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© 2017 EDIZIONI MINERVA MEDICA Minerva Anestesiologica 2017 November;83(11):1190-8

Online version at http://www.minervamedica.it DOI: 10.23736/S0375-9393.17.11802-X

REVIEW

Perioperative cardiac arrest in the operating

room environment: a review of the literature
Jochen HINKELBEIN 1 *, Janusz ANDRES 2, Karl-Christian THIES 3, Edoardo DE ROBERTIS 4

1Department of Anesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne,
Germany; 2Department of Anesthesiology and Intensive Therapy, Jagiellonian University, Cracow,
Poland; 3Department of Anesthesiology, University Medical Center, Greifswald, Germany; 4Department of
Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
*Corresponding author: Jochen Hinkelbein, Department of Anesthesiology and Intensive Care Medicine, University Hospital Co-
logne, 51149 Cologne, Germany. E-mail: jochen.hinkelbein@uk-koeln.de

A B STRACT
INTRODUCTION: Cardiac arrest in the operating room (OR) environment is a rare but potentially catastrophic event
with mortality rates of more than 50%. Contributing factors are known, and the event is generally rapidly recognized, as
patients are usually under full monitoring. The nature of the cardiac arrest in the OR is different to other environments
as it is not only related to the patient’s conditions but likewise to the anaesthetic and the surgical procedure. The aim of
this article is to review recent literature on cardiac arrest in the immediate perioperative environment with a focus on
incidence, causes and treatment.
EVIDENCE ACQUISITION: Retrospective analysis of literature published in PubMed.
EVIDENCE SYNTHESIS: Several recent retrospective registry studies have investigated the incidence of perioperative
cardiac arrest; in non-cardiac surgery patients, the incidence is reported to range from 0.2 to 1.1 per 10,000 adults and
from 1.4 to 4.6 per 10,000 children.
CONCLUSIONS: Successful management of cardiac arrest during surgery and beyond requires not only individual tech-
nical skills and a well-organized team response, but also an institutional safety culture embedded in everyday practice
through continuous education, training and multidisciplinary cooperation. Evidence based guidelines and standardized
treatment algorithms addressing the particularities of peri-operative cardiac arrest would be helpful to facilitate training.
Existing guidelines are not comprehensive enough to cover specific aspects in depth; for the future, more detailed and
more explicit guidelines are required.
(Cite this article as: Hinkelbein J, Andres J, Thies KC, De Robertis E. Perioperative cardiac arrest in the operating room envi-
ronment: a review of the literature. Minerva Anestesiol 2017;83:1190-8. DOI: 10.23736/S0375-9393.17.11802-X)
Key words: Operating rooms - Heart arrest - Cardiopulmonary resuscitation - Intraoperative complications - Periopera-
tive medicine.

Introduction support (ALS) algorithms for both prevention

and treatment of intraoperative unexpected

“N o patient whose death is preventable cardiac arrest.2, 3 Both articles formed the base
or other proprietary information of the Publisher.

should die in an operating room or in a
hospital – ever” wrote William R. Berry in his
editorial in the Canadian Journal of Anaesthe-
sia in the year 2012.1 His editorial is accompa-
nied by two articles, one on cardiopulmonary
resuscitation (CPR) in the operating room
(OR) and one on intraoperative advanced life
for a call for Operation Room Advanced Life
Support (OR-ALS) Guidelines.4 Despite the
fact that sudden cardiac arrest is considered
rare during both general and regional anesthe-
sia, it is a potentially catastrophic event.2, 5
Data collected from 250 US hospitals (1.3
million surgical cases) showed that one out

1190 Minerva Anestesiologica November 2017

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INTRAOPERATIVE AND PERIOPERATIVE CARDIAC ARREST HINKELBEIN
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
of 203 surgical patients undergoes CPR (1 in
33 for cardiac surgery vs. 1 in 258 for general
surgery) resulting in a mortality of 70% dur-
ing the following 30 postoperative days.6 The
risk of intraoperative and early postoperative
cardiac arrest (including postanesthesia care)
remains 5.6 per 10,000 cases.7 Only 45% of
intraoperative cardiac arrest (IOCA) survivors
have good functional outcome by day 90.8
The aim of this article is to review the recent
literature on cardiac arrest in the OR and dur-
ing the immediate postanesthesia period with
a focus on incidence, causes and treatment op-
tions.
Evidence acquisition
A review of the published literature on
IOCA addressing adult patients was conducted
in PubMed. The key words used for the search
included “cardiac arrest,” “OR,” “intraop-
erative,” “asystole,” “ventricular fibrillation,”
“ventricular tachycardia,” “algorithm,” “treat-
ment,” “VT,” and “VF.”
Search terms were used in multiple com-
binations. The search was limited to English
language and human subjects and articles
supplemented by reference lists of publica-
tions. Finally, duplicate records and irrelevant
articles were eliminated. Search results were
screened in a stepwise manner to identify eli-
gible studies/reports. The search was limited
to the last 10 years (2006-2016) and supple-
mented by important older publications if nec-
essary.
Evidence synthesis
Identification/diagnosis of IOCA
Cardiac arrest during anesthesia is distinct
from cardiac arrest in other settings because
or other proprietary information of the Publisher.
it is usually witnessed and frequently antici-
pated. Cardiac arrests are always observed,
patients are monitored, intravenous access is
established, and resuscitation equipment is im-
mediately available.9
Moreover, the underlying causes are not
only related to individual patient factors, but
Vol. 83 - No. 11 Minerva Anestesiologica 1191
also to the effect of surgery and anesthesia. In
the OR, cardiac arrests are generally rapidly
recognized, mainly because patients are under
continuous anesthesia monitoring.1 However,
as individual practitioners rarely encounter
cardiac arrest, the speed with which the diag-
nosis is made and the consistency of manage-
ment vary considerably.9
Asystole and ventricular fibrillation (VF)
will be detected immediately, but the onset of
pulseless electrical activity (PEA) might not
be so obvious and integration of all parame-
ters (capnography, pulse oximetry, and pulse
check or arterial line analysis) is necessary to
establish a timely diagnosis.4 Loss of the pulse
oximetry signal and decreasing end-tidal CO2-
readings should prompt the anesthesiologist
towards a pulse check.10
Perioperative cardiac arrest hardly ever oc-
curs without warnings, which can be subtle;
unexpected vital function changes should alert
the anesthesiologist to ruling out imminent
cardiac arrest and raising concerns with the
team if confirmed. Non-technical skills, as de-
scribed in the paragraph on “Human factors”,
are essential to optimise the team response to
cardiac arrest.
To date, there is no uniformly accepted
definition of anesthesia-related or periopera-
tive cardiac arrest,9 which has resulted in in-
homogeneous data collection and analysis for
research. Furthermore, the time frames to ana-
lyze intraoperative CPR-related outcome data
vary widely among studies ranging from the
time of “drug intake for premeditation” to “30
days after surgery” or more specific “during
induction of anesthesia” to “during the stay in
the operating theatre”;9 also a huge variety is
caused by inhomogeneous inclusion criteria
for patients.
Incidence of cardiac arrest in the OR
The reported incidence of IOCA varies
widely across studies. This is mainly due to
lack of an unambiguous definition of periop-
erative cardiac arrest. Further reasons could be
that the majority of the publications are retro-
spective with different inclusion criteria. Also,
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HINKELBEIN INTRAOPERATIVE AND PERIOPERATIVE CARDIAC ARREST
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the anesthetic environment has become much
safer than it was 50 years ago,9 safety stand-
ards and technology have improved, and pa-
tient safety ranks high on the political agenda.
Despite these positive developments signifi-
cant risks still remain.1
Several recent publications have reported
the rate of cardiac arrest in surgical patients
during their hospital stay but have not specifi-
cally addressed the immediate perioperative
phase.7
Perioperative cardiac arrests occur infre-
quently.2 In developed countries, the incidence
of anesthesia-related cardiac arrest in non-car-
diac surgery patients is reported to range from
0.2 to 1.1 per 10,000 in adults 4, 9 and from 1.4
to 4.6 per 10,000 in children.9 The incidence
of perioperative cardiac arrest is higher in chil-
dren, especially newborns and infants.9
The European Resuscitation Council (ERC)
reports even higher incidences in the 2015
Guidelines: their overall incidence of periop-
erative cardiac arrest ranges from 4.3 to 34.6
per 10,000 procedures.10 This wide range re-
flects differences in case-mix (some include
neonates and/or cardiac surgery) and in the
definition of “perioperative.” 10 The incidence
is higher in high-risk groups such as the elderly
where it has been reported as 54.4 per 10,000
cases 11 and in patients undergoing emergency
surgery where an incidence of 163 per 10,000
cases has been reported.10, 12
A large prospective and retrospective case
analysis study of all perioperative cardiac ar-
rests occurring during a 10-year period (1989-
1999) in a single teaching institution showed
an overall incidence of cardiac arrest from all
causes of 19.7 per 10,000 anesthetics and a risk
of death related to anesthesia-attributable perio-
perative cardiac arrest of 0.55 per 10,000 anes-
thetics.3 A single-center experience published
in 2014 documented mortality of 7 per 10,000
or other proprietary information of the Publisher.
patients within 24 hours of surgery during a 10-
year period.13 Another single-centre study of
emergency response pages in a large academic
OR suite found a rate of 1 in 1400 cases.14
Nunnally et al. extracted data of all cardiac
arrests and immediate perioperative deaths
from the National Anesthesia Clinical Out-
1192 Minerva Anestesiologica November 2017
comes Registry (NACOR) for the period from
2010 to 2013 and analysed for anesthesia-re-
lated risk factors.7 In the NACOR database, a
total of 951 cardiac arrests were reported dur-
ing OR and PACU care.7 The authors found the
risk of cardiac arrest was 5.6 per 10,000 cases
(i.e. approximately, 1 in 1800 patients), which
is less than in previous reports of in-hospital
arrests in surgical patients overall, with an as-
sociated mortality from the arrest of 58.4%.7
Kazaure et al.,6 using data from the Ameri-
can College of Surgeons-National Surgical
Quality Improvement Program (NSQIP), noted
an overall risk of 1 in 200 for in-hospital car-
diac arrest in patients undergoing surgery and
a rate of 1 in 1400 patients for CPR in the OR.7
Ellis et al.13 documented mortality of 7 per
10,000 occurring within 24 hours of surgery
in a single centre from 1999 to 2009, which
would imply a cardiac arrest rate of at least 1
in 1400.7 Weingarten et al.14 documented a 1 in
1400 rate of emergency page activations in op-
erative cases at the Mayo Clinic, with a higher
rate in children aged <1 year.7
Taken together, recent data suggests that the
incidence of perioperative cardiac arrest in a
patient population for surgery is approximate-
ly 1 in 1400 cases. However, this might under-
report the true frequency 4 since solid data do
not exist and specific registries are lacking.
Besides the incidence of cardiac arrest in
the OR environment, Chaparov et al.2 report
on the duration of intraoperative CPR. Their
literature search revealed case reports of suc-
cessful resuscitation after cardiac arrest lasting
from 21 to 315 min;2 longer CPR efforts could
be justified in the OR environment since no-
flow-time is likely to be significantly shorter
compared to out-of-hospital CA. Systematic
reviews or randomized controlled trials (RCT)
are not published on this topic yet.
Risk identification and patient-associated risk
factors
Many factors can contribute to cardiac ar-
rest in the OR (Table I). Perioperative cardiac
arrest, mostly multifactorial in origin, results
from a coincidence of factors such as poor
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INTRAOPERATIVE AND PERIOPERATIVE CARDIAC ARREST HINKELBEIN

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Table I.—Common situations and problems associated gery 15 were found to be significant predictors
with perioperative cardiac arrests in adults [modified of cardiac arrest in the OR.
from Moitra et al.3].
The rate of cardiac arrest increases with age
Anesthesia-related problems
and ASA PS (Figures 1, 2).7 The incidence of
–– Anesthetic drug overdose (e.g., inhalation or intravenous)
–– Neuraxial block with sympathicolysis cardiac arrest and associated mortality rates
–– Systemic toxicity of local anaesthetic drugs are significantly higher in males.7 The highest
–– Malignant hyperthermia incidence of cardiac arrest are in patients with
–– Drug administration errors (e.g., dosage)
Respiratory problems
ASA class IV or V (Figure 2) and in patients
–– Hypoxemia aged <1 year and >80 years.7 There are several
–– Severe bronchospasm factors such as hypoxia, acute blood loss with
Cardiovascular problems shock, pulmonary embolism, myocardial in-
–– Vasovagal reflex (e.g., bradycardia, asystoly)
–– Hypovolemic and/or hemorrhagic shock
farction, arrhythmia or electrolyte disturbanc-
–– Gas embolism es, which all can be the cause or confounding
–– Acute electrolyte imbalance (high K+, low Ca++) factors in perioperative cardiac arrest.4
–– Transfusion-related or anaphylactic reaction
–– Acute coronary syndrome (cardiac shock)
–– Pulmonary thromboembolism
40
–– Severe pulmonary hypertension
–– Pacemaker failure (e.g., bradycardia, asystole)
–– Prolonged Q-T syndrome
Arrests per 10,000 cases

30
–– Oculo-cardiac reflexes
25.9
–– Electroconvulsive therapy (e.g., bradycardia, asystole)
–– Tako-Tsubo Syndrome 20
Severely reduced blood flow (acute reduced blood flow)
–– Increased intra-abdominal pressure
–– Tension pneumothorax
10 9.2
–– High positive end-exspiratory pressure 6.2
–– Surgical maneuvres 1.5 1.9
2.4 2.7 3.1
4.5 3.6
1.7 1.7

<1 1-18 19-49 50-64 65-79 80+

Survival Mortality Age group 95% confidence
pre-operative patient condition, inadequate interval

risk assessment, inappropriate anesthesia man- Figure 1.—Cardiac arrest data by age group subdivided by
agement, and human factor breakdown.1, 9 It outcome, expressed as arrests per 10,000 cases [adapted
from Nunnally et al.7].
is important to recognize that the patient risk
profile is changing with an increasingly older
and sicker population. It is thus mandatory to
acknowledge the new risk factors and inter- 503.1
vene by changing our clinical practice to fur- 200

ther decrease morbidity and mortality in the

operating room.
Arrests per 10,000 cases

150
There is a considerable heterogeneity in the
patient collectives regarding the investigated age 100 102.6

groups, patient comorbidities, and surgical proce-

dures.9 Data from recent studies suggest a close
link between the rate of cardiac arrests in the
or other proprietary information of the Publisher.

50

perioperative period and associated risk factors. 14.8 16.519,6

Recently, Goswami et al.15 have shown that 1.1
0.1 0.3
4.4
1.8
1 2 3 4 5
combined indicators of preoperative patient’s
Survival Mortality Physical status
health were important predictors of cardiac ar- 95% confidence
interval

rest. After adjusting for various comorbidities

Figure 2.—Cardiac arrest data by ASA physical status, sub-
the ASA physical status (ASA PS) together divided by outcome, expressed as arrests per 10,000 cases
with functional capacity and urgency of sur- [adapted from Nunnally et al.7].

Vol. 83 - No. 11 Minerva Anestesiologica 1193

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not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
HINKELBEIN INTRAOPERATIVE AND PERIOPERATIVE CARDIAC ARREST
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Kazaure et al.6 showed that perioperative
cardiac arrest and CPR in surgical patients
were associated with the presence of comor-
bidities (58.7% for no comorbidity, 63.1% for
one comorbidity, and 72.8% for more than 2
comorbidities). Cardiac arrests were (in 75%
of cases) associated with septicemia (26.7%),
ventilator dependence (22.1%), bleeding
(13.9%), or renal failure (11.9%).
Human factors
Environmental considerations are gradually
becoming more important than technical im-
provements. Educational efforts concentrate
on creating safer environments by recognizing
the role of human factors and Non-Technical-
Skills in patient safety. Efficient communica-
tion, task management, situational awareness,
team work, decision making, a non-threaten-
ing error culture, and a general preparedness
for crisis management are the cornerstones
of patient safety in the operating room.9, 16
Perioperative incident management strongly
depends, therefore, on environmental, organi-
zational, and workplace associated factors that
influence the margin of patient safety.9
A substantial percentage of cardiac arrests in
the OR environment is human factor-related:
53% of cardiac arrests in a Japanese study,17
83% anesthesia-related deaths in a Danish
study,18 and all cardiac arrests in a French
study 9 were attributed to a breakdown of hu-
man factors.
The preoperative team brief and the WHO
checklist were recently introduced to address
human factors in the OR. The checklist helps
facilitating a common understanding of the
risk profile of a procedure amongst the team
and also to plan ahead for untoward incidents.
The introduction of the checklist has reduced
perioperative mortality significantly.19
or other proprietary information of the Publisher.
Furthermore, regular training helps devel-
oping a thorough understanding of the indi-
vidual roles and responsibilities and also the
complex team interactions required to suc-
cessfully manage perioperative cardiac ar-
rests. There is good evidence that ALS train-
ing increases survival of cardiac arrest in the
1194 Minerva Anestesiologica November 2017
non-OR environment.20 Anesthesiologists are
prone to make cognitive errors and a specific
training programme addressing human factors
in the OR may be helpful to improve patient
safety.21
General vs. regional anesthesia
In the 19th century, cardiac arrest was related
to the use of general anesthesia (GA).9 The in-
cidence of perioperative cardiac arrest during
GA is higher than in regional anesthesia (RA;
Figure 3).10 In a study from the Mayo Clinic
the incidence of cardiac arrest for patients re-
ceiving GA was almost three times higher (4.3
per 10,000) than for those receiving RA care.10
Fatal outcome is associated with physiolog-
ical effects of neuraxial blocks as a result of
the loss of sympathetic reflexes, drug toxicity,
convulsions, and early or delayed hypoxia.9
Epidemiologic reviews of cardiac arrest dur-
ing neuraxial anesthesia suggest an incidence
of 1.3-18 per 10,000 patients.3 A recent review
of cardiac arrests during neuraxial anesthesia
reports a prevalence of 1.8 cardiac arrests per
10,000 patients, with more arrests occurring
in patients receiving spinal anesthesia vs. all
the other techniques (2.9 vs. 0.9 per 10,000 pa-
tients, respectively; P=0.041).3 In this review,
cardiac arrest during neuraxial anesthesia was
associated with a greater chance of survival
compared with cardiac arrest during GA.3
In a recent Italian clinical survey on com-
20
Arrests per 10,000 cases
15
10
9.2
5
4.2
2.1 1.3
4.3
2.7
Local
1.7
0
Regional
2.4 0.5
Monitored Other Epidural/ General
anesthesia anesthesia care spinal
Survival Mortality Anesthesia type
95% confidence
interval
Figure 3.—Cardiac arrest data by anesthesia type subdivided
by outcome, expressed as arrests per 10,000 cases [Adapted
from Nunnally et al.7].
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not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
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INTRAOPERATIVE AND PERIOPERATIVE CARDIAC ARREST HINKELBEIN
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plications associated with RA performed in 17
hospitals analysing 34,147 neuraxial blocks
(4954 epidural/combined spinal-epidural;
29,193 spinal) and 29,545 peripheral blocks,
the incidence of major complications was
0.07/1000, but no deaths were reported.22
Causes of perioperative cardiac arrest
During the last decades, airway and venti-
lation mishaps have undoubtedly contributed
to the majority of the anesthesia-related car-
diac arrests.9 Vital function monitoring (pulse
oximetry, capnography, disconnection and low
pressure alarms) and improved clinical prac-
tice, with adoption of algorithm for airways
management have most likely decreased the
incidence of airway-related cardiac events.15
Today, there are many recognised causes of
cardiac arrest in the operating room; neverthe-
less, reversible causes are of primary concern,
particularly those that are related to the anes-
thetic.1 Abdominal and thoracic surgery have
the highest risk of suffering IOCA.7 Periopera-
tive cardiac arrest is caused by patient factors
as comorbidities, physiological effects of the
procedure, side effects of the anesthetic, and
human breakdown,10 which are all interrelated.
With increasing patient age, pre-existing
disease or trauma, and new surgical interven-
tions cardiac arrest remains a serious concern.9
High risk patients should be identified during
the team brief and through the WHO checklist
at latest; adequate precautions should be taken
as for instance advanced monitoring, applica-
tion of self-adhesive defibrillation pads before
induction of anesthesia, adequate vascular ac-
cess, or preparing sufficient amounts of blood
products.4 If a critical incident is anticipated it
is also helpful to confirm role allocations and
possible rescue strategies within the team in
order to create a shared mental model.
or other proprietary information of the Publisher.
Several specific causes of perioperative
cardiac arrest have been recognized:10 hypov-
olemia (e.g., acute blood loss), cardiac-relat-
ed (e.g., coronary heart disease, myocardial
infarction, arrhythmia or electrolyte distur-
bances, pulmonary embolism, air-embolism),
drug-related (e.g., muscle relaxants), airway
Vol. 83 - No. 11 Minerva Anestesiologica 1195
loss, physiological impact of the procedure,
ventilation failure, anaphylaxis (e.g., drugs,
blood products), stress or the Tako-Tsubo syn-
drome.4, 23, 24
The incidence of Tako-Tsubo cardiomyopa-
thy is estimated at 2-8 per year and per 1 mil-
lion.23-25 Many reports show the onset in the
preoperative 26 and postoperative period 25, 27, 28
without an association to anesthesia. Only few
onsets are reported to happen in the intraopera-
tive period,25, 29 during anesthesia or anesthe-
sia induction.
The amount of intraoperative transfused
blood, a surrogate of blood loss, was also shown
to be an important predictor of IOCA.15 IOCA
from blood loss is far more common than from
transmural myocardial infarction from plaque
rupture.3 Similarly, prolonged hypoxemia and
hypercarbia resulting from unexpected airway
problems is a well-recognized cause of cardiac
arrest in the OR.3 Bradycardic arrest in the OR
can be caused by hypoxaemia, vagotonic an-
algesics, vagal reactions, sympatholysis from
anaesthetic agents and regional/neuraxial an-
esthetic techniques.3
A prospective and retrospective case analysis
study of all perioperative cardiac arrests during
a 10-year period looked at incidence, cause, and
outcome of cardiac arrests attributable to anes-
thesia:30 most perioperative cardiac arrests were
related to medication administration, airway
management, and technical problems of central
venous access. Improvements focused on these
three areas may result in better outcomes.30
Therapy
Successful management of cardiac arrest
during operative procedures, requires not only
individual knowledge and skills but also an in-
stitutional safety culture, which must be embed-
ded into education, training, and everyday prac-
tice of our specialty.9 Every resuscitation event
should have a designated team leader who di-
rects and coordinates the resuscitation, with a
central focus on immediately addressing revers-
ible causes and delivering high-quality CPR.10
Surgery should be stopped unless it is address-
ing a reversible cause of the cardiac arrest.10
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Patients are in an ideal environment for the
management of cardiac arrest;31, 32 defibrilla-
tors and resuscitation drugs are usually readily
available along with personnel who are famil-
iar with their use, and chest compressions can
be initiated immediately.1 Therefore, compared
with other settings, the response may be both
more timely and more focused.3 However, car-
diac arrest in the OR carries a very high mortal-
ity (58%); in the light of ever increasing patient
age and comorbidity and expanding indications
for surgery, cardiac arrests in the OR must
therefore stay in the center of our attention.9
The theatre environment offers immediate ac-
cess to treatments that are not readily available
outside the operating room, as extracorporeal
life support, fast access to the cardiac catheteri-
zation lab, resuscitative thoracotomy, internal
chest compressions and massive transfusion.
As the causes of cardiac arrest in the OR
environment are different from what we en-
counter in other settings and also because of
the wider range of therapeutic options at hand,
new standardized, multi-disciplinary guide-
lines and treatment algorithms are necessary.4
The European Resuscitation Council (ERC)
have published a paragraph on “Cardiac arrest
in the operating room” as part of their 2015
guidelines, which are a significant step into
the right direction.10 The NICE Guidelines for
Managing Cardiac Arrest during Neurosurgery
in Adult Patients published in 2014 provide
excellent specialist guidance.33
The ERC recommendations 10 together with
the previously published proposition 3 might
be the basis for development of specific recom-
mendations for the prevention and treatment
of perioperative cardiac arrest. The practical
value of using cognitive aids in this scenario
should also be considered.34
Ideally IOCA should also be managed ac-
cording to specific corresponding evidence-
or other proprietary information of the Publisher.
based principles.4 The relatively low rate of car-
diac arrest during anesthesia makes it difficult
to conduct controlled studies on this subject and
may explain why IOCA has not been included
so far in the guideline evaluation process.4
Moitra et al. made a significant contribu-
tion to the management of this problem and
1196 Minerva Anestesiologica November 2017
to close the gap.1 They propose a set of algo-
rithms designed to guide anesthetic care to pre-
vent cardiac arrest to treat it if it should occur.
Their article discusses the management of the
most common causes of cardiac arrest under
anesthesia.4 This is the first time that such al-
gorithms and protocols have been published in
a peer-reviewed journal, after their prototype
publication on the American Society of An-
esthesiologists’ website in 2008.3, 4 However,
even armed with these modified algorithms,
we still face considerable challenges to make
them easily applicable in the clinical setting.1
Conclusions
Cardiac arrest in the perioperative setting is
rare and has a different spectrum of causes that
compel specific adaptations and expansion of
ALS algorithms.3 Since it is both uncommon
and heterogeneous, perioperative cardiac arrest
has not been described or studied to the same
extent as cardiac arrest in the community.3
Until now recommendations for management
are based on expert opinion and physiological
understanding rather than on the standards ap-
plied in the development of ALS protocols.3
“No patient whose death is preventable
should die in an OR or in a hospital – ever.”
In order to achieve this goal, there is a clear
need to develop international, multidiscipli-
nary ALS guidelines for prevention and treat-
ment of cardiac arrest during the perioperative
period and expanding the existing guidelines
produced through the ILCOR process.4 Spe-
cific Cardiac Arrest guidelines for the OR and
the perioperative environment are long over-
due. Such guidelines could save thousands of
human lives in addition to those saved by out-
of-hospital CPR.35
Key messages
—— Cardiac arrest in the perioperative
setting is rare and has a different spectrum
of causes that compel situation-specific
adaptations and expansion of ALS algo-
rithms.
 ©
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not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
INTRAOPERATIVE AND PERIOPERATIVE CARDIAC ARREST HINKELBEIN
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
—— The incidence of perioperative cardi-
ac arrest ranges from 4.3 to 34.6 per 10,000
procedures.
—— So far, recommendations are based
on expert opinion and physiological under-
standing rather than on the standards cur-
rently being used in the generation of ALS
protocols.
—— Immediate action is needed to de-
velop international, multidisciplinary ALS
guidelines for prevention and treatment of
cardiac arrest in the perioperative period.
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 ©
COPYRIGHT 2017 EDIZIONI MINERVA MEDICA
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies

HINKELBEIN INTRAOPERATIVE AND PERIOPERATIVE CARDIAC ARREST

(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material
discussed in the manuscript.
Article first published online: March 28, 2017. - Manuscript accepted: March 22, 2017. - Manuscript revised: March 1, 2017. - Manu-
script received: November 15, 2016.
or other proprietary information of the Publisher.

1198 Minerva Anestesiologica November 2017