Cardiac Arrest in the Operating Room: Part 2—Special Situations in the Perioperative Period

Matthew D. McEvoy, MD; Karl-Christian Thies, MD, FRCA, FERC, DEAA; Sharon Einav, MD; Kurt Ruetzler, MD; Vivek K. Moitra, MD, FCCM; Mark E. Nunnally, MD, FCCM; Arna Banerjee, MD; Guy Weinberg, MD; Andrea Gabrielli, MD, FCCM; Gerald A. Maccioli, MD, FCCM; Gregory Dobson, MD; Michael F. O'Connor, MD, FCCM


Anesth Analg. 2018;126(3):889-903. 

In This Article

Abstract and Introduction


As noted in part 1 of this series, periprocedural cardiac arrest (PPCA) can differ greatly in etiology and treatment from what is described by the American Heart Association advanced cardiac life support algorithms, which were largely developed for use in out-of-hospital cardiac arrest and in-hospital cardiac arrest outside of the perioperative space. Specifically, there are several life-threatening causes of PPCA of which the management should be within the skill set of all anesthesiologists. However, previous research has demonstrated that continued review and training in the management of these scenarios is greatly needed and is also associated with improved delivery of care and outcomes during PPCA. There is a growing body of literature describing the incidence, causes, treatment, and outcomes of common causes of PPCA (eg, malignant hyperthermia, massive trauma, and local anesthetic systemic toxicity) and the need for a better awareness of these topics within the anesthesiology community at large. As noted in part 1 of this series, these events are always witnessed by a member of the perioperative team, frequently anticipated, and involve rescuer–providers with knowledge of the patient and the procedure they are undergoing or have had. Formulation of an appropriate differential diagnosis and rapid application of targeted interventions are critical for good patient outcome. Resuscitation algorithms that include the evaluation and management of common causes leading to cardiac in the perioperative setting are presented. Practicing anesthesiologists need a working knowledge of these algorithms to maximize good outcomes.


Advanced cardiac life support (ACLS) was originally developed as an extension of basic life support with a focus on out-of-hospital cardiac arrest (OHCA).[1] OHCA is now recognized as a distinct entity from in-hospital cardiac arrest (IHCA), particularly in relation to more common etiology of arrest, average response rescue time, and survival.[2] As noted previously,[1] periprocedural cardiac arrest (PPCA) is different from both OHCA and medically related IHCA. The etiologies of the crisis, the perioperative team knowledge of the patient's comorbidities, the awareness of current physiological state, and the immediate rescue response time significantly improve restoration of spontaneous circulation and survival to discharge when compared to other forms of IHCA.[3–6]

In addition to these differences in clinical presentation and management, numerous studies have also demonstrated knowledge and skill deficiencies in the proper assessment and management of perioperative crises within the anesthesiology community.[7–12] Frequent and concise updates of the knowledge content necessary for managing high-stakes perioperative events is necessary for preparing anesthesiologists and perioperative teams to provide appropriate and timely care.[13,14] As noted in part 1, while previous publications have described cardiac arrest and crisis management in the operating room, the most recent update in ACLS prompted a part 1 review of the current literature concerning perioperative life-threatening crisis and cardiac arrest. Accordingly, the goal of this part 2 review is to offer an updated clinical perspective of cardiac arrest during the perioperative period. In part 1, we summarize the causes and outcomes of perioperative cardiac arrest, review concepts in resuscitation of the perioperative patient, and propose a set of algorithms to aid in the prevention and management of cardiac arrest during the perioperative period. In this article, we discuss special anesthesia-related crises and the management thereof.

This review is focused on 8 special circumstances in the perioperative period that, while uncommon, are essential for all practicing anesthesiologists to know. The clinical scenarios presented are severe anaphylaxis, tension pneumothorax, local anesthetic systemic toxicity (LAST), malignant hyperthermia (MH), severe hyperkalemia, hypertensive crisis, trauma-related cardiac arrest, and pulmonary embolism (PE; thrombus or gas). Each scenario will be presented with a brief review of pathophysiology and epidemiology followed by recommendations on proper assessment, initial management, and subsequent management of each perioperative crisis based on a comprehensive review of the literature. The information presented in this article represents the background behind the management recommendations proposed in widely available crisis management checklists such as the Stanford and Harvard crisis checklists that are familiar to many practicing anesthesiologists.[15,16] It should be noted that these well-recognized clinical entities are presented as single cause of a life-threatening crisis and out of the clinical contest of more complex condition like septic shock or multiorgan system failure.