Recommended Citation
Rashid M, Khorasani A. Proceeding with coronary artery bypass graft following cardiac arrest during anesthesia induction. Presented at: Midwest Anesthesia Residents Conference. (MARC); April 26, 2025; Indianapolis, IN.
Presentation Notes
Presented at: Midwest Anesthesia Residents Conference. (MARC); April 26, 2025; Indianapolis, IN.
Abstract
Introduction: Cardiac arrest following induction of anesthesia is a rare but serious event that significantly increases morbidity and mortality in patients undergoing cardiac surgery. Data from the American College of Surgeons National Surgical Quality Improvement Program indicates that approximately 3% of cardiac surgery patients undergo cardiopulmonary resuscitation (CPR) following cardiac arrest [1]. However, the exact incidence of arrests occurring specifically after the induction of general anesthesia remains unknown. This presents a challenging decision: whether to proceed with coronary artery bypass grafting (CABG) following a peri-induction arrest or to cancel the procedure. Case Presentation: An 80-year-old male with hypertension, hyperlipidemia, and a family history of coronary artery disease presented with exertional dyspnea for one year. A cardiac workup showed normal sinus rhythm on ECG, mild valvular disease on TTE, and a severe perfusion defect on Lexiscan stress test. Coronary angiography revealed severe coronary artery disease, including 99% stenosis of the right coronary artery (RCA) and 80% stenosis of the left anterior descending (LAD) artery, making him a candidate for coronary artery bypass grafting (CABG). On the day of surgery, after induction, the patient developed severe bradycardia with a heart rate of 20–30 bpm, profound hypotension (BP 36/27 mmHg), and ST elevations in leads II, III, and aVF. He required four rounds of CPR, 4 mg of epinephrine, and glycopyrrolate to stabilize. TEE revealed severe right ventricular hypokinesia and dilation. Given the critical situation, the surgical team was immediately advised to proceed with coronary artery bypass grafting (CABG). A four-vessel CABG was performed with 157 minutes on cardiopulmonary bypass (CPB). Due to persistent hemodynamic instability, an intra-aortic balloon pump (IABP) was inserted. During the procedure, the patient developed ventricular fibrillation, requiring amiodarone, escalating doses of vasopressors, and blood product transfusions. Given his critical condition, sternal closure was delayed, and he was transferred to the Surgical Intensive Care Unit (SICU) on IABP and milrinone. By postoperative day (POD) 2, he underwent delayed sternal closure. By POD 3, he demonstrated hemodynamic stability, allowing for IABP removal. By POD 4, he was extubated and weaned off vasoactive support. With continued improvement, he was transferred to telemetry and later discharged to a cardiac rehabilitation program. Conclusion: This case highlights the challenges of peri-induction cardiac arrest in CABG patients, exacerbated by the lack of standardized protocols and limited outcome data. Rapid resuscitation and TEE-guided diagnosis facilitated timely revascularization, leading to a full recovery. It underscores the importance of early recognition, advanced hemodynamic monitoring, and prompt intervention in optimizing outcomes. Additionally, it raises the critical dilemma of whether to proceed with CABG after cardiac arrest, emphasizing the need for future research to establish standardized management strategies. 1. Newland MC, et al. (2002) Anesthesiology. 97(1):108-115. 2. Sprung J, et al. (2003) Anesthesiology. 99(2):259-269.
Type
Oral/Podium Presentation
Affiliations
Advocate Illinois Masonic Medical Center