Special Cardiac Arrest Situations in the Perioperative Period

To the Editor We congratulate the group of 12 experts who wrote the 2-part review article on cardiac arrest in the operating room.1,2 We would like to add the following positive comments to the special situations in the perioperative period. First, tension pneumothorax occurring during laparoscopic surgery should be best described as capnothorax because it consists mainly of insufflated CO2 passing from the peritoneal cavity to the pleural cavity through congenital or surgically produced communications. It may be treated without a chest tube or needle decompression. Simply stopping peritoneal insufflation and applying some end-expiratory positive pressure in the airway (similar to a recruitment maneuver) will push CO2 back to the peritoneal space.3 Second, regarding hyperkalemia, there are 2 situations in which hyperkalemia can develop rapidly and which should be borne in mind when a cardiac arrest happens “out of the blue”: (1) anesthesia-induced rhabdomyolysis in the presence of an unsuspected muscle disease, as described in some children with Duchenne muscular dystrophy4; (2) tumor-lysis syndrome in patients with a rapidly growing non-Hodgkin lymphoma or hyperleucocytic lymphoblastic leukemia that can be induced by a single “routine” dose of dexamethasone given to prevent postoperative nausea and vomiting or may occur spontaneously.5 This requires the urgent start of hemodialysis as the production of potassium is massive. Third, fat embolism can occur during or after orthopedic surgery. Early extracorporeal membrane oxygenation could be lifesaving. Finally, in the case of air or gas embolism, external cardiac massage breaks down the pouch of air into smaller ones and thus unlocks passage into the pulmonary arteries. Placing the patient in the head-down and left lateral decubitus is not helpful and could delay the start of effective resuscitation.6 Francis Veyckemans, MDDépartement d’AnesthésieRéanimation pédiatrique Hôpital Jeannede Flandre, CHU de LilleLille, France[email protected]