Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1

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

Disclosures

Anesth Analg. 2018;126(3):876-888. 

In This Article

Abstract and Introduction

Abstract

Cardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure. In this setting, there can be formulation of a differential diagnosis and a directed intervention that treats the likely underlying cause(s) of the crisis while concurrently managing the crisis itself. Management of cardiac arrest of the perioperative patient is predicated on expert opinion, physiologic rationale, and an understanding of the context in which these events occur. Resuscitation algorithms should consider the evaluation and management of these causes of crisis in the perioperative setting.

Introduction

Advanced cardiac life support (ACLS) was developed as an extension of basic life support (BLS). While ACLS was originally developed to manage patients who experienced sudden cardiac arrest in the community, it was subsequently imported into the hospital setting without adaptation or modification. Since their inception, BLS and ACLS have been intended for patients who suddenly collapse or who are found unresponsive.[1] BLS remains the foundation of ACLS, and ACLS remains organized around the electrocardiogram (ECG) and clinical signs of an (in)adequate circulation. ACLS remains focused on common cardiac causes of circulatory arrest and incorporates cardioversion, defibrillation, and pharmacotherapy to restore a spontaneous circulation.[2–4] While prior publications have described cardiac arrest and crises management in the operating room, the most recent update in ACLS prompted a review of the current literature concerning perioperative cardiac arrest and other crises.[5,6] Accordingly, the goal of this 2-part review is to offer an updated clinical perspective of cardiac arrest during the perioperative period. In the first part, 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 guide and prevent cardiac arrest during the perioperative period. In the second part, we discuss the management of special anesthesia-related and periprocedural crises.

Cardiac arrest in the perioperative setting is distinct because the arrest is almost always witnessed, and precipitating causes are often known. Compared to other settings, the response is potentially timelier, focused, and can reverse causes such as medication side effects and airway crisis.[7] Caregivers who take care of patients who undergo surgery usually know relevant medical history and witness a crisis that deteriorates over minutes to hours. Aggressive measures can be taken to support the patient to avert or delay the need for ACLS. In the era of shared decision making, the amount of escalation that is indicated when caring for a specific patient might be appropriately limited by an understanding of the patient's and family's wishes regarding heroic measures.

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