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MY MEMORABLE CASE!
AN UNANTICIPATED CARDIAC ARREST
&UNUSUAL POST-RESUSCITATION
PSYCHO-BEHAVIOURAL PHENOMENA & NEAR DEATH EXPERIENCE (NDE)
IN A PATIENT WITH PREGNANACY INDUCED HYPERTENSION
(PIH) AND TWIN PREGNANCY POSTED FOR ELECTIVE
LOWER SEGMENT CAESARIAN SECTION (LSCS):
A CASE REPORT
DR. MRIDUL M. PANDITRAO
CONSULTANT
Department Of Anesthesiology&
Intensive Care
Public Hospital Authority’s RAND MEMORIAL HOSPITAL
Freeport, Grand BahamaCommonwealth of the Bahamas
FORMERLY:
PROFESSOR, HEAD,IN-CHARGE OF ICUDEAN OF FACULTY OF MEDICINEDEPTT. OF ANAESTHESIOLOGY & CRITICAL CAREPAD. Dr. D.Y.PATIL MEDICAL COLLEGEPIMPRI, PUNEINDIA
INTRODUCTION
PERI-PARTUM MORBIDITY & MORTALITY
VARIED AETIOLOGIES of CARDIAC ARREST
SUCCESSFUL RESUSCITATION?
AFTER THAT????
A CASE OF POST CARDIAC ARREST
RESUSCITATION (CPR) UNDERGOING
ELECTIVE LSCS FOR PIH AND TWINS!
INTERESTING, UNEXPLANABLE PHENOMENA
IN POST-OP PERIOD!
CASE REPORT
24 Yrs. Old primi-gravida near term
B.P. 160/122 mm Hg.
Twins
Anti-hypertensive /other Therapy
Development of S/S of impending Eclampsia
Planned Elective L.S.C.S.
ANAESTHETIC MANAGEMENT
Standard Balanced G.A.
At birth of both Babies : infusion of Pitocin
Obstetricians: Intramyometrial Injections
Carbiprost x 3 injections
Pitocin 10 I.U.
“SUDDEN CARDIAC ARREST!”
CPR Started
Revived successfully in 3.5 – 4 minutes
ANAESTHETIC MANAGEMENT(CONTD.)
Surgery was allowed to commence. B.P. on Higher range 150-160/100-110
mm Hg. At the end of surgery, patient was
making spontaneous respiratory efforts.
Reversal was given and patient was extubated when she was fully conscious and responding to verbal commands.
Patient was shifted to ICU after 30 min.
IN ICU IMMEDIATE POST-OPERATIVELY
Patient had no recollection of intra-operative events
Did not recognize her relatives.
Patient Was drowsy but awake
Anticerebral oedema therapy was given.
NEXT 24 HOURS– 1 WEEK
Patient became oriented gradually, but had amnesia
Vitals and physiological functions were normal
Had difficulty with speech initially which later
improved
Patient was discharged after 1 week
JUST BEFORE DISCHARGE
Recollection of immediate pre-operative period
Anterograde amnesia after that
Remembrance of “travelling through dark terrain
with a distant bright light at the end of it”
Seemed to have heard “She’s no more/ She is
dead!”
REVIEW AT 6 MONTHS
Till 3 months ‘unusual experiences’
In Mirror, seeing her own image !
“Out Of Body” experiences
Hearing again that “ She is No More!”
Establishment of normal relationship with
own newborns, spouse and other family members
DISCUSSION
The “Near Death Experiences” – NDES
Have been described in detail in literature*
Neither discussed amongst medical fraternity
nor taught in syllabi and curricula and left in
the realm of the ambiguity**.•Greyson B, Stevenson I. Phenomenology of Near death experience. Am J Psychiatry 1980; 137:1193 – 6.•Gabbard GO, Twemlove SW, Jones FC. Do ‘Near-death experiences’ occur only near death? J. Nerv Ment.dis. 1981; 169:374 – 7• Kircher PM. Love is the Link: A Hospice Doctor shares her experiences of Near Death & Dying, New York 1995, Larson Publications•Blackmore, SJ. Near-death experiences in India: They have tunnels too. Journal of Near-Death Studies 1993 11(4) ;205-11•Parnia S, Waller DG, Yeates R, Fenwick P. A qualitative and quantitative study of the incidence, features and etiology of near death experiences in cardiac arrest survivors. Resuscitation 2001;48:149 - 56
“NEAR DEATH EXPERIENCES” – NDES
Especially Post cardiac Arrest & return after CPR
Unexplainable phenomenon
Cultural variations
But commonly reported through out the world
Never given importance by Medical fraternity
• French CC. Near-death experiences in cardiac arrest survivors. Prog. Brain Res.2005;150:351 - 67 • James D. What emergency Department staff need to know about Near Death experiences. Topics in Emergency Medicine
2004; 26:29 - 34.
Peri partum morbidity and even mortality is again a well
documented phenomenon*
Especially where surgical intervention has been required
Morbidity and mortality might be due to various etio-
pathological processes involved
Treatment modalities logically may be varied with their
final outcome.
• Say L, Pattison R C, GulazogluA M: WHO systematic review of maternal morbidity and mortality, the prevalence of severe acute maternal morbidity (near miss), Reproductive Health,2004,1 (1), 3
• Minauskiene M, Nadasauskiene R, Padaiga Z, Makari S: Systematic review on the incidence and prevalence of severe maternal morbidity; Medicina (Kaunas) 2004, 40 (4): 299-
Exact cause of the Catastrophe?
Cause of cardiac arrest is still a dilemma
“Delivery of babies?” or Intra-myometrial
injections of Carbiprost / Oxytocin
Post-CPR psychological Phenomena?
“O-O-B” experiences, “Dark Tunnel” have been
reported.
Carboprost tromethamine (Hemabate)®,
Methylated analogue of Prostaglandin F2 α (PGF2 α)
In clinical practice for fairly sometime
Many obstetrician use it*
to stimulate myometrial contractility,
increase the tone,
decrease the bleeding and reduce the incidence of PPH.
Routinely given by many Obstetricians intra-myometrially
• Brancazio LR, Stizel RE Uterine Simulates & Relaxants. In: Craig CR., Stitzel RE, editors. Modern Pharmacology with Clinical Applications. 6 th ed, Philadelphia: Lippincott Williams & Wilkins; 2003, p. 719-721
• Singh N, Singh U. Methylergometrine and carboprost tromethamine prophylaxis for post partum hemorrhage; J Obstet Gynecol of India 2005 ,55: 325-8
Oxytocin, although nowadays rare.
Carboprost, Misoprostol and other
uterine stimulants causing cardiac
arrest has been documented*.
• Adverse event in female receiving Hemabate (Carboprost). Reported by a physician from United States on 2007-03-09. Patient: female ...
www.druglib.com/adverse-reactions_side-effects/hemabate/seriousness_serious/
Successful revival of the patient suggests
Whatever was the cause of the event, was acute, transient
and not related to any organic lesion.
Further confirmed by the fact that she did not require any
support or any further sustained pharmacological intervention
The experiences that our patient had can be included under
the realm of NDEs, as per the Greyson’s NDE Scale (of more
than 7 )
• French CC. Near-death experiences in cardiac arrest survivors. Prog. Brain Res.2005;150:351 - 67 • James D. What emergency Department staff need to know about Near Death experiences. Topics in Emergency Medicine 2004; 26:29 - 34.
Various psychological phenomena in post-CPR
period
But our patient’s few more peculiar psycho-
behavioural experiences are not explainable to us.
Discussion with psychiatrists has not been very
conclusive.
Till date, this has been an enigma to us.
CONCLUSION
PIH Patient for elective LSCS, under GA
Suffered C-P Arrest,
Following delivery of babies and
Intra-myometrial Injections of a prostaglandin and
Oxytocin.
Post CPR ‘peculiar’ psycho-behavioral phenomena, which were
self-limiting.
Can be cofirmed as NDEs
Patient is now living “peaceful” life.
CONCLSION
Complicated Obstetrics can be very challenging and
put us through unusual situations
Intra-myometrial use of uterine stimulants can
be very risky and should be avoided as far as
possible
Making all healthcare givers, well acquainted
with the knowledge of “Out of Body”/ NDEs in
post CPR period must be part of our curriculum
In addition to already reported behavioral changes,
new experiences could be added to the existing list.
It is our fervent wish and earnest effort to make all aware that:
Post CPR NDEs might be
difficult to explain but are a
real phenomena
Clinicians must be, less
sceptic & more considerate
about their existence !!
ALREADY PUBLISHED AS A CASE REPORT:
Indian J Anaesth. 2010 Sep-Oct; 54(5): 467–469. doi: 10.4103/0019-5049.71035PMCID: PMC2991660An unanticipated cardiac arrest and unusual
post-resuscitation psycho-behavioural phenomena/near death experience in a patient with pregnancy induced hypertension and twin pregnancy undergoing elective lower segment caesarean section
Mridul M Panditrao, Chanchal Singh,1 and Minnu M Panditrao
Thank You!