A Case Report of Multifactorial Cardiac Arrest During Anesthetic Induction in a High-Risk Patient

Abstract

A 73-year-old Thai male patient weighing 72 kg with comorbidities of diabetes, hypertension, and stage 4 chronic kidney disease received regular medications including atenolol, hydralazine, and enalapril. He was scheduled for surgery to treat urinary tract calculi. Prior to enter the operating room, he received atenolol 50 mg and manidipine 20 mg. During anesthesia induction, propofol 140 mg, cisatracurium 8 mg, succinylcholine 100 mg, fentanyl 100 mcg, and intravenous 2% lidocaine with preservative 40 mg (0.56 mg/kg) were administered. Lidocaine was given two minutes before endotracheal intubation to reduce airway reflexes. During intubation, the patient developed bradycardia (HR 50 bpm), severe hypotension (BP 60/40 mmHg), and unpalpable pulse. Electrocardiogram revealed pulseless electrical activity. The patient received two cycles of cardiopulmonary resuscitation along with atropine and adrenaline until circulation returned. Post-CPR, troponin I levels increased from 10.11 to 3,861.5 pg/mL; consequently, the surgery was aborted, and he was transferred to the intensive care unit. The provisional diagnosis was Local Anesthetic Systemic Toxicity induced by lidocaine, affecting the central nervous and cardiovascular systems, leading to cardiac arrest. Contributing factors potentially triggering this event included advanced age, severe chronic kidney disease, and preoperative administration of atenolol and manidipine, as well as the synergistic effects of lidocaine, propofol, fentanyl, succinylcholine, and cisatracurium that induced hypotension, bradycardia, and arrhythmias. This event emphasizes the importance of risk factor and drug interaction assessments in anesthetic practice.