‘No patient whose death is preventable should die in an operating room or in a hospital – ever’ wrote William R. Berry in his recent editorial.1 The editorial is accompanied by two articles in the same issue of the Canadian Journal of Anaesthesia – one on cardiac arrest in the operating room requiring prolonged resuscitation2 and the second on anaesthesia advanced circulatory life support.3 Both articles are important recent contributions to the problem of sudden unexpected cardiac arrest during anaesthesia (SUCADA).
Charapov and Eipe2 presented a case of prolonged (55 min) and successful intraoperative resuscitation of a 53-year-old man undergoing an urgent abdominal procedure after which the patient was alive with a good neurological outcome 14 months after the event. In the discussion section of the article, the authors undertook a search and reviewed the literature with regard to the duration and outcomes of resuscitation during anaesthesia in the period 1990 to 2010. They identified 19 published case reports and performed in-depth analysis of cardiac arrest causes, outcome predictors and factors that support extending or limiting the duration of cardiopulmonary resuscitation in the perioperative period.
At present, the incidence of unexpected cardiac arrest during anaesthesia is reported to be 0.5 to 1.0 cases per 10 000 anaesthetics in adults, more often in neuraxial anaesthesia and much more often in children, especially neonates.4 However, this incidence might underreport the true frequency. Cardiac arrest during anaesthesia is regarded by many anaesthesiologists as the perioperative catastrophe.5 There are several factors such as hypoxia, acute blood loss with shock, pulmonary embolism, myocardial infarction, arrhythmia or electrolyte disturbances which all can contribute to, or even trigger, a cardiac arrest during anaesthesia.
Management of sudden cardiac arrest in both the out-of-hospital and in-hospital setting is governed by clear evidence-based guidelines included in the recent consensus document.6 Those guidelines are a result of an exhaustive evaluation process undertaken by the International Liaison Committee on Resuscitation (ILCOR http://www.ilcor.org). Neither current7 nor previously published resuscitation guidelines have specifically addressed an intraoperative cardiac arrest, which differs from other types of in-hospital cardiac arrest and, ideally, should also be managed according to its own corresponding evidence-based principles. However, the relatively low rate of cardiac arrest during anaesthesia makes it difficult to conduct controlled studies on this subject and may explain why intraoperative cardiac arrest has not been included so far in the guideline evaluation process.
Patients in the operating room are monitored extensively and, as a consequence, there should be no delay in diagnosing a cardiac arrest. However, this may not always be the case – recent data highlight delays of 2 min or more in identifying the need for and initiating defibrillation in the operating room, resulting in decreased survival in cardiac arrest patients.8 If there is a strong possibility of cardiac arrest, it may be advisable to apply self-adhesive defibrillation paddles before induction of anaesthesia. Asystole and ventricular fibrillation should be detected in the operating room immediately. However, the detection of pulseless electrical activity might not be so obvious and capnography, pulse oximetry and pulse check or arterial line analysis may be required to establish a diagnosis. Failure to rescue a deteriorating patient is the most common ‘cause’ of cardiac arrest in the operating room, but in most cases, such failure to rescue tends to be due to the serious condition of the patient despite the timely recognition of the problem and the provision of maximum support.
Moitra et al.3 propose a set of algorithms and protocols to guide anaesthetic care for both prevention and treatment of cardiac arrest during anaesthesia. The study discusses in detail the management of the most common causes of cardiac arrest combined with anaesthesia. This is the first time that these algorithms and protocols have been published in a peer-reviewed journal, after their prototype publication on the American Society of Anesthesiologists’ website in 2008.9 We will now learn how useful they are in clinical settings. These protocols and algorithms are a ‘user friendly’ version of the approach previously proposed by Runciman et al.10 and described in a manual on systemic management of crisis in the operating room. Moitra et al.3 stated: ‘after performing a review of the relevant literature, we offer these suggestions, hoping that they will inspire systematic studies and more formal guidelines to manage these rare perioperative events.’
In the view of the Helsinki Declaration on patient safety in anaesthesiology,11 as well as the positive effect of the surgical safety checklist on patient outcome,12 the algorithms proposed by Moitra et al. for the prevention and treatment of cardiac arrest during anaesthesia are very much welcomed by anaesthesiologists and others. It is worth stating that a recent study using high-fidelity simulation scenarios proved that checklist use results in a many-fold reduction in the failure to adhere to important steps in the management of critical incidents in the operating room.13 We still need to ensure these algorithms are easy to use in clinical settings.
In our opinion, there is an urgent need to develop international, anaesthesia-centred, advanced life support guidelines in support of the existing guidelines produced as a result of the evaluation process undertaken by the ILCOR. To save some thousands of human lives in addition to those saved by out-of-hospital CPR,14 action is needed because, as already stated, ‘no patient whose death is preventable should die in an operating room or in a hospital – ever’.1
Assistance with the article: none.
Financial support and sponsorship: none of the authors received financial or other support from any of the companies mentioned in this article.
Conflicts of interest: none declared.
Comment from the Editor: this editorial was checked and accepted by the editors, but was not sent for external peer-review. BWB is an associate editor of the European Journal of Anaesthesiology.
1. Berry WR. Cardiac resuscitation in the operating room: reflections on how we can do better. Can J Anaesth
2. Charapov I, Eipe N. Cardiac arrest in the operating room requiring prolonged resuscitation. Can J Anaesth
3. Moitra VK, Gabrielli A, Maccioli GA, O’Connor MF. Anesthesia advanced circulatory life support. Can J Anaesth
4. Zuecher M, Ummehofer W. Cardiac arrest during anesthesia. Curr Opin Crit Care
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6. Nolan JP, Hazinski MF, Billi JE, et al. Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation
7. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010. Section 4. Adult advanced life support. Resuscitation
8. Mhyre JM, Ramachandran SK, Kheterpal S, et al. Delayed time to defibrillation after intraoperative and periprocedural cardiac arrest. Anesthesiology
9. Gabrielli A, O’Connor MF, Maccioli GA. Anesthesia advanced circulatory life support. February 2008. The American Society of Critical Care Anesthesiologists & The American Society of Anesthesiologists, Committee on Critical Care Medicine. http://old.asahq.org/clinical/Anesthesiology-CentricACLS.pdf
[Accessed 11 July 2012].
10. Runciman WB, Kluger MT, Morris RW, et al. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Qual Saf Healthcare
11. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki Declaration on patient safety in anaesthesiology. Eur J Anaesthesiol
12. de Vries EN, Prius HA, Crolla RM. Effect of comprehensive surgical safety system on patient outcome. N Engl J Med
13. Ziewacz EJ, Ariaga AF, Bader AM, et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg
14. Hinkelbein J, Böttiger BW. The message is clear to save an additional 100 000 lives per year in Europe: ‘harder and faster for cardiopulmonary resuscitation’. Eur J Anaesthesiol