Objectives

The probable cause is one or more of: something related to surgery or anaesthesia; the patient’s underlying medical condition; the reason for surgery; equipment failure.

The first priority is to start chest compressions, then get help, then find and treat the cause using the guideline.

 

START

❶ IMMEDIATE ACTION

  • Declare “cardiac arrest” to the theatre team AND note time.
  • Delegate one person (minimum) to chest compressions 100 min-1, depth 5 cm.
  • Call for help: nearby theatres / emergency bell / senior on-call / dial emergency number.
  • Call for cardiac arrest trolley.
  • As soon as possible, delegate task of evaluating potential causes (Box A).

❷ Adequate oxygen delivery

  • Increase fresh gas flow, give 100% oxygen AND check measured FiO2.
  • Turn off anaesthetic (inhalational or intravenous).
  • Check breathing system valves working and system connections intact.
  • Rapidly confirm ventilator bellows moving or provide manual ventilation.

❸ Airway

  • Check position of airway device and listen for noise (including larynx and stomach).
  • Confirm airway device is patent (consider passing suction catheter).
  • If expired CO2 is absent, presume oesophageal intubation until absolutely excluded.

❹ Breathing

  • Check chest symmetry, rate, breath sounds, SpO2, measured expired volume, ETCO2.
  • Evaluate the airway pressure using reservoir bag and APL valve.

❺ Circulation

  • Check rate and adequacy of chest compressions (visual and ETCO2).
  • Encourage rotation of personnel performing compressions.
  • If i.v. access fails or impossible use intraosseous (IO) route.
  • Check ECG rhythm for no more than 5 seconds.
  • Follow Resuscitation Council (UK) and ERC Guidelines.
  • See Boxes B and C for reminders about drugs and defibrillation.

❻ Systematically evaluate potential underlying problems and act accordingly (Box A).

❼ If there is return of spontaneous circulation, re-establish anaesthesia.

 

Box A: POTENTIAL CAUSES

4 H’s, 4 T’s:

 

Hypoxia (→ 2-2)

Hypovolaemia

Hypo/hyperkalaemia

Hypothermia

Tamponade (→ 3-9)

Thrombosis (→3-5)

Toxins

Tension pneumothorax
 

Specific peri-operative problems:

 

Vagal tone

Drug error

Local anaesthetic toxicity (→ 3-10)

Acidosis

Anaphylaxis (→ 3-1)

Embolism, gas/fat/amniotic (→ 3-5)

Massive blood loss (→ 3-2)

 

Box B: DRUGS FOR PERI-OPERATIVE CARDIAC ARREST

Fluid bolus 20 ml.kg-1 (adult 500 ml).

Adrenaline 10 µg.kg-1 (adult 1000 µg – may be given in increments).

Atropine 10 µg.kg-1 (adult 0.5-1 mg) if vagal tone likely cause.

Amiodarone 5 mg.kg-1 (adult 300 mg) after 3rd shock.

Magnesium 50 mg.kg-1 (adult 2 g) for polymorphic VT/hypomagnesaemia.

Calcium chloride 10% 0.2 ml.kg-1 (adult 10 ml) for magnesium overdose, hypocalcaemia or hyperkalaemia.

Thrombolysis for suspected massive pulmonary embolus.

Box C: DEFIBRILLATION

Continue compressions while charging: Biphasic 4 J.kg-1 (adult 150-200 J)

DO NOT check pulse after defibrillation.

Use 3 stacked shocks in cardiac catheterisation lab.

Box D: DON'T FORGET!

·         Use waveform capnography. No expired CO2 = lungs not being ventilated (assume and exclude oesophageal intubation). Very rarely, absent/minimal expired CO2 = CPR not occurring OR pulmonary circulation disconnected from systemic (e.g. in major trauma). Sudden increase in ETCO2 usually signals return of spontaneous circulation.

·         Optimise position for chest compressions (use overhead for bariatric patients).

·         Uterine displacement in pregnant patients.

Ventilator can free up hands but remember to set to volume control. Minimise intrathoracic pressure: avoid excessive tidal volume and hyperventilation.

 

Editorial Information

Author(s): The Association of Anaesthetists of Great Britain and Ireland 2018. www.aagbi.org/qrh Subject to Creative Commons license CC BY-NC-SA 4.0. You may distribute original version or adapt for yourself and distribute with acknowledgement of source. You may not use for commercial purposes. Visit website for details. The guidelines in this handbook are not intended to be standards of medical care. The ultimate judgement with regard to a particular clinical procedure or treatment plan must be made by the clinician in the light of the clinical data presented and the diagnostic and treatment options.

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