Perioperative Resuscitation and Life Support

Educational Objectives

The goal of this program is to improve the management of perioperative cardiac arrest (PCA). After hearing and assimilating this program, the clinician will be better able to:

1. Improve PCA survival outcomes.
2. Illustrate postcardiac arrest management protocols.

Summary

Cardiac arrest (CA): perioperative resuscitation and life support (PeRLS) is a course offered by the American Society of Anesthesiologists (ASA) as an alternative to advanced cardiovascular life support (ACLS); CA can be caused by external factors during surgery or anesthesia, eg, a dislodged port leading to subcutaneous emphysema, acidosis, heart failure; outcomes improve with early recognition (prevents CA), initiation of effective interventions to delay the CA, and therapy targeted to manage the condition (eg, management with PeRLS algorithm for right ventricle failure)

Resuscitation training: the Joint Commission states that everyone involved in resuscitation should receive training beyond ACLS and be educated about the code response systems and the policies and protocols specific to their institution; training to ensure that the skills are current and proficient is emphasized; a “one size fits all” approach is not effective; managing ST-segment elevated myocardial infarction, stroke, or arrhythmia before the CA is important

History: resuscitation techniques have evolved over thousands of years; the 20th century brought significant advancements, including closed-chest cardiac massage and effective defibrillation; modern cardiopulmonary resuscitation (CPR) — began in the 1960s when the American Heart Association started training physicians to resuscitate patients; ACLS was introduced in 1979; automated implantable cardioverter defibrillators became common in the 1990s; guidelines and algorithms for anesthesiologists to perform CPR in the operating room (OR) and improve resuscitation during surgery and anesthesia were initially published in 2018; the PeRLS course has been offered since 2022

Perioperative CA (PCA): the incidence of PCA is ≈5 in 10,000; ≈33% of PCA is related to anesthesia, eg, medication or airway issues (66% because of surgery); PCA occurs in a highly monitored and specialized setting where advanced interventions can improve outcomes; thus, the survival rate is higher after PCA vs out-of-hospital CA (35% vs 10%); the incidence of anesthesia-related mortality is 1 in 10,000; since the causes of CA related to anesthesia are often reversible (eg, medication or airway issues), outcomes are generally better

Predictors of PCA survival (Ramachandran et al [2013]): using the “Get With The Guidelines–Resuscitation” ACLS data, bleeding (most common; irreversible), emergency surgery, surgery after hours and on weekends, prolonged hypotension, sicker patients, and complicated surgeries were identified as predictors of mortality from PCA; return of spontaneous circulation (ROSC) occurred in 60% of participants; survival rate was 45% at 24 hr and 30% at discharge; 65% of survivors had a good neurologic outcome; PCA prevention is always better than resuscitation as only 20% of patients with PCA survive with good neurologic outcomes; location-specific differences — the majority of PCA occurred in the OR (attributed to bleeding or airway issues); airway issues, arrhythmias, hypotension, hypovolemia, and other factors can lead to CA in the postanesthesia care unit (PACU); multisystem organ failure causes CA in the intensive care unit (ICU); the response time was similar between OR, PACU, and ICU CAs; survival rates were highest in PACU CAs (because of reversible causes), followed by OR and ICU CAs (irreversible causes worsen outcomes); the outcomes in the telemetry unit were better than those on the general hospital floor

Key points: early response time, reversibility, and high-quality resuscitation significantly improve PCA outcomes; it is important to reverse PCA with defibrillation and epinephrine (EPI), and identify the cause within the 20-min window (while maintaining perfusion); appropriate resuscitation improves survival; 2-in deep chest compression, maintaining a compression rate of 100 to 120 compressions/min, higher chest compression fraction, shorter pauses for intubation, and rhythm assessment influence outcomes; pauses in ventilation do not affect outcomes

Association between intubation and survival: Andersen et al (2017) found that patients who were intubated sooner (within 15 min after PCA) had lower ROSC, reduced survival to discharge, and worse neurologic outcomes; early intubation does not improve outcomes, as it may lead to pauses in ventilation, decreased venous return, and other factors that delay ROSC; however, securing the airway is vital for patients experiencing respiratory arrest

Defibrillation time: defibrillation should be performed within the first 2 min of PCA; a 2-min delay (defibrillation at 4 min) decreases chances of survival by 50%; delays in defibrillation in the PACU have been associated with a reduction in the survival rate; however, a clear trend between delayed defibrillation in the OR and worse outcomes has not been identified

Epinephrine: for nonshockable rhythms, early EPI increases ROSC, improves survival to hospital discharge, and leads to better neurologic outcomes; can also be administered after defibrillation in cases of shockable rhythms

Post-CA management: TTM-2 study (Dankiewicz et al [2021]) — temperature control (ie, preventing fever) is more important than hypothermia (cooling to 32°C-35°C); research suggests too much oxygen may worsen outcomes in patients with shock or CA; a study limiting oxygen exposure in CA survivors found no difference; more conservative oxygen targets do not improve survival; targeting a higher mean arterial pressure (77 vs 63 mm Hg) did not impact outcomes

PeRLS course: specifically designed for anesthesiologists and targets the patients and problems they encounter; since PCA differs from CA in other settings, early recognition and lower doses of EPI are recommended; PeRLS includes management strategies for scenarios faced by anesthesiologists (eg, local anesthetic systemic toxicity, malignant hyperthermia, high spinal anesthesia, pneumothorax, anaphylaxis), perioperative factors (eg, anesthetic, surgery, bleeding, and airway issues), relevant interventions (eg, extracorporeal membrane oxygenation, transesophageal echocardiography, open cardiac massage), and specific pathophysiology; consists of 5 modules, interactive scenarios with specialized algorithms, and knowledge checks; its content is evolving

Running a code: is complicated; for improved outcomes, provide effective resuscitation, perform chest compressions, deliver defibrillation, and use EPI at the appropriate time; one should identify rhythms and ensure that they do not miss a secondary rhythm (eg, ventricular fibrillation that occurs later); pay attention to the monitor, keep track of the time, identify reversible causes (“Hs and Ts”), document, and plan post-CA care; the code blue pit crew model — a way of adapting crew resource management to CA (adapted to perioperative setting); the team needs a leader, clear communication, and defined roles to improve outcomes; leading the code from a step back, ensuring tasks are done correctly, is more beneficial for the patient than attempting to perform multiple tasks simultaneously

Readings

Andersen LW, Granfeldt A, Callaway CW, et al. Association between tracheal intubation during adult in-hospital cardiac arrest and survival. JAMA. 2017;317(5):494-506. doi:10.1001/jama.2016.20165; Castan C, Münch A, Mahling M, et al. Factors associated with delayed defibrillation in cardiopulmonary resuscitation: A prospective simulation study. PLoS One. 2017;12(6):e0178794. doi:10.1371/journal.pone.0178794; Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus normothermia after out-of-hospital cardiac arrest. N Engl J Med. 2021;384(24):2283-2294. doi:10.1056/NEJMoa2100591; Ramachandran SK, Mhyre J, Kheterpal S, et al. Predictors of survival from perioperative cardiopulmonary arrests: a retrospective analysis of 2,524 events from the Get With The Guidelines-Resuscitation registry. Anesthesiology. 2013;119(6):1322-1339. doi:10.1097/ALN.0b013e318289bafe.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Lyaker was recorded at the 2024 Annual Convention and Conclave of the American Osteopathic College of Anesthesiologists, held September 7-10, 2024, in Palm Springs, CA, and presented by the American Osteopathic College of Anesthesiologists. For information on upcoming CME activities from this presenter, please visit aocaonline.org. Audio Digest thanks the speakers and the American Osteopathic College of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

AN670802

Qualifies for:

ABA MOCA

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.