A tale of surviving three consecutive cardiorespiratory arrests on table during a right sided pneumonectomy.

Background: Intraoperative cardiorespiratory arrest secondary to lower airway obstruction is often difficult to manage. We describe the management of one such technically challenging case of three consecutive cardiorespiratory arrests during a right pneumonectomy in a young boy.

Methods: A 10 years boy with a large fleshy vascular endobronchial tumor (biopsy proven squamous papilloma), completely occluding the right main-stem bronchus with collapse-consolidation of underlying right lung, was posted for a right pneumonectomy. There were dense adhesions of lung to the parieties and the lung was completely damaged. Twenty-five minutes into the surgery, patient started desaturating and the anesthetist was having difficulty in ventilating him. Check bronchoscopy showed endobronchial bleeding and the double lumen tube abutting the tumor. He was turned supine and CPR performed along with suctioning of blood and repositioning of tube. Patient revived and surgery continued. One and a half hour into the surgery the boy had a second cardiorespiratory arrest due to similar airway obstruction and managed in similar fashion. Lower lobectomy was speedily done to gain access to the hilum followed by quick completion pneumonectomy. Immediately following specimen removal, the patient had the third cardiorespiratory arrest and anesthetist was unable to ventilate the patient even after suctioning and repositioning of tube. With patient in lateral position, through the thoracotomy, right bronchial stump was opened and a quick bronchial intubation performed by the surgeon in chief. On opening the bronchus a tumor ball was seen occluding the left main bronchus, which probably got detached from the main tumor during pneumonectomy. Residual tumor was delivered out and the bronchial stump closed. Patient was transferred to ICU on ventilatory support.

Results: Postoperatively he was extubated after 48 hours and was found to have no neurological deficit. Chest drain came out on POD2 and he was discharged on POD5.

Conclusions: Promptly and methodically addressing this technical challenge helped us to prevent mortality. We also managed to avoid neurological sequelae of cardiorespiratory arrest. Learning point in this case is that when faced with a similar situation, it's important to stay calm and focused and to handle the challenge in a scientific and logical manner.