Perioperative Cardiac Arrest Complicated by Acute Pulmonary Edema Following Myomectomy: A Case Report from a Resource Limited Sitting

Abstract

Background: Perioperative cardiac arrest is a rare but catastrophic complication of anesthesia and surgery, associated with high morbidity and mortality, particularly in resource-limited settings. Airway mismanagement and inappropriate fluid administration remain among the most preventable contributing factors. Acute pulmonary edema may further complicate post-resuscitation recovery and significantly worsen outcomes. Case Presentation: We report the case of a 42-year-old woman with poorly controlled chronic hypertension who underwent elective myomectomy under spinal anesthesia at a peripheral hospital. Following failure of spinal anesthesia, conversion to general anesthesia was performed without definitive airway protection. The patient subsequently developed severe hypoxemia progressing to cardiac arrest approximately 30-40 minutes intraoperatively. After initial resuscitation attempts, she was transferred to a tertiary center, where return of spontaneous circulation was achieved. Investigations revealed severe hypoxic respiratory failure and radiological findings consistent with acute pulmonary edema, likely secondary to excessive crystalloid and blood transfusion combined with post-arrest lung injury. Management included prompt endotracheal intubation, lung-protective mechanical ventilation, vasopressor support, and aggressive but carefully monitored diuresis in the intensive care unit. Outcome: The patient demonstrated rapid clinical and radiological improvement, was successfully extubated on day four, and achieved full neurological and functional recovery. She was discharged home in stable condition after eight days of hospitalization, with no residual cardiopulmonary deficits on follow-up. Conclusion: This case highlights that perioperative cardiac arrest complicated by acute pulmonary edema can be survivable, even in resource-constrained environments, when timely resuscitation and structured post-cardiac arrest care are provided. The report underscores the critical importance of early definitive airway management with endotracheal intubation when spinal anesthesia fails and conversion to general anesthesia is required. Furthermore, even in the setting of perioperative hypotension, fluid resuscitation should be judicious and goal-directed rather than overly liberal, as excessive crystalloid administration may precipitate acute pulmonary edema and worsen patient outcomes. System-level preparedness remains essential to prevent avoidable anesthesia-related morbidity and mortality.