Copyright 2019 Crystal OGuin DNP CRNA All Rights Reserved Disclosure Statement I have no financial relationships with any commercial interest related to the content of this activity ID: 1038274
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1. Unique Aspects of Perioperative ArrestCopyright 2019. Crystal O’Guin, DNP, CRNA. All Rights Reserved.
2. Disclosure StatementI have no financial relationships with any commercial interest related to the content of this activity. I will not discuss off-label use during my presentation.
3. Learner OutcomesCompare differences in perioperative arrest and out-of-OR arrest.Employ team dynamics to facilitate crisis management during intraoperative arrest.Evaluate perioperative arrest scenarios that require unique management in the context of this setting.Explore pharmacological alternatives for specific perioperative arrest scenarios.
4. Interactive Questions live.voxvote.comPIN: 96367
5. Audience Poll Give one word to describe a code in the OR…live.voxvote.comPIN: 96367
6. Incidence & OutcomesEstimated at 5.6 per 10,000 cases (Nunnally et al., 2015; Moitra et al., 2018) NACOR Retrospective analysis (Nunnally et al., 2015)ACS-NSCIP Retrospective analysis (Kazaure, et al., 2013)GWTG-R Registry data (Ramachandran, 2013)Better outcomes than outside OR but mortality rates still >50% (Hinkelbein, Andres, Thies, & E, 2017; Moitra et al., 2018)
7. Aggregate Outcomes & IncidenceNon-Cardiac Surgery 4.3: 10kGA 5.5:10kRegional 1.5:10kMAC 0.7:10kSurvival= 34.5%In-Hospital Overall: 40.2: 10kSurvival= 18%Image: Wanderer, J.P. & Rathmell, J.P. (2014) Anesthesiology, 120 (4). Permissions under Fair Use & via email w/ Dr. Wanderer
8. Patient CharacteristicsSurvivorship decreased with advanced age, higher ASA physical status, emergencies, contaminated wounds (Nunnally et al., 2015; Moitra et al., 2018) Pre-existing neurological disability (Ramachandran, 2013)Abdominal & thoracic surgery have the highest risk of IOCAAsystole is most common cardiac arrest arrhythmia in 24 hour perioperative period (Moitra et al., 2018 )
9. Acute reduced blood flow– Increased intra-abdominal pressure– Tension pneumothorax– High positive end-expiratory pressure– Surgical maneuvers Respiratory problems– Hypoxemia– severe bronchospasmCardiovascular problems– Vasovagal reflex (e.g., brady, asystole)– Hypovolemic &/or hemorrhagic shock– Gas embolism– Electrolytes (high K+, low Ca++)– Transfusion-related or anaphylaxis – Acute coronary syndrome – Pulmonary VTE– Severe pulmonary HTN– Pacemaker failure (e.g., brady, asystole)– Prolonged QT syndrome– Oculocardiac reflexesAnesthesia-related problems– Anesthetic drug overdose (e.g., inhalation or IV) – Neuraxial block with sympatholysis– Systemic toxicity of local anesthetic – Malignant hyperthermiaCauses of perioperative arrestChart adapted from text of (Hinkelbein, Andres, Thies, & E, 2017)
10. Audience Poll What is the most common cause of arrest that is attributable to anesthesia? live.voxvote.comPIN: 96367
11. Causes attributable to anesthesia2002 Newland & Ellis, et al.medication administrationairway managementtechnical problems of central venous access2014 Ellis & Newland, et al.
12. Ellis & Newland (2014) Attributable CauseImage: Ellis & Newland, 2014
13. Human FactorsTunnel VisionPremature ClosureGroup stress (e.g. following the leader) Post-completion errorsWorking memory and memory retrieval errors(Wen & Howard, 2017)
14. Audience Poll a. Are Crisis Management Checklists readily available in your OR suite? b. Have you had training with using a Crisis Management Checklist in a perioperative emergency? live.voxvote.comPIN: 96367
15. Stanford Anesthesia Cognitive Aid Group*. Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2016 (Version 3) Crisis Resource ManagementEMIC:Emergency Manuals
16. Immediate actions: CV compromise Get help immediately, request crash cart Notify surgeon (stop surgery; evaluate surgical variables) Ensure pulse; chest compressions PRN Turn off/reduce anesthetic; open fluids; ensure vascular access adequate Airway secure; 100% O2; evaluate EtCo2 for acute changes as most rapid hemodynamic assessment Consider bedside ultrasound/chest xray/I-stat/TEE (Moitra et al., 2018; Stanford Cognitive Aid Group, 2016) Image: fortunarkeringcompany.com
17. Ventilation During CPRCommon pitfall is hyperventilationGoal is 10 breaths/min or less; 1 sec inspiratory time, & tidal volume ~500 ml (just enough for chest rise)Chest compressions are continuous with an advanced airway w/ ventilation @ 10 breaths/minNo airway= 30 compressions: 2 breaths until airway securedLaryngoscopy/ intubation while CPR in progress when feasible to minimize interruption in chest compressions (Moitra et al., 2018 )
18. Effective CPRRate 100-120 per minuteDepth at least 2 inchesRecoil of chest wall Most important concept is uninterrupted chest compressionsChange compressors as needed at 2 minute intervals10 second pauses at 2 minute intervals for assessmentUse endpoints: Diastolic ABP ~30- 40; EtCo2 ~20 Sudden sustained rise (35-40) in EtCo2? Indicates ROSCPost-shock- immediately resume compressions (no pulse check) image: Wikimedia commons
19. "This Beating Heart" by Phill Buckland is licensed under CC BY-NC 4.0 ACLS Protocol for Cardiac ArrestEvidence based basic guidelines originally intended for sudden collapse & unwitnessed arrests (Moitra et al., 2018 ) Not designed for the operative setting applies with adaptationsOR arrest advantagesA-ACLSimage: AHA (2015)
20. OR Pulseless ArrestAHA (2015)2 Branches: VF/ VT v. PEA/ asystoleFocuses on high quality CPR & early defibrillationEpi 1mg q 3-5 minH & T’s VF/ VT consideration for Lidocaine or AmiodaroneMoitra (2018) OR Specific ACLS algorithmIncludes consideration for specific intra-op causesCaCl++ is on the algorithm for VT/ hyperkalemiaVasopressin is on the algorithm as an epi alternativeEpi is titrated 100mcg- 1000mcg/ doseConsideration for early ECMO or rescue PTCAMainstays are still excellent CPR & early defibrillationDon’t forget- uninterrupted chest compressions & avoid hyperventilation!
21. Image: Moitra, V. K., Einav, S., Thies, K. C., Nunnally, M. E., Gabrielli, A., Maccioli, G. A., . . . O'Connor, M. F. (2018). Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1. Anesth Analg, 126(3), 876-888. doi:10.1213/ANE.0000000000002596
22. Audience Poll 3Does your facility routinely suspend DNRs for surgery?live.voxvote.comPIN: 96367
23. DNR in the OR Automatic suspensionRequired reconsiderationFull attemptLimited attempt with regard to specific proceduresLimited attempt with regard to patient’s goals and values
24. Special Perioperative Situations Auto-PEEP Tension Pneumothorax Local anesthetic systemic toxicity (LAST) Anaphylaxis Malignant hyperthermia (MH) Severe hyperkalemiaPulmonary embolism (PE; thrombus or gas)Prone CPRPregnant CPRE-CPR
25. Auto-PEEPLazarus PhenomenonOccurs in COPD/ asthma during positive-pressure ventilation & leads to hypotension & potential for CV collapseExpiratory flow waveform does not return to zeroTo diagnose: disconnect ETT from ventilator for 10–20 seconds & note increase in BPExacerbated by hyperventilationIMPROVEMENT? Begin to provide maximal therapy for bronchospasm, & change ventilation to small tidal volumes (<6 mL/kg), a low respiratory rate (<10/min), & a short inspiratory time (Moitra et al., 2012 ) "GCC Trip To Israel in 2007" by Marion Doss is licensed under CC BY-SA 2.0 https://www.flickr.com/photos/7337467@N04/2831387847
26. Tension PneumothoraxHemodynamic compromise worse in those receiving PPV (as opposed to spontaneous ventilation)Sx: hypoxia, tachycardia, sudden hypotension, SQ emphysema, unilateral breath sounds, eventual PEAALWAYS SUSPECT w/ acute decompensation during laparoscopic surgery; consider in COPD patientsConsider bedside usg or tube thoracostomy but do not delay care if unstableUnstable (see below; image: emergencymanual.stanford.edu)
27. LASTPNB’s carry greatest risk (still rare @ 1-10: 10,000)Presentation varies greatly: seizures are not present in ~half; delayed onset is also commonTreatment for cardiac arrest is vastly different from ACLSReduce individual epinephrine boluses to ≤ 1 mcg/kgAvoid vasopressin, calcium channel blocks, beta blockers, or other local anestheticsRapid BOLUS is critical to effect of Lipid Emulsion Amiodarone is anti arrhythmic of choice (no lidocaine)Propofol is not a substitute for intralipidContinue CPR for a prolonged period; consider ECMO
28. Anaphylaxis Direct causative agent usually unknownHypersensitivity incidence 15: 10,000 cases (severe 2: 10,000)Difficult to discern under anesthesia, progression to shockSuspend any infusions, give epi (100-300 mcg IV), give a fluid bolus, intubate early, epi infusion PRN (0.05–0.3 µg/kg/min) B2 agonist (inh), IV steroids, antihistamines also appropriate Bimodal; risk of recrudescence (admit to ICU x 24 hours)Image: International Anesthesia Research Society (IARS). Anesth Analg, 126(3). p. 735.
29. MHKeys are recognition & dantrolene Mortality up to 80% w/o dantroleneUse cognitive aids for rare eventsAVOID CCB’s for arrhythmiasimage: standford.emergencymanual.eduDantrolene or Ryanodex 2.5 mg/kg IV is the key therapy for MH.
30. HyperkalemiaDysrhythmias vary widely (peaked T-waves, QRS widening, diminished P waves; bradycardia, av blocks, VT, VF) vs. NO changes in ESRDGive CaCl; promote intracellular shift; promote excretionImage: Based on text of McEvoy, et al. (2018)
31. Pulmonary EmbolusThromboembolism, venous gas embolism, & fat embolism (VTE most common) Sx: unexplained hypotension with drop in Etco2; desat- only mild improvement w/ increased Fio2; bronchospasm w/ increased PIP; dysrhythmias or bradycardia; increased CVP/ pulmonary pressures; progression to PEAGas embolism seen in a variety of surgical casesAdapted from text in McEvoy, et al (2018)
32. Prone CPRImage: https://clinicalgate.com/intraoperative-crisis-management-in-spine-surgery-what-to-do-when-things-go-bad/
33. MayfieldⓇ Headrest CPR Image: http://www.cardion.cz/file/107/wallchart-patient-positioning-eng.pdf
34. Pregnancy & cardiac arrestDefibrillation and drug doses are unchangedCPR should be performed with manual 30 degree left uterine displacementAim for IV access above the diaphragm because of potential IVC compression (Truhlar et al., 2015)Consider the need for an emergency Caesarean section as soon as a pregnant woman goes into cardiac arrest (Truhlar et al., 2015)best survival rate for infants over 24–25 weeks’ gestation occurs when delivery of infant is achieved within 4- 5 min after the mother’s cardiac arrest (Truhlar et al., 2015)
35. Extracorporeal CPR (ECPR)ECPR/ ECMO is the use of extracorporeal circuit & gas exchange to provide temporary life support in patients with reversible pulmonary or cardiac failureImage: http://www.ecmokolkata.com/gallery.php#prettyPhoto[pp_gal]/0/
36. ECPR in Paris Image: https://www.jems.com/articles/print/volume-42/issue-12/features/how-physicians-perform-prehospital-ecmo-on-the-streets-of-paris.html
37. Questions? Reach me @ co482@georgetown.eduThank you!
38. ReferencesAHA (2015) Advanced Cardiac Life Support Manual. Dallas, TX: American Heart AssociationASA (2013) Ethical guidelines for the anesthesia care of patients with DNR orders or other directives that limit treatment. Accessed July 4, 2018 @ https://webcache.googleusercontent.com/search?q=cache:pGVzOEKQuawJ:https://www.asahq.org/~/media/sites/asahq/files/public/resources/standards-guidelines/ethical-guidelines-for-the-anesthesia-care-of-patients.pdf+&cd=1&hl=en&ct=clnk&gl=us&client=safariASRA (2018) LAST Checklist. Accessed April 22, 2018 @ https://www.asra.com/content/documents/asra_last_checklist_2018.pdfCharapov, I., & Eipe, N. (2012). Cardiac arrest in the operating room requiring prolonged resuscitation. Can J Anaesth, 59(6), 578-585. doi:10.1007/s12630-012-9698-4Ellis, S. J., Newland, M. C., Simonson, J. A., Peters, K. R., Romberger, D. J., Mercer, D. W., . . . Lisco, S. J. (2014). Anesthesia-related cardiac arrest. Anesthesiology, 120(4), 829-838. doi:10.1097/ALN.0000000000000153Hinkelbein, J., Andres, J., Thies, K. C., & E, D. E. R. (2017). Perioperative cardiac arrest in the operating room environment: a review of the literature. Minerva Anestesiol, 83(11), 1190-1198. doi:10.23736/S0375-9393.17.11802-XLiu, H., Yu, L., Yang, L., & Green, M. S. (2017). Vasoplegic syndrome: An update on perioperative considerations. J Clin Anesth, 40, 63-71. doi:10.1016/j.jclinane.2017.04.017McEvoy, M. D., Thies, K. C., Einav, S., Ruetzler, K., Moitra, V. K., Nunnally, M. E., . . . O'Connor, M. F. (2018). Cardiac Arrest in the Operating Room: Part 2-Special Situations in the Perioperative Period. Anesth Analg, 126(3), 889-903. doi:10.1213/ANE.0000000000002595Moitra, V. K., Einav, S., Thies, K. C., Nunnally, M. E., Gabrielli, A., Maccioli, G. A., . . . O'Connor, M. F. (2018). Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist: Part 1. Anesth Analg, 126(3), 876-888. doi:10.1213/ANE.0000000000002596Moitra, V. K., Gabrielli, A., Maccioli, G. A., & O'Connor, M. F. (2012). Anesthesia advanced circulatory life support. Can J Anaesth, 59(6), 586-603. doi:10.1007/s12630-012-9699-3Newland, M. C., Ellis, S. J., Lydiatt, C. A., Peters, K. R., Tinker, J. H., Romberger, D. J., . . . Anderson, J. R. (2002). Anesthetic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US teaching hospital. Anesthesiology, 97(1), 108-115.
39. ReferencesRamachandran, S. K., Mhyre, J., Kheterpal, S., Christensen, R. E., Tallman, K., Morris, M., . . . American Heart Association's Get With The Guidelines-Resuscitation, I. (2013). Predictors of survival from perioperative cardiopulmonary arrests: a retrospective analysis of 2,524 events from the Get With The Guidelines-Resuscitation registry. Anesthesiology, 119(6), 1322-1339. doi:10.1097/ALN.0b013e318289bafeResuscitation Council (UK). (2014). Management of cardiac arrest during neurosurgery in adults guidance. Accessed July 6, 2018 @ http://www.resus.org.uk/EasysiteWeb/getresource.axd?AssetID=870&type=Full&servicetype=AttachmentStanford Anesthesia Cognitive Aid Group. Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2016 (Version 3) Truhlar, A., Deakin, C. D., Soar, J., Khalifa, G. E., Alfonzo, A., Bierens, J. J., . . . Cardiac arrest in special circumstances section, C. (2015). European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation, 95, 148-201. doi:10.1016/j.resuscitation.2015.07.017Wen, L. Y., & Howard, S. K. (2017). Perioperative ACLS/Cognitive Aids in Resuscitation. Int Anesthesiol Clin, 55(3), 4-18. doi:10.1097/AIA.0000000000000150Weinberg, G. L. (2012). Lipid emulsion infusion: resuscitation for local anesthetic and other drug overdose. Anesthesiology, 117(1), 180-187. doi:10.1097/ALN.0b013e31825ad8deYuerek, M., & Rossano, J. W. (2017). ECMO in Resuscitation. Int Anesthesiol Clin, 55(3), 19-35. doi:10.1097/AIA.0000000000000149