title: Fatal intraoperative cardiac arrest after application of surgifoam into a bleeding iliac screw defect.
abstract: METHODS
  Case report.
  
  
  OBJECTIVE
  To describe the presentation, management, and autopsy findings in a case of a fatal intraoperative cardiac arrest after application of an absorbable hemostatic agent into a bleeding iliac bone screw defect.
  
  
  BACKGROUND
  To the authors' knowledge, this represents the first reported complication of intraoperative death associated with Surgifoam (Ethicon) thromboembolization to the heart and lung microcirculation after its application into a bleeding bone defect.
  
  
  METHODS
  A 56-year-old male was undergoing revision fusion surgery for pseudarthrosis after multilevel thoracolumbosacral fusion with pelvic fixation for degenerative scoliosis. Intraoperatively, upon removal of the right iliac screw, heavy venous bleeding was encountered, which was stopped after application of 10 mL of Surgifoam into the screw defect. Approximately 5 minutes later, the patient's end tidal CO2 dropped, and his pulse was lost. Epinephrine was administered and the patient was immediately turned to supine position and cardiopulmonary resuscitation initiated. Cardiopulmonary resuscitation was performed unsuccessfully for 30 minutes at the end of which the patient was pronounced dead.
  
  
  RESULTS
  Autopsy findings revealed angulated particles of hemostatic agent with entrapped red blood cells partially to completely occluding small-to-medium-sized vessels of the heart and lungs. The cause of death was pulmonary and cardiac embolization of foreign material from the surgical screw defect to the vessels of the heart and lungs, significantly compromising respiration and blood flow causing sudden death.
  
  
  CONCLUSIONS
  Although Surgifoam is an excellent hemostatic agent for use in spinal surgery, it must be used with extreme caution in the setting of heavily bleeding bone defects after pedicle cannulation or removal of instrumentation. In cases when brisk venous bleeding is encountered, signifying potential compromise of an emissary vein, use of other hemostatic agents such as bone wax may be a safer option.
  
  
  METHODS
  N/A.
authors.affiliation: *Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY †Office of the Chief Medical Examiner of the City of New York, New York, NY; and ‡Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Branko
authors.initials: B
authors.lastname: Skovrlj
authors.forename: Soriaya
authors.initials: S
authors.lastname: Motivala
authors.forename: Fedor
authors.initials: F
authors.lastname: Panov
authors.forename: Jeremy
authors.initials: J
authors.lastname: Steinberger
authors.forename: Jeremy
authors.initials: J
authors.lastname: Stuelpnagel
authors.forename: Samuel K
authors.initials: SK
authors.lastname: Cho
authors.forename: John
authors.initials: J
authors.lastname: Caridi
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control*; D001863:Bone Screws; D017809:Fatal Outcome; D006323:Heart Arrest / Q000139:chemically induced*; D006490:Hemostatics / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011542:Pseudarthrosis / Q000601:surgery; D011655:Pulmonary Embolism / Q000139:chemically induced*; D012086:Reoperation; D013123:Spinal Fusion / Q000009:adverse effects*
chemical_list: D006490:Hemostatics