American Journal of Emergency Medicine 33 (2015) 1108.e5–1108.e7
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Successful cardiopulmonary cerebral resuscitation in patient with severe acute pancreatitis Abstract Severe acute pancreatitis (SAP) is a critical illness in clinical practice, which is characterized by intensive inflammatory response in the early phase and infected pancreatic necrosis in the later phase. Despite the knowledge of SAP and critical care support technology got significant progress in recent years, SAP still carries approximately 30% mortality rate. Some SAP patients also have many other kinds of underlying disease such as hyperlipidemia, hypertension, coronary atherosclerotic heart disease, and heart rhythm abnormalities, which are related to cardiopulmonary arrest to some extent. Thus, the incidence of unpredictive cardiopulmonary arrest is high. Recently, a SAP patient in our intensive care unit had sudden cardiac arrest. After 52 minutes of cardiopulmonary resuscitation, she had return of spontaneous circulation and regained consciousness within 2 hours. To our knowledge, there is no successful report after such long resuscitation in SAP patients. She was receiving continuous renal replacement therapy (CRRT) and continuous veno-venous hemofiltration, in the event of cardiopulmonary arrest. No study reported what kind of role CRRT can play when cardiac arrest occurs. Usually, we would stop existing CRRT when cardiac arrest occurred. We would not start CRRT for the complexity of operation and additional loss of blood. This time, we used CRRT to regulate electrolyte and acid-base imbalance and implement hypothermia brain protection, which played an important role in the patient that we report here. We strongly recommended a prolonged cardiopulmonary cerebral resuscitation in some not quite old SAP patients and continue to use existing CRRT but not remove it.
respiratory distress syndrome (severe), acute kidney injury (level III), pancreatic necrosis, and infection (Fig. 1) and transferred to our hospital on August 5. She was in critical condition with Acute Physiology and Chronic Health Evaluation II score of 22. We continued mechanical ventilation, CRRT, and drainage of infected pancreatic necrosis. At 11:04, August 12, the patient complained of chest discomfort and lost her consciousness, which was witnessed by a nurse. Electrocardiogram showed ventricular fibrillation and then cardiac arrest. Cardiopulmonary resuscitation (CPR) was started immediately with chest compression and defibrillation. Advanced airway had been confirmed in good condition. Ventricular fibrillation and defibrillation repeated and succeeded 8 times. Continuous renal replacement therapy continued but modulated to induce hypothermia brain protection. Arterial blood gas analysis showed metabolic acidosis and hyperkalemia (potassium, 5.4 mmol/L). Potassium-free CRRT and glucose/insulin solution infusion were used to correct hyperkalemia and acidosis. Ice cap and CRRT were used to induce hypothermia and brain protection during resuscitation. After 52 minutes, patients had return of spontaneous circulation. After 110 minutes, she regained consciousness. Chest x-ray showed no rib injury 10 hours after CPR (Fig. 2). After CPR, she received several times of minimally invasive percutaneous drainage and endoscopic debridement for infected pancreatic necrosis. Two months later, abdominal computed tomographic scan prompted that the necrotic tissues around pancreas had been basically cleaned (Fig. 3), and chest x-ray showed no obvious abnormalities in the lung (Fig. 4). She was discharged from hospital with full recovery on November 10, 2014.
Severe acute pancreatitis (SAP) is a critical illness in clinical practice, which is characterized by intensive inflammatory response in the early phase and infected pancreatic necrosis in the later phase [1]. Despite the knowledge of SAP and a lot of critical care support technology improvement in recent years, SAP still carries approximately 30% mortality rate [2]. Many SAP patients had already acquired respiratory failure, renal failure, even shock, and multiple-organ dysfunction syndrome when they arrived at the emergency department (ED) [3,4]. One case of SAP patient in our intensive care unit (Department of General Surgery, Jingling Hospital, Nanjing, People's Republic of China) had unpredictive cardiac arrest. She was receiving continuous renal replacement therapy (CRRT), continuous veno-venous hemofiltration, and ventilator treatment and also the central venous pressure and invasive arterial pressure monitoring, which helped us a lot in the recovery process. She had return of spontaneous circulation after a long time of cardiopulmonary cerebral resuscitation and regained consciousness within 2 hours. A 49-year-old woman developed sudden severe upper abdominal pain on July 16, 2014. She was diagnosed with severe acute pancreatitis and treated in a local county hospital. The patient developed acute
Fig. 1. Computed tomography shows large areas of tissue necrosis around the pancreas on admission to our hospital.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
1108.e6
B. Li et al. / American Journal of Emergency Medicine 33 (2015) 1108.e5–1108.e7
Fig. 2. Computed tomography shows necrotic tissue around the pancreas basically cleaned 2 months after CPR.
The patient that we report here was in stage of pancreatic necrosis and infection of severe acute pancreatitis. She was in critical condition on admission, and all the intensive treatments were undertaken, including ventilation, CRRT, antibiotics, parapancreatic drainage, fluid management, and nutritional support. It was difficult for her to have survived after prolonged resuscitation without any neurologic defect. In summary of the reasons for the success of this patient, CRRT was the most impressive one. Usually, we would stop existing CRRT when cardiac arrest occurred to facilitate the return of blood. We would not take the initiative to start CRRT for the complexity of operation and additional loss of blood [5]. In the present case, we continued the existing CRRT to regulate electrolyte and acid-base imbalance and implement hypothermia for brain protection, which was proved to be effective. Continuous renal replacement therapy, also known as continuous blood purification, can effectively remove inflammatory cytokines, regulate fluid balance, and maintain a stable internal environment in critically ill patients [6]. It is effective in the treatment of patients with SAP and is conventionally used for SAP in different stage [7,8]. Tatsumi et al [9] ever used CRRT to treat a case of cardiopulmonary arrest caused by severe metabolic alkalosis and hypermagnesemia in a patient with anorexia nervosa and chronic renal failure after spontaneous circulation was restored. The present patient developed acute renal failure, and continuous veno-venous hemofiltration was ongoing in the event of cardiopulmonary arrest. Continuous renal replacement therapy was used to correct acidosis and hyperkalemia during CPR. Hemodialysis machine was also
Fig. 4. Chest x-ray shows no notable abnormalities the lung 2 months after CPR.
used to carry out therapeutic hypothermia with a target temperature of 33°C during process of resuscitation. The 2010 American Heart Association guideline pointed out that adequate coronary perfusion pressure is an indispensable condition for the restoration of spontaneous circulation. Friess et al [10] found that hemodynamic directed resuscitation targeting coronary perfusion pressures greater than 20 mm Hg during 10 minutes of CPR improved short-term survival. In the present case, she had existing arterial catheter and allowed us to evaluate the real-time effect of chest compressions. Her diastolic blood pressure was always maintained above 45 mm Hg during chest compressions. Cardiopulmonary arrest can be caused by variety of reasons. It is important to identify the cause and remove reversible factors positively that led to cardiac arrest. Spontaneous ventricular fibrillation was accounted for the cardiac arrest. The heart physician implements professional treatment on her later. She was discharged from hospital after 3 months, and there was no recurrence of cardiac arrest till now. We report a case here aimed to remind all ED physicians and intensive care unit physicians to maintain a high index of suspicion for cardiac arrest in SAP patients and make full use of invasive monitoring methods and SAP treatment instrument to achieve full and effective recovery; we strongly recommended a prolonged cardiopulmonary cerebral resuscitation in some not quite old SAP patients and continue to use existing CRRT but not remove it. Baiqiang Li, MD Lu Ke, MD Xiao Shen, MD Zhihui Tong, MD Gang Li, MD Jing Zhou, MD Dongliang Yang, MD Xianghong Ye Jieshou Li, MD WeiQin Li, MD* Department of General Surgery, SICU, Jinling Hospital Nanjing University School of Medicine, Nanjing, People’s Republic of China *Corresponding author. Department of General Surgery SICU, Jinling Hospital, Nanjing University School of Medicine No. 305 East Zhongshan Road, Nanjing 210002, China E-mail addresses: [email protected], [email protected]
Fig. 3. Chest x-ray shows no rib injury 10 hours after CPR.
http://dx.doi.org/10.1016/j.ajem.2015.01.004
B. Li et al. / American Journal of Emergency Medicine 33 (2015) 1108.e5–1108.e7
References [1] Al Mofleh IA. Severe acute pancreatitis: pathogenetic aspects and prognostic factors. World J Gastroenterol 2008;14:675–84. [2] Zhang L, Zhou J, Ke L, Nie Y, Tong Z, Li W, et al. Role of heart rate variability in predicting the severity of severe acute pancreatitis. Dig Dis Sci 2014;59(10): 2557–64. [3] Piwinski S. Severe acute pancreatitis. JAMA 2004;292(11):1305 [author reply 1305]. [4] Zerem E. Treatment of severe acute pancreatitis and its complications. World J Gastroenterol 2014;20(38):13879–92. [5] Takahashi H, Takezawa J, Fukuoka T, Mayumi T. Critical appraisal of treatments in emergency settings. Nihon Geka Gakkai Zasshi 1999;100(7): 449–54.
1108.e7
[6] Quintard JM, Barbot O, Thevenot F, de Matteis O, Benayount L, Leibinger F. Partial extracorporeal carbon dioxide removal using a standard continuous renal replacement therapy device: a preliminary study. ASAIO J 2014;60(5):564–9. [7] Cui HX, Xu JY, Li MQ. Efficacy of continuous renal replacement therapy in the treatment of severe acute pancreatitis associated acute respiratory distress syndrome. Eur Rev Med Pharmacol Sci 2014;18(17):2523–6. [8] Podkorytova OL, Tomilina NA, Bibkov BT, Vtorenko VI, Shirinskii VG, Loktev VV, et al. Replacement renal therapy in complex treatment of severe acute pancreatitis. Anesteziol Reanimatol 2008;6:63–6. [9] Tatsumi H, Masuda Y, Imaizumi H, Kuroda H, Yoshida S, Kyan R, et al. A case of cardiopulmonary arrest caused by laxatives-induced hypermagnesemia in a patient with anorexia nervosa and chronic renal failure. J Anesth 2011;25(6):935–8. [10] Friess SH, Sutton RM, Bhalala U, Maltese MR, Naim MY, Bratinov G, et al. Hemodynamic directed cardiopulmonary resuscitation improves short-term survival from ventricular fibrillation cardiac arrest. Crit Care Med 2013;41(12):2698–704.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Successful cardiopulmonary cerebral resuscitation in patient with severe acute pancreatitis Abstract Severe acute pancreatitis (SAP) is a critical illness in clinical practice, which is characterized by intensive inflammatory response in the early phase and infected pancreatic necrosis in the later phase. Despite the knowledge of SAP and critical care support technology got significant progress in recent years, SAP still carries approximately 30% mortality rate. Some SAP patients also have many other kinds of underlying disease such as hyperlipidemia, hypertension, coronary atherosclerotic heart disease, and heart rhythm abnormalities, which are related to cardiopulmonary arrest to some extent. Thus, the incidence of unpredictive cardiopulmonary arrest is high. Recently, a SAP patient in our intensive care unit had sudden cardiac arrest. After 52 minutes of cardiopulmonary resuscitation, she had return of spontaneous circulation and regained consciousness within 2 hours. To our knowledge, there is no successful report after such long resuscitation in SAP patients. She was receiving continuous renal replacement therapy (CRRT) and continuous veno-venous hemofiltration, in the event of cardiopulmonary arrest. No study reported what kind of role CRRT can play when cardiac arrest occurs. Usually, we would stop existing CRRT when cardiac arrest occurred. We would not start CRRT for the complexity of operation and additional loss of blood. This time, we used CRRT to regulate electrolyte and acid-base imbalance and implement hypothermia brain protection, which played an important role in the patient that we report here. We strongly recommended a prolonged cardiopulmonary cerebral resuscitation in some not quite old SAP patients and continue to use existing CRRT but not remove it.
respiratory distress syndrome (severe), acute kidney injury (level III), pancreatic necrosis, and infection (Fig. 1) and transferred to our hospital on August 5. She was in critical condition with Acute Physiology and Chronic Health Evaluation II score of 22. We continued mechanical ventilation, CRRT, and drainage of infected pancreatic necrosis. At 11:04, August 12, the patient complained of chest discomfort and lost her consciousness, which was witnessed by a nurse. Electrocardiogram showed ventricular fibrillation and then cardiac arrest. Cardiopulmonary resuscitation (CPR) was started immediately with chest compression and defibrillation. Advanced airway had been confirmed in good condition. Ventricular fibrillation and defibrillation repeated and succeeded 8 times. Continuous renal replacement therapy continued but modulated to induce hypothermia brain protection. Arterial blood gas analysis showed metabolic acidosis and hyperkalemia (potassium, 5.4 mmol/L). Potassium-free CRRT and glucose/insulin solution infusion were used to correct hyperkalemia and acidosis. Ice cap and CRRT were used to induce hypothermia and brain protection during resuscitation. After 52 minutes, patients had return of spontaneous circulation. After 110 minutes, she regained consciousness. Chest x-ray showed no rib injury 10 hours after CPR (Fig. 2). After CPR, she received several times of minimally invasive percutaneous drainage and endoscopic debridement for infected pancreatic necrosis. Two months later, abdominal computed tomographic scan prompted that the necrotic tissues around pancreas had been basically cleaned (Fig. 3), and chest x-ray showed no obvious abnormalities in the lung (Fig. 4). She was discharged from hospital with full recovery on November 10, 2014.
Severe acute pancreatitis (SAP) is a critical illness in clinical practice, which is characterized by intensive inflammatory response in the early phase and infected pancreatic necrosis in the later phase [1]. Despite the knowledge of SAP and a lot of critical care support technology improvement in recent years, SAP still carries approximately 30% mortality rate [2]. Many SAP patients had already acquired respiratory failure, renal failure, even shock, and multiple-organ dysfunction syndrome when they arrived at the emergency department (ED) [3,4]. One case of SAP patient in our intensive care unit (Department of General Surgery, Jingling Hospital, Nanjing, People's Republic of China) had unpredictive cardiac arrest. She was receiving continuous renal replacement therapy (CRRT), continuous veno-venous hemofiltration, and ventilator treatment and also the central venous pressure and invasive arterial pressure monitoring, which helped us a lot in the recovery process. She had return of spontaneous circulation after a long time of cardiopulmonary cerebral resuscitation and regained consciousness within 2 hours. A 49-year-old woman developed sudden severe upper abdominal pain on July 16, 2014. She was diagnosed with severe acute pancreatitis and treated in a local county hospital. The patient developed acute
Fig. 1. Computed tomography shows large areas of tissue necrosis around the pancreas on admission to our hospital.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
1108.e6
B. Li et al. / American Journal of Emergency Medicine 33 (2015) 1108.e5–1108.e7
Fig. 2. Computed tomography shows necrotic tissue around the pancreas basically cleaned 2 months after CPR.
The patient that we report here was in stage of pancreatic necrosis and infection of severe acute pancreatitis. She was in critical condition on admission, and all the intensive treatments were undertaken, including ventilation, CRRT, antibiotics, parapancreatic drainage, fluid management, and nutritional support. It was difficult for her to have survived after prolonged resuscitation without any neurologic defect. In summary of the reasons for the success of this patient, CRRT was the most impressive one. Usually, we would stop existing CRRT when cardiac arrest occurred to facilitate the return of blood. We would not take the initiative to start CRRT for the complexity of operation and additional loss of blood [5]. In the present case, we continued the existing CRRT to regulate electrolyte and acid-base imbalance and implement hypothermia for brain protection, which was proved to be effective. Continuous renal replacement therapy, also known as continuous blood purification, can effectively remove inflammatory cytokines, regulate fluid balance, and maintain a stable internal environment in critically ill patients [6]. It is effective in the treatment of patients with SAP and is conventionally used for SAP in different stage [7,8]. Tatsumi et al [9] ever used CRRT to treat a case of cardiopulmonary arrest caused by severe metabolic alkalosis and hypermagnesemia in a patient with anorexia nervosa and chronic renal failure after spontaneous circulation was restored. The present patient developed acute renal failure, and continuous veno-venous hemofiltration was ongoing in the event of cardiopulmonary arrest. Continuous renal replacement therapy was used to correct acidosis and hyperkalemia during CPR. Hemodialysis machine was also
Fig. 4. Chest x-ray shows no notable abnormalities the lung 2 months after CPR.
used to carry out therapeutic hypothermia with a target temperature of 33°C during process of resuscitation. The 2010 American Heart Association guideline pointed out that adequate coronary perfusion pressure is an indispensable condition for the restoration of spontaneous circulation. Friess et al [10] found that hemodynamic directed resuscitation targeting coronary perfusion pressures greater than 20 mm Hg during 10 minutes of CPR improved short-term survival. In the present case, she had existing arterial catheter and allowed us to evaluate the real-time effect of chest compressions. Her diastolic blood pressure was always maintained above 45 mm Hg during chest compressions. Cardiopulmonary arrest can be caused by variety of reasons. It is important to identify the cause and remove reversible factors positively that led to cardiac arrest. Spontaneous ventricular fibrillation was accounted for the cardiac arrest. The heart physician implements professional treatment on her later. She was discharged from hospital after 3 months, and there was no recurrence of cardiac arrest till now. We report a case here aimed to remind all ED physicians and intensive care unit physicians to maintain a high index of suspicion for cardiac arrest in SAP patients and make full use of invasive monitoring methods and SAP treatment instrument to achieve full and effective recovery; we strongly recommended a prolonged cardiopulmonary cerebral resuscitation in some not quite old SAP patients and continue to use existing CRRT but not remove it. Baiqiang Li, MD Lu Ke, MD Xiao Shen, MD Zhihui Tong, MD Gang Li, MD Jing Zhou, MD Dongliang Yang, MD Xianghong Ye Jieshou Li, MD WeiQin Li, MD* Department of General Surgery, SICU, Jinling Hospital Nanjing University School of Medicine, Nanjing, People’s Republic of China *Corresponding author. Department of General Surgery SICU, Jinling Hospital, Nanjing University School of Medicine No. 305 East Zhongshan Road, Nanjing 210002, China E-mail addresses: [email protected], [email protected]
Fig. 3. Chest x-ray shows no rib injury 10 hours after CPR.
http://dx.doi.org/10.1016/j.ajem.2015.01.004
B. Li et al. / American Journal of Emergency Medicine 33 (2015) 1108.e5–1108.e7
References [1] Al Mofleh IA. Severe acute pancreatitis: pathogenetic aspects and prognostic factors. World J Gastroenterol 2008;14:675–84. [2] Zhang L, Zhou J, Ke L, Nie Y, Tong Z, Li W, et al. Role of heart rate variability in predicting the severity of severe acute pancreatitis. Dig Dis Sci 2014;59(10): 2557–64. [3] Piwinski S. Severe acute pancreatitis. JAMA 2004;292(11):1305 [author reply 1305]. [4] Zerem E. Treatment of severe acute pancreatitis and its complications. World J Gastroenterol 2014;20(38):13879–92. [5] Takahashi H, Takezawa J, Fukuoka T, Mayumi T. Critical appraisal of treatments in emergency settings. Nihon Geka Gakkai Zasshi 1999;100(7): 449–54.
1108.e7
[6] Quintard JM, Barbot O, Thevenot F, de Matteis O, Benayount L, Leibinger F. Partial extracorporeal carbon dioxide removal using a standard continuous renal replacement therapy device: a preliminary study. ASAIO J 2014;60(5):564–9. [7] Cui HX, Xu JY, Li MQ. Efficacy of continuous renal replacement therapy in the treatment of severe acute pancreatitis associated acute respiratory distress syndrome. Eur Rev Med Pharmacol Sci 2014;18(17):2523–6. [8] Podkorytova OL, Tomilina NA, Bibkov BT, Vtorenko VI, Shirinskii VG, Loktev VV, et al. Replacement renal therapy in complex treatment of severe acute pancreatitis. Anesteziol Reanimatol 2008;6:63–6. [9] Tatsumi H, Masuda Y, Imaizumi H, Kuroda H, Yoshida S, Kyan R, et al. A case of cardiopulmonary arrest caused by laxatives-induced hypermagnesemia in a patient with anorexia nervosa and chronic renal failure. J Anesth 2011;25(6):935–8. [10] Friess SH, Sutton RM, Bhalala U, Maltese MR, Naim MY, Bratinov G, et al. Hemodynamic directed cardiopulmonary resuscitation improves short-term survival from ventricular fibrillation cardiac arrest. Crit Care Med 2013;41(12):2698–704.
