Do-Not-Resuscitate Orders
during Anesthesia and Urgent Procedures:
Case 1 Discussion
The probable cause of Mr. S's arrest is a cephalad migration of local anesthetic in the subarachnoid space, leading to a "high spinal block." As a result of migration of the local anesthetic from the lumbar segments to high thoracic or even cervical segments, weakness or paralysis of respiratory muscles, including intercostal muscles and diaphragmatic muscles can result. The effect of local anesthetic on segments contributing to the cardiac accelerator fibers can cause bradycardia, and even cardiac arrest. With cardiopulmonary support, prognosis for total recovery from this event is excellent, with only rare cases of central nervous system damage or death reported. CPR would not be futile from a medical standpoint.
Intubation and institution of mechanical ventilation will not alone restore Mr. S's circulation, and these measures alone will be useless. Medications to treat blood pressure and bradycardia will require at least temporary artificial circulation. From the standpoint of medical futility, intubation and mechanical ventilation would be senseless unless accompanied by full CPR, if even briefly.
It is hard to argue ethically for the institution of CPR in this patient, who while neurologically impaired, appeared to have full capacity to understand and make decisions regarding his own medical care. Despite preoperative discussion which included information about the good prognosis from CPR in the OR, the patient stated clearly his wishes to not be resuscitated if an arrest occurs. Instituting CPR in this patient because the cause of arrest is anesthetic-related, would be like justifying transfusion in a Jehovah's Witness against their will because the surgery was the cause of life-threatening hemorrhage, yet adhering to their wishes if hemorrhage was due to non-surgical injuries.
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