Intra-Operative Cardiac Arrest

This page is dedicated to intra-operative cardiac arrest, rather than cardiac arrest occurring outside the theatre environment.

The topic appeared as a CRQ in September 2024; marks were lost on 'Factors that trigger discussions about treatment escalation plans'.

Resources

For cardiac arrest in other circumstances, see the separate pages on:

Obstetric cardiac arrest
Paediatric and neonatal arrest and resuscitation
Cardiac arrest while pinned for neurosurgery
Arrest following cardiac surgery
Cardiac arrest in general

Overall incidence 1 in 3,000

In elective surgery only: 1 in 6,500
For ASA 1 patients: 1 in 10,600
For ASA 1 or 2 patients: 1 in 8,500

56% male
Median age 60.5yrs

Patient factors

Very young age
Frailty
Comorbid
Higher ASA grade:

ASA 1-2: 27%
ASA 3: 37%
ASA 4-5: 4-5: 37%

Surgical factors

Emergency surgery; 71% of arrests occurred during non-elective cases, despite these cases only representing 36% of all those included
Complex or major surgery; 60% of arrests occurred during complex/major surgical cases, despite these cases only representing 28% of all those included
Out of hours surgery
Specific surgical specialties:

Ortho-trauma (12%)
Lower GI (10%)
Cardiac surgery (9.4%)
Vascular surgery (8.1%)
Interventional cardiology (5.5%)

Location

Main theatre suite: 51%
Critical care: 12%
Anaesthetic room: 11%
Cardiac cath lab: 6.1%

Phase of surgery

Intra-operative under GA (34%)
Post-operative after recovery (17%)
Induction (13%)
Between induction and start of surgery (13%)

The AAGBI cover pretty much all bases by describing the cause of arrest as likely to be 'something related to surgery or anaesthesia; the patient’s underlying medical condition; the reason for surgery or equipment failure'

The standard reversible causes of cardiac arrest (4Hs and 4Ts) are still applicable, though the Resus Council say there should be a focus on identifying and correcting:

Hypovolaemia e.g. from anaphylaxis or bleeding
Hypoxia e.g. from airway issues
Tension pneumothorax
Thrombosis i.e. pulmonary embolism

Specific causes

31% of death from cardiac arrest in NAP7 were deemed 'inexorable'; in 32% of cases there were elements of poor care before cardiac arrest occurred

Primary specific causes of intra-operative arrest as assigned by the NAP7 panel

Major haemorrhage (17%)

Bradyarrhythmia (9.4%)

Cardiac ischaemia (7.3%)

Septic shock (6.8%)

Isolated, severe hypotension (6.1%)

Severe hypoxaemia (6.1%)

Anaphylaxis (4%)

Vagal outflow (3.7%)

BCIS (2.3%)

High neuraxial block (0.7%)

Laryngospasm (0.6%)

Rhythms

Overall non-shockable rhythms (82%) were much more common
Breakdown by rhythm

52% PEA
15% asystole
15% bradycardia
6% VT
6% VF

The management of intra-operative cardiac arrest mostly follows a standard ALS algorithm
Differences in considerations and management are described below

Initial management

The opening gambit should be familiar:

Declare cardiac arrest and (delegate someone to) start chest compressions
Turn off any maintenance anaesthetic
Call for help and the cardiac arrest trolley

Check the position of the airway and ensure its patency; NB if EtCO₂ is absent then presume oesophageal intubation until absolutely excluded

Increase the F_iO₂ to 1.0

Ensure the breathing system is working adequately
Can manually ventilate the patient or use the ventilator; if using the ventilator use a volume control mode

Ensure adequate chest compressions

Ensure adequate access (IV or IO)
Drugs are the same, although give adrenaline incrementally rather than as a 1mg bolus

Management otherwise follows the standard ALS algorithm

Differences in management

The Resus Council say we should 'use ultrasound to guide resuscitation' but offer no further information on what that means
With reference to the relevant reversible courses of cardiac arrest, it is presumably intended to be useful in:

Checking for oesophageal intubation causing hypoxia, as per the AAGBI guidelines (2022)
Looking for evidence of pneumothorax
Point of care echocardiography, looking at the right heart to support a suspected diagnosis of PE (as well as general assessment of cardiac function)
Aiding assessment of volume status

The other tidbits from the Resus Council relate to alternative methods of CPR, namely:

Consider open cardiac compression in place of standard close cardiac compression
Consider extra-corporeal CPR if conventional CPR is failing e.g. ECMO, CPB

In NAP7, 75% achieved ROSC, which is higher than for other in-hospital cardiac arrests
Of those who achieved ROSC, 44% survived to discharge
Of those discharged from hospital, 88% had a good functional outcome (mRS 0-3)

Of the anaesthetists who experienced a perioperative cardiac arrest, 4.5% reported an impact on their subsequent ability to deliver patient care

Organisation of services

Standardised, age-appropriate resuscitation equipment available in every site where anaesthesia takes place

Recognise, and modify techniques for, high-risk cardiovascular settings, e.g.:

Hypovolaemia with cardiovascular instability
Those with frailty or elderly patients
Vascular surgery
Those with pre-existing bradycardia ± expected vagal stimulus during surgery

Training, practice and institutional protocols for managing predictable perioperative complications e.g. cardiac arrest, haemorrhage, anaphylaxis and airway difficulty

Trust policy for the management of an unexpected death associated with anaesthesia and surgery

The Independent Healthcare Provider Network (IHPN) and Private Healthcare Information Network (PHIN) should work with commissioners of care, regulators and inspectors to improve engagement with safety-related national audit projects in the independent hospital sector to assess the quality and safety of care delivered

Greater clarity in adult and paediatric cardiac arrest guidelines pertaining to:

When to start chest compressions
Dosing of adrenaline
Indications for use of calcium and bicarbonate
Indications for eCPR (e.g. CPB or ECMO)

Before

Use validated risk-scoring tools routinely as part of pre-operative assessment and shared decision making

Patients should be provided with a realistic assessment of likely outcomes of their treatment, routinely including important risks such as risk of death

Treatment escalation inc. DNACPR recommendations should be discussed and documented as early as possible preoperatively, if:

Clinical frailty score ≥5
ASA 5
Objective risk scoring of mortality >5%

Infants and neonates should be recognised as high risk of airway difficulty and, when critically ill, of cardiovascular collapse soon after induction; senior and expert care at all times should be available

During

Regardless of location, anaesthesia should not be performed unless appropriate preoperative observations, investigations, risk assessment and team brief have been performed

Robust supervision, including clear processes for contacting assistance during emergency, should be in process, especially for paediatric or remote cases

A standard procedure to effectively call for help, which includes an audible alarm, should be provided across all locations where anaesthesia takes place

Consistent monitoring as per AAGBI guidelines

Level of monitoring should match patient risk, with a lower threshold for continuous invasive arterial blood pressure monitoring in theatre/recovery

High-risk or deteriorating patients should be anaesthetised in theatre on the operating table

Training and competency in administering IV adrenaline (bolus and infusion)

In monitored patients in early cardiac arrest or a severe low flow state, initially give small doses of intravenous adrenaline (eg 50 µg in adults or 1 µg/kg in children) or an infusion of adrenaline, and if return of spontaneous circulation (ROSC) is not achieved within the first 4 minutes (about two 2-minute cycles of CPR) of cardiac arrest, give further adrenaline boluses using the standard cardiac arrest dose (1 mg in adults or 10 µg/kg in children)

After

All cardiac arrests should be reviewed to understand the cause, discover potential learning and support staff; learning should be shared across the whole perioperative team

All cases of cardiac arrest should be communicated to the patient, next of kin, or parents if the patient is a child, as part of the duty of candour