To the Editor
Cardiac arrest during spinal anesthesia with the resultant severe to lethal neurologic injury was highlighted by Caplan in his 1988 review of closed malpractice insurance claims.1 Preemptive treatment as well as pharmacologic arrest protocols have been put forth, but none address one basic physiological aspect of the heart: The heart is a non-sucking pump (i.e., myocardial relaxation coupled with central venous pressure allows for passive filling of the heart).2 During cardiac arrest while the patient is under axial anesthesia, no matter how vigorously the closed chest is massaged, the cardiac output will not be enough to sustain perfusion to the brain. In addition, with the arterial vascular system dilated distal to the sympathetic block, one would surmise a preferential perfusion to the lower body in spite of CNS auto regulation.
In 1952, a Tasmanian orthopedic surgeon described a case in which a 4-year-old boy in surgery for fractures of the hand unexpectedly developed cardiac arrest. He was initially unable to establish normal cardiac rhythm. As was the custom at the time, he performed open chest cardiac massage. He describes the heart as being “small and empty,” and his manual compressions of the heart were not effective in circulating blood. He immediately had the legs elevated vertically and felt the volume of the heart double almost instantly. It also began to beat spontaneously. He continued by wrapping the legs from foot to hip with Esmarch bandages.3 Woodward subsequently published 4 additional case reports in which cardiac arrest was successfully treated by elevating the legs.4
Elevating the legs has 2 functions. First, it functions to restore preload to the heart, facilitating closed chest massage, and secondly, it increases flow resistance to these areas possibly providing less of a steal from CNS perfusion.
The Woodward maneuver is a simple means of generating cardiac preload as well as some increase in peripheral vascular resistance. Once circulation has ceased, bombardment with pharmacology will be ineffective without some means of circulation. We suggest that if preventative strategies fail to avert a cardiac arrest that the first line of defense be the Woodward maneuver.
A.J. Bogosian, MD
Swedish Hospital Medical Center
Matthew N. Ashbach, MS IV
University of Washington College of Medicine
- Caplan RA, Ward RJ, Posner K, Cheney FW. Unexpected cardiac arrest during spinal anesthesia: a closed claims analysis of predisposing factors. Anesthesiology 1988;68:5-11.
- Pollard JB. Cardiac arrest during spinal anesthesia: common mechanisms and strategies for prevention. Anesth Analg 2001;92:252-6.
- Woodward WW. Treatment of cardiac arrest: filling the heart by expelling blood from the limbs. Lancet 1952;1:82.
- Woodward WW. Cardiac arrest treated by elevation of the limbs for fifteen seconds. Lancet 1960;2:1120.