A 4 year old girl, with a history of tracheoesophageal fistula post reconstruction, tracheomalacia and serial esophageal dilations for strictures, presented to the hospital for dilation of her esophagus. During the EGD,... [ view full abstract ]
A 4 year old girl, with a history of tracheoesophageal fistula post reconstruction, tracheomalacia and serial esophageal dilations for strictures, presented to the hospital for dilation of her esophagus. During the EGD, material was seen in the lumen of the esophagus. On closer inspection it was seen that her central venous catheter had eroded and was spanning the lumen. After discovery of the port’s erosion, a procedure was planned to insert a new port and under esophageal visualization removal of the existing subclavian port, which was still aspirating blood. The patient was discharged and brought back in for the procedure.
Anesthesia was induced without incident. The right lower extremity port was inserted and removal of left upper extremity port began. An esophageal balloon was inserted just distal to the line and inflated by the surgeon in an attempt to tamponade the esophagus as the line was removed. Unfortunately the esophageal balloon moved distal to the site causing insufflation of the esophagus. The EtCO2 began to drop (an occurrence which had occurred with previous dilations from a presumed tracheal compression)
The patient’s SpO2 dropped to 80's. Manual ventilation began, the lungs were auscultated and breaths sounds were clear. The heart rate began to drop. The surgeon deflated the esophageal balloon and some blood was seen. Suction was passed through the ETT tube, with no return. A small amount of blood was seen from patient’s mouth.
The heart rate continued to drop despite 2 doses of atropine 200mcg through a peripheral IV, followed by 3 doses of epinephrine 100mcg doses. Pulses could not be felt and CPR was started.
Venous distention in the neck could be seen. RBC in 60ml boluses where given for presumed esophageal and thoracic hemorrhage. TTE was performed by the surgeon and followed by emergent pericardiocentesis with aspiration of about 10mls of air.
A second surgeon performed an emergent thoractomy, gaining access to pericardial space, with no evidence of tamponade, the surgeon began direct cardiac massage and confirmed both lungs were pink with adequate inflation.
The patient developed VT and needed defibrillation and direct cardiac massage. Resuscitation continued with PALS. The patient returned to sinus rhythm, the blood pressure stabilized without vasopressors. Bilateral chest tubes were placed. A femoral arterial line inserted by Anesthesia attending. The surgeons closed all incisions, and the patient was transferred from the OR to the PICU.
After discussion in the department, it was felt that the cardiac arrest was likely caused by an acute air embolus. The esophagus was inadvertently insufflated with the scope at the time of pulling out the line from the subclavian vein. The stabilization occurred once direct cardiac massage was given disrupting the air embolus.
The patient was discharged shortly afterwards.
