br J Anaesth. 2020; 124(3):234-238. Soar J, Becker LB, Berg KM, et al. Cardiopulmonary resuscitation in special circumstances. Lancet. 2021; 398(10307):1257-1268. Berry WR. Cardiac resuscitation in the operating room: reflections on how we can do better. Can J Anaesth. 2012; 59(6):522-6. Charapov I, Eipe N. Cardiac arrest in the operating room requiring prolonged resuscitation. Can J Anaesth. 2012; 59(6):578-85. Hinkelbein J, Andres J, Thies KC, et al. Perioperative cardiac arrest in the operating room environment: a review of the literature. Minerva Anestesiol. 2017; 83(11):1190-1198. Chopard R, Behr J, Vidoni C, et al. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med. 2022; 11(16):4807. Konstantinides SV, Meyer G, Bueno H, et al. 2019 ESC guidelines for the diagnosis and management of acute Pulmonary Embolism developed in collaboration with the European respiratory society (ERS). Eur Heart J. 2020; 41:543–603. Beckerman Z, Bolotin G. Surgical treatment of acute massive Pulmonary Embolism. Adv Exp Med Biol. 2017; 906:75–88. Dodd A, Hughes A, Sargant N, et al. Evidence update for the treatment of anaphylaxis. Resuscitation. 2021; 163: 86–96. Carlson JN, Cook S, Djarv T , et al. Second dose of epinephrine for anaphylaxis in the first aid setting: a scoping review. Cureus 2020; 12: e11401. Soar J, Nolan JP, B€ottiger BW, et al. European resuscitation Council guidelines for resuscitation 2015: section 3, adult advanced life support. Resuscitation. 2015; 95: 100-47. Schmid F, Goepfert MS, Kuhnt D, et al. The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery . Anesth Analg. 2011;112:78–83. Moitra VK, Einav S, Thies KC, et al. Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist Part 1. Anesth Analg. 2018; 127(3):e49-e50. Ackland GL, Brudney CS, Cecconi M, et al. Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine. Br J Anaesth. 2019; 122: 542-51. Wesselink EM, Kappen TH, Torn HM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018; 121: 706-21. kulec R, Vojtisek P, Cerny V. Correlation between end-tidal carbon dioxide and the degree of compression of heart cavities measured by transthoracic echocardiography during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Crit Care. 2019; 23(1):334. American College of Emergency Physicians Guidelines for the Use of Transesophageal Echocardiography (TEE) in the ED for Cardiac Arrest. 2017. Available at: https://www.acep.org/patient-care/policy-statements/guidelines-for-the-use-of-transesophageal-echocardiography-tee-in-the-ed-for-cardiac-arrest/. Accessed April 3, 2020. Clattenburg EJ, Wroe P, Brown S. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: a prospective cohort study. Resuscitation. 2018; 122:65-8. Huis In 't Veld MA, Allison MG, Bostick DS. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017;119:95-8. Fair J 3rd, Mallin MP, Adler A, et al. Transesophageal Echocardiography During Cardiopulmonary Resuscitation Is Associated With Shorter Compression Pauses Compared With Transthoracic Echocardiography. Ann Emerg Med. 2019; 73(6):610-616. Riendeau Beaulac G, Teran F, Lecluyse V, et al. Transesophageal Echocardiography in Patients in Cardiac Arrest: The Heart and Beyond. Can J Cardiol. 2023; 39(4):458-473. Teran F, Dean AJ, Centeno C. Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department. Resuscitation. 2019; 137:140-7. Teran F, Prats MI, Nelson BP, et al. Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week. J Am Coll Cardiol. 2020; 76(6):745-754. Additional Declarations No competing interests reported. Supplementary Files 1.mp4 2.mp4 3.pdf Cite Share Download PDF Status: Published Journal Publication published 31 Mar, 2025 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Revision requested 27 Nov, 2024 Reviews received at journal 21 Nov, 2024 Reviews received at journal 11 Nov, 2024 Reviewers agreed at journal 11 Nov, 2024 Reviewers agreed at journal 11 Nov, 2024 Reviewers invited by journal 08 Nov, 2024 Editor invited by journal 17 Oct, 2024 Editor assigned by journal 16 Oct, 2024 Submission checks completed at journal 16 Oct, 2024 First submitted to journal 15 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5269261","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":383654373,"identity":"4f7f0ab1-c1c1-4a05-be53-bfaf49b6a3ea","order_by":0,"name":"Qiong Wang","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qiong","middleName":"","lastName":"Wang","suffix":""},{"id":383654374,"identity":"ff510c12-0c52-4262-8c18-118217fa9878","order_by":1,"name":"Bin Lu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIie3PMWvCQBTA8XccXJZnXE/E6kc4yaCDH+YFoS5JccwqgZtKZ7vUr9Cp4nbhwCl+gi5C9yK4ZLKNuhV6cXS4P284Hu83HIDPd4eFgGAAxqA4sD1lkwcR5MZJxJXIM+HqUD5GIW6pkcCF1O/Oq7bxm0wGbiLTws5BxuugZboo+ExDAlBlHw7yRHZZk00eUoQoUg07w57LTwdJlMWavFtUU5SYavZCnOkbST1yJjiqm8lwsSRFQjQR/KYziTY5RnAwNNQoqHD9pR2k9ogw6a3b5aiKTz/9/uqr2FfZ/+QSO/1ZGPe9z+fz+Zr6BXTBTkO+zu5CAAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Lu","suffix":""}],"badges":[],"createdAt":"2024-10-15 13:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5269261/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5269261/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12871-025-03021-1","type":"published","date":"2025-03-31T15:57:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71481016,"identity":"e7834717-a8b5-4e94-838f-fe6db5e6ed62","added_by":"auto","created_at":"2024-12-16 06:00:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1009487,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"P.png","url":"https://assets-eu.researchsquare.com/files/rs-5269261/v1/f21ae4cac06c38dd72c35363.png"},{"id":80082856,"identity":"8c72aa90-4a4e-4db6-a8d1-d05805d06952","added_by":"auto","created_at":"2025-04-07 16:09:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1703646,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5269261/v1/26384801-71c1-4e68-9724-1c6832db0d6d.pdf"},{"id":71481021,"identity":"5fd5badc-b60d-42b8-ba86-195620906c9a","added_by":"auto","created_at":"2024-12-16 06:00:08","extension":"mp4","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":9582434,"visible":true,"origin":"","legend":"","description":"","filename":"1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-5269261/v1/7888c8c3bbc076d82f2545d6.mp4"},{"id":71481018,"identity":"b2b9b3a6-2c24-41ed-bf65-86d291247a26","added_by":"auto","created_at":"2024-12-16 06:00:07","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":10456990,"visible":true,"origin":"","legend":"","description":"","filename":"2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-5269261/v1/408864112c8a44061772f69b.mp4"},{"id":71481017,"identity":"f4d7f599-35e5-4ae8-85f7-6ff729df1ae7","added_by":"auto","created_at":"2024-12-16 06:00:07","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":1036178,"visible":true,"origin":"","legend":"","description":"","filename":"3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5269261/v1/acd0ec79e60899cc351083a2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A high-quality and prolonged cardiopulmonary resuscitation after cardiac arrest in a spinal endoscopic surgery: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eThe causes of peri-operative cardiac arrest (PERIOPCA) may not only be related to the patient's own disease, but also to anesthesia and surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Sometimes it is difficult to identify the cause in a short period of time, which may prolong the time for cardiopulmonary resuscitation (CPR) and lead to poor survival [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is crucial to know how to perform a high-quality CPR during this period when the reason is unclear, as it affects the outcome of the patient and whether there will be any residual effects [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In this case, although we did not find the etiology, the patient not only successfully recovered spontaneous circulation after a prolonged CPR, but also had no complications, which brought us a lot of inspiration.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThis patient was a 50-year-old man (height: 170 cm; weight: 60 kg) with a cervical radiculopathy in C4\u0026thinsp;~\u0026thinsp;C5. He was suffering from pain and numbness in his left upper extremity, and was scheduled to undergo cervical discectomy under spinal endoscopy. The patient had undergone appendectomy and hernia repair, and both operations were successful. He was usually in good health and his medical history, physical examination results, and blood chemistry findings were unremarkable. Cardiac ultrasound and lower limb color Doppler ultrasound did not show any abnormalities (Fig.\u0026nbsp;1A, Fig.\u0026nbsp;1B). We evaluated the functional status of each system and considered ASA Ⅱ.\u003c/p\u003e \u003cp\u003eAfter the patient entered the operating room, we monitored electrocardiogram, pulse oxygen saturation, noninvasive blood pressure, end tidal carbon dioxide concentration, and body temperatureand, and completed radial artery catheterization under local anesthesia to monitor invasive blood pressure. The patient's HR was 61 bpm, BP was 120/70 mmHg, and SpO\u003csub\u003e2\u003c/sub\u003e was 98% then. Preoperative blood gas analysis was also normal. While breathing oxygen through the mask, we used midazolam 2 mg, propofol 80 mg, etomidate 8 mg, sufentanil 25 ug, rocuronium 50 mg to complete anesthesia induction and endotracheal intubation. When the anesthesia is successfully completed, turned the patient over to prone position and prepared for disinfection. During this period, 1g of aminotoluene acid was instilled. During the operation, 2% sevoflurane was inhaled to maintain anesthesia, and rocuronium and sufentanil were added every hour.\u003c/p\u003e \u003cp\u003eThe patient was stabled at the beginning of the surgery, and the vital signs were as follows: BP 100/65 mmHg, HR 60 bpm, and SpO2 100%. Half an hour later, HR gradually increased to 85 bpm, then increased to 97 bpm after one minute, and the BP remained around 100/59 mmHg. About a minute later, the waves of ECG and S\u003csub\u003eP\u003c/sub\u003eO2 suddenly disappeared, while the invasive blood pressure was 30/24 mmHg, and its waveform was similar to that of venous blood pressure. We immediately touched the brachial artery and found that there was no beat, which was judged to be cardiac arrest, so we immediately asked the surgeon in operation to perform chest compressions. During chest compressions, we found that the wave of SpO2 appeared and the invasive blood pressure began to rise, which further confirmed our judgment. The surgeon immediately covered the surgical area, and then we rolled the patient onto a stretcher to continue CPR, while epinephrine was given every 5 min [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, we found it was difficult to return to spontaneous circulation (ROSC). We checked the patient and found no signs of skin allergy or tension pneumothorax. Then we realized that the problem might be complex, so we placed an esophageal ultrasound (TEE) to observe whether the heart was abnormal or whether there was pulmonary embolism. No obvious abnormalities were found in the pericardium and four cardiac chambers under ultrasound. We can't find the inducement for the moment, so we can't remove the crisis immediately. We can only continue CPR and correct the internal environment. We adjusted the amplitude of pressing the thorax so that MAP reached to 60 mmHg, and adjusted the position of pressing according to the ultrasonic display so that the force on the heart is uniform. Manual lung recruitment was performed intermittently to ensure oxygen supply. During the period, multidisciplinary consultation was invited, and everyone was helpless. We thought it would be a pity to give up the rescue, so we continued CPR for an hour and a half. To our surprise, we first observed isolated valve movement, then we continued to press the chest (Fig.\u0026nbsp;1C). After a while, we found the synchronized movement of the ventricular wall and the monitor showed that the ECG activity also recovered. Slowly, the heart beated more and more forcefully (Fig.\u0026nbsp;1D), and finally there was no need for chest compressions to assist. When adrenaline is pumped and pure oxygen was inhaled by mechanical ventilation, MAP can be maintained above 60 mmHg, and SpO2 can be maintained above 98%. Then we transferred the patient to ICU for further supportive treatment, further brain protection, and treatment of pulmonary edema, acute renal failure and other complications\u003c/p\u003e \u003cp\u003eIn the evening, the patient could open his eyes for a short time when we call him. On the third day, the patient's consciousness has recovered and he could nod his head to respond, but still needed vasoactive drugs to maintain BP. When the seventh day, the patient's consciousness had recovered well, and the drug could be stopped. After another three days, the patient's lung function also recovered well, so we removed the tracheal tube for the patient. When we talked with him, he could recall the things before the operation, and there was no obvious damage to the advanced brain function. On day 20, we transferred the patient to the nephrology department to continue the treatment of renal failure, and on day 32, the patient's renal function recovered well and no longer needed dialysis. After several days of observation, the patient was discharged after ensuring that his condition was stable.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe showed a healthy middle-aged man who had sudden cardiac arrest during cervical surgery. After one and a half hours of CPR, the patient finally recovered and was discharged after more than a month. To our surprise, after such a long time of CPR, the function of each organ of the patient finally recovered well without serious sequelae and we know this good outcome is not easy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although the resuscitation time after cardiac arrest varies from 21 minutes to 315 minutes, the good prognosis is often due to the young age of patients, good functional status, and ultimately reversible causes of cardiac arrest, and immediate high-quality CPR [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This case has given us a lot of thoughts. We believe that the causes of cardiac arrest are worth exploring, but how to do a good job of high-quality CPR after cardiac arrest is often more important.\u003c/p\u003e \u003cp\u003eUsually, cardiac arrest in the operating room is related to hypovolemia, drugs, electrolyte disturbance, hypoxia, surgical operation, allergy, heart disease, etc [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Through physical examination and blood gas analysis, we ruled out most of these possible causes, but we cannot rule out the possibility of air embolism caused by surgical procedures. Based on the ultrasound images, we found a small amount of gas in the right ventricle that is difficult to confirm, but no signs of right ventricular enlargement and dysfunction, and because the patient's condition was unstable, we could not further perform pulmonary CTA [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore the evidence of pulmonary embolism is insufficient (Fig.\u0026nbsp;2A). We also suspected the existence of anaphylactic shock, but there was no relevant manifestation in the whole body skin, and the symptoms were not relieved after the use of epinephrine [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. We have not yet found the exact cause of the patient's cardiac arrest.\u003c/p\u003e \u003cp\u003eHowever, the most important inspiration for us from this case is how to do a good job in perioperative monitoring, and how to do high-quality CPR. In this case, the ECG, invasive blood pressure, and SpO2 showed abnormalities simultaneously. We immediately became alert to it and then judged it as cardiac arrest by touching the artery. We emphasize the importance of invasive blood pressure because it is timely and synchronized. If there is no invasive blood pressure monitoring, we may suspect whether the wire of the instrument falls off or the instrument is faulty, which may delay the best rescue time [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. After all, we often encounter false alarms from sensors, and this experience will interfere with our judgment at this time [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Although the change of end tidal carbon dioxide can also provide some information, it needs to be analyzed in combination with the patient's situation at that time [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Therefore, for surgeries where it is inconvenient to observe patients in special positions or for surgeries with complex procedures, it is crucial to monitor before surgery. In addition, invasive blood pressure provides us with certain guidance during CPR. We know that in order to ensure cerebral perfusion, the MAP cannot be lower than 60mmHg [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, the effectiveness of our chest compressions can be timely feedback from invasive blood pressure, and we can make timely adjustments accordingly. Personalized hemodynamic-directed CPR aims at the quality of CPR, and achieves the predetermined hemodynamic goals including systolic blood pressure, diastolic blood pressure, coronary perfusion pressure, etc. by operating the chest compression depth and vasopressor dose [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Compared with standardized CPR, it can increase brain tissue oxygenation, improve survival, and improve neurological prognosis. We believe that this is also an important reason why the patients' cognitive function is not affected after a long-term CPR.\u003c/p\u003e \u003cp\u003eThe first advantage of TEE is etiological diagnosis. The identification of cardiac activity, heart rhythm, left and right ventricular function, and pericardial effusion / tamponade were listed as the key objectives of TEE examination [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. When we found that the problem was quite complex, we ruled out hypovolemia, pericardial tamponade, and myocardial infarction through ultrasound examination in this case. It provided us with continuous images which mean that we have more chance for diagnosis. At the same time, it also reduces the interruption time of chest compressions compared with TTE [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. During chest compressions, we will continuously observe the force on the heart to ensure that our compression site and amplitude are effective. Although there are uniform regulations on the location, amplitude, and frequency of chest compressions, it must be acknowledged that through ultrasound, we can make an assessment of area of maximal compression and provide real-time feedback on the quality of chest compressions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Therefore, shortening the interval time of CPR and improving the quality of CPR is another major advantage of TEE. In addition, Cardiac ultrasound can also provide us with vital signs such as cardiac standstill or pseudo-pulseless electrical activity [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In this case, we first noticed that the heart valves began to move, followed by activity on the ECG, and finally observed a strong contraction of the entire heart. If there is no ultrasound monitoring, we will not detect the improvement of the condition in a timely manner. On the contrary, we may give up the rescue due to the long rescue time. In general, TEE monitoring can provide continuous myocardial activity images, identify most reversible causes of cardiac arrest, shorten the interruption of CPR, optimize the quality of chest compressions, and guide the resuscitation process [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur case suggests that in the perioperative period, when encountering unexplained cardiac arrest, quick judgment is the first step, which relies on sufficient monitoring equipment and rich clinical experience. Secondly, ultrasound should be used early for bedside diagnosis, while guiding us to perform high-quality CPR and providing us with timely CPR results. Third, CPR will inevitably produce complications such as pulmonary edema, so it is particularly important to actively deal with the lung condition in order to ensure that the brain is not hypoxic. Finally, even if you don't find the exact etiology of cardiac arrest after a long period of CPR, we should not give up easily. When we perform high-quality CPR, we can minimize the complications caused by cardiac arrest to the greatest extent possible.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ecm\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecentimetre\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ekg\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ekilogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026micro;g\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emicrogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emg\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emilligram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eblood pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eaverage arterial pressure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eheart rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSpO2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epulse oxygen saturation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ebpm\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebeats per min\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputed tomography angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintensive care unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was approved by the Institutional Ethics Committee of Zigong Fourth People’s Hospital. The patient had signed the informed consent for this anesthesia procedure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of \u0026nbsp;this article and any accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was funded by Sichuan Key Clinical Specialty project (2022-16).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e’\u003c/strong\u003e\u003cstrong\u003econtributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQiong Wang collected all the patient initial data and drafted the manuscript; Bin Lu completed the anesthesia management; Both authors read and approved the fnal manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eArmstrong RA, Soar J, Kane AD, et al. Peri-operative cardiac arrest: epidemiology and clinical features of patients analysed in the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia. 2024;79(1):18-30.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKane AD, Cook TM, Armstrong RA, et al. The incidence of potentially serious complications during non-obstetric anaesthetic practice in the United Kingdom: an analysis from the 7th National Audit Project (NAP7) activity survey. Anaesthesia. 2024; 79(1):43-53.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRattana-Arpa S, Chaikittisilpa N, Srikongrak S, et al. Incidences and outcomes of intra-operative vs. postoperative paediatric cardiac arrest: A retrospective cohort study of 42 776 anaesthetics in children who underwent noncardiac surgery in a Thai tertiary care hospital. Eur J Anaesthesiol. 2023; 40(7):483-494.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHarper NJN, Nolan JP, Soar J, et al. Why chest compressions should start when systolic arterial blood pressure is below 50 mm Hg in the anaesthetised patient. Br J Anaesth. 2020; 124(3):234-238.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSoar J, Becker LB, Berg KM, et al. Cardiopulmonary resuscitation in special circumstances. Lancet. 2021; 398(10307):1257-1268.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBerry WR. Cardiac resuscitation in the operating room: reflections on how we can do better. Can J Anaesth. 2012; 59(6):522-6.\u003c/li\u003e\n \u003cli\u003eCharapov I, Eipe N. Cardiac arrest in the operating room requiring prolonged resuscitation. Can J Anaesth. 2012; 59(6):578-85.\u003c/li\u003e\n \u003cli\u003eHinkelbein J, Andres J, Thies KC, et al. Perioperative cardiac arrest in the operating room environment: a review of the literature. Minerva Anestesiol. 2017; 83(11):1190-1198.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eChopard R, Behr J, Vidoni C, et al. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med. 2022; 11(16):4807.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKonstantinides SV, Meyer G, Bueno H, et al. 2019 ESC guidelines for the diagnosis and management of acute Pulmonary Embolism developed in collaboration with the European respiratory society (ERS). Eur Heart J. 2020; 41:543\u0026ndash;603.\u003c/li\u003e\n \u003cli\u003eBeckerman Z, Bolotin G. Surgical treatment of acute massive Pulmonary Embolism. Adv Exp Med Biol. 2017; 906:75\u0026ndash;88.\u003c/li\u003e\n \u003cli\u003eDodd A, Hughes A, Sargant N, et al. Evidence update for the treatment of anaphylaxis. Resuscitation. 2021; 163: 86\u0026ndash;96.\u003c/li\u003e\n \u003cli\u003eCarlson JN, Cook S, Djarv T , et al. Second dose of epinephrine for anaphylaxis in the first aid setting: a scoping review. Cureus 2020; 12: e11401.\u003c/li\u003e\n \u003cli\u003eSoar J, Nolan JP, B\u0026euro;ottiger BW, et al. European resuscitation Council guidelines for resuscitation 2015: section 3, adult advanced life support. Resuscitation. 2015; 95: 100-47.\u003c/li\u003e\n \u003cli\u003eSchmid F, Goepfert MS, Kuhnt D, et al. The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery . Anesth Analg. 2011;112:78\u0026ndash;83.\u003c/li\u003e\n \u003cli\u003eMoitra VK, Einav S, Thies KC, et al. Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist Part 1. Anesth Analg. 2018; 127(3):e49-e50.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAckland GL, Brudney CS, Cecconi M, et al. Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine. Br J Anaesth. 2019; 122: 542-51.\u003c/li\u003e\n \u003cli\u003eWesselink EM, Kappen TH, Torn HM, et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth. 2018; 121: 706-21.\u003c/li\u003e\n \u003cli\u003ekulec R, Vojtisek P, Cerny V. Correlation between end-tidal carbon dioxide and the degree of compression of heart cavities measured by transthoracic echocardiography during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. Crit Care. 2019; 23(1):334.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAmerican College of Emergency Physicians Guidelines for the Use of Transesophageal Echocardiography (TEE) in the ED for Cardiac Arrest. 2017. Available at: https://www.acep.org/patient-care/policy-statements/guidelines-for-the-use-of-transesophageal-echocardiography-tee-in-the-ed-for-cardiac-arrest/. Accessed April 3, 2020.\u003c/li\u003e\n \u003cli\u003eClattenburg EJ, Wroe P, Brown S. Point-of-care ultrasound use in patients with cardiac arrest is associated prolonged cardiopulmonary resuscitation pauses: a prospective cohort study. Resuscitation. 2018; 122:65-8.\u003c/li\u003e\n \u003cli\u003eHuis In \u0026apos;t Veld MA, Allison MG, Bostick DS. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017;119:95-8.\u003c/li\u003e\n \u003cli\u003eFair J 3rd, Mallin MP, Adler A, et al. Transesophageal Echocardiography During Cardiopulmonary Resuscitation Is Associated With Shorter Compression Pauses Compared With Transthoracic Echocardiography. Ann Emerg Med. 2019; 73(6):610-616.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRiendeau Beaulac G, Teran F, Lecluyse V, et al. Transesophageal Echocardiography in Patients in Cardiac Arrest: The Heart and Beyond. Can J Cardiol. 2023; 39(4):458-473.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTeran F, Dean AJ, Centeno C. Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department. Resuscitation. 2019; 137:140-7.\u003c/li\u003e\n \u003cli\u003eTeran F, Prats MI, Nelson BP, et al. Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week. J Am Coll Cardiol. 2020; 76(6):745-754.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cardiac arrest, cardiopulmonary resuscitation, transesophageal echocardiography","lastPublishedDoi":"10.21203/rs.3.rs-5269261/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5269261/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThere are many reasons for perioperative cardiac arrest, and early identification, rapid diagnosis, and effective resolution of the etiology can generally lead to treatment for patients. However, for patients with unexplained cardiac arrest or those who have undergone prolonged cardiopulmonary resuscitation, how anesthesiologists can effectively rescue them and improve the quality of their recovery is a question worth considering.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation: \u003c/strong\u003eThe patient was a 50-year-old man with a cervical spondylotic radiculopathy. He was scheduled for cervical discectomy under spinal endoscopy under general anesthesia. We performed routine anesthesia induction and monitor. Half an hour after the operation, the patient had sudden cardiac arrest and then we immediately performed cardiopulmonary resuscitation. At the same time, we also performed physical examination on the patient and placed an esophageal ultrasound probe, hoping to find out possible causes such as anaphylactic shock, pulmonary embolism, cardiac tamponade, etc. Although we did not find the exact etiology finally, we continued to perform high-quality cardiopulmonary resuscitation for up to 90 minutes and never stopped rescuing the patient. Fortunately, the patient returned to spontaneous circulation, and he was discharged after about a month of treatment and rehabilitation. After one year of follow-up, the patient still had no sequelae and resumed daily activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eWe want to express that not all cardiac arrest can be explained in a limited time, especially in complex surgical procedures. But early identification of cardiac arrest and adherence to high-quality cardiopulmonary resuscitation can increase survival rates to a certain extent and improve the prognosis of patients.\u003c/p\u003e","manuscriptTitle":"A high-quality and prolonged cardiopulmonary resuscitation after cardiac arrest in a spinal endoscopic surgery: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 05:59:41","doi":"10.21203/rs.3.rs-5269261/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-28T04:46:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-21T20:15:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-11T12:51:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59594142231062415539831577150166021733","date":"2024-11-11T07:50:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"286879652445502765107297363945632243030","date":"2024-11-11T05:39:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-09T00:03:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-17T09:14:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-17T03:08:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-17T03:08:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2024-10-15T13:49:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"63ca099b-4bdb-4cb5-b0ed-724aacadf1c7","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-07T16:08:25+00:00","versionOfRecord":{"articleIdentity":"rs-5269261","link":"https://doi.org/10.1186/s12871-025-03021-1","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2025-03-31 15:57:37","publishedOnDateReadable":"March 31st, 2025"},"versionCreatedAt":"2024-12-16 05:59:41","video":"","vorDoi":"10.1186/s12871-025-03021-1","vorDoiUrl":"https://doi.org/10.1186/s12871-025-03021-1","workflowStages":[]},"version":"v1","identity":"rs-5269261","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5269261","identity":"rs-5269261","version":["v1"]},"buildId":"veTbxFhMMB0_faC6-Wkog","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}