Resuscitation incoherence after cardiac arrest due to acute intraoperative pulmonary emboli related acute right heart failure: A case report


Resuscitation incoherence is a mismatch between macrocirculation, microcirculation, and cellular parameters after resuscitation. We report a 34-year-old obese male patient, suffering from end-stage renal disease or chronic kidney disease (CKD), underwent routine hemodialysis three times a week and hypercoagulability state with rivaroxaban therapy. He had a cardiac arrest during kidney transplant surgery. Acute right heart failure causing cardiac arrest was presumably caused by acute intraoperative pulmonary embolism. Hemodynamic and resuscitation incoherence occurred and proper treatment was needed. At the time of cardiac arrest, hemodynamic coherence was lost and resuscitation was performed to restore this loss by correcting the possible causes of cardiac arrest. Although the return of spontaneous circulation (ROSC) was successfully achieved, a type 1 resuscitation incoherence occurred where the macrocirculation was optimal but cellular parameters were disturbed by cell hypoxia, characterized by high levels of lactate. Type 2 resuscitation incoherence was also found in this patient until the end of treatment in the intensive care unit (ICU). Cellular parameters such as lactate levels and the venoarterial carbon dioxide tension difference to arteriovenous oxygen content difference ratio (P[v-a]CO2)/(C[a-v]O2) continued to improve during ICU treatment, but cell hypoxia might occur since the central venous pressure (CVP) value as a macrocirculation parameter was likely to increase, presumed to be caused by incomplete resolved acute pulmonary embolism related chronic thromboembolic pulmonary hypertension.